The value of village health volunteers In times of universal health care

For 35 years, Thailand’s primary healthcare system has rested on the shoulders of a legion of Village Health Volunteers. Now that Thailand has had universal healthcare for some years, is this model – which was originally established to boost poor rural communities’ access to essential healthcare – obsolete?

GUEST CONTRIBUTION by Zoe Swartz, Mariko Powers, and Katie Mathieson

Mekhala Nonsiri, 47, has high blood pressure and can barely walk due to calcium deficiency in her bones. There is a chance that her health will improve if she continues to take medication, but for the moment the help of Ms. Uthumporn is all she can count on.

Mekhala Nonsiri, 47, has high blood pressure and can barely walk due to calcium deficiency in her bones. There is a chance that her health will improve if she continues to take medication, but for the moment the help of Ms. Uthumporn is all she can count on.

KHON KAEN – Mekhala Nonsiri sits in the doorway of her two-room rented home in a slum community of Khon Kaen. She suffers from a calcium deficiency in her bones that makes walking nearly impossible. Living with a disability in an urban slum is already a challenge, but without the daily visits of a Village Health Volunteer (VHV) her life would be much harder.

Ms. Nonsiri lives in Theparak 5, one of Khon Kaen’s shanty communities. Set back from the slum’s narrow thoroughfare by an even narrower alley, her home overlooks the train tracks. Like everyone here, she is accustomed to pausing conversations amid the deafening clamor of passing trains.

Ms. Mekhala has plenty to fret over, but one thing she does not have to worry about is eating lunch. Each day, Uthumporn Srichai a Village Health Volunteer, checks on Ms. Mekhala and brings her a meal, free of charge. The 52-year-old has been a VHV for six years and looks after 15 disabled residents in Theparak 5 and its neighboring slums.

In her community, Ms. Uthumporn and the other nine VHVs serve as liaisons between villagers and the formal health sector. They provide basic services such as checking blood pressure, health consultations, first aid, and sometimes transportation to the hospital.

Thailand established this healthcare delivery system in 1980 after the country’s ratification of the Alma Ata Declaration, an international agreement to promote the health of all people.

In the 1980s, transportation in rural areas – where the bulk of the population lived – was difficult. Medical care was costly – prohibitively so for the poor. It made sense for communities to develop ways to take care of their own health.

Thailand in 2015 is quite different. According to the United Nations Development Programme, the number of impoverished households in Isaan dropped from 3.4% in 1996 to less than 1.3% by 2009. Northeastern people are more educated and urbanized.

Most importantly, a low-cost universal healthcare system was put in place in 2002.

Nevertheless, the VHV program continued to expand. There were 700,000 VHVs in 2005; now there are more than a million, each working with seven to twelve families in every community in Thailand. VHVs are expected to systematically coordinate their work with government public health policies.

The national budget for the VHV program is over 7.2 billion baht (US$240 million) annually, which includes funds for the 600-baht monthly stipend volunteers have received since 2001.

Given the changes in Thailand’s poverty demographics and the expansion of access to the healthcare system, are VHVs still necessary?

Dr. Amorn Nondasuta, Thailand’s former Permanent Secretary of Public Health, was in charge of the national primary healthcare program from 1983 to 1986. Now 87 years old and retired, it was under his watch that Thailand’s community health volunteer program was initiated 35 years ago.

The mission of the program has always been to expand “community access” by placing primary healthcare into the hands of villagers and creating “health autonomy,” Dr. Amorn says in an email to The Isaan Record. He originally hoped to see “the people fully in control of their own health, via behavior change or health planning and management.” But this mission, Dr Amorn admits, “has not been fully realized so far.”

A 1997 report found that the use of VHVs declined as Thailand urbanized and access to medical services improved. As a result, “more and more people self-refer into this level of care,” the report states.

“City people have many choices to visit doctors, so they don’t use VHVs,” says Vanarat Kongkam, who oversees the VHV program in Khon Kaen municipality.

Proponents of the program point out that the VHV program is closely tied to community development, a role that cannot be fulfilled by formal health services alone.

“VHVs are the role models of people in the communities. They are dedicated to many social causes. They become respected and may be elected headman,” says Waraporn Chukhanhom, Secretary to the Director of Public Health for Khon Kaen City District.

Government officials working with VHVs echo this sentiment and insist that the program still plays a crucial role for Thailand’s healthcare system. From the beginning, says Ms. Vanarat, the program was “exclusively designed to give poor people access to healthcare.”

In many cases, lack of transportation is an additional barrier to medical care. For rural residents in remote communities in Isaan, traveling to the hospital can be particularly burdensome. In order to tackle this problem, the VHV program in Isaan has established “Happy Pavilions” – small healthcare stations where volunteers provide basic care close to rural residents’ homes.

“The Happy Pavilion program works well,” Ms. Waraporn says, adding that it helps vulnerable populations “reduce the cost of hospital visits.”

As VHVs are members of the communities they serve, they know the day-to-day struggles of their neighbors and can track the general well-being of the families under their care. They can support people with mobility challenges by assisting them, giving baths, or providing diet-appropriate meals.

Most important, say proponents, the volunteers help villagers navigate the medical bureaucracy and personalize healthcare. When Ms. Mekhala first started to have trouble walking, she couldn’t afford to buy a wheelchair. With the support of her VHV, Ms. Uthumporn, she was able to secure municipality funds to purchase one.

The VHV program also provides basic healthcare training to selected villagers. In this way, they can serve as a bridge to the formal health system and actively support preventive healthcare in their communities.

Ms. Somphaan [here standing with her daughter] spends most of her day working in the fields, but every two hours she stops what she is doing to care for her elderly mother. Her mother’s hand is tied to the bed so that she does not rip out her feeding tube. Most VHVs work a separate full time job and only spend a few hours a week volunteering. Thailand’s Potential Support Ratio is rapidly falling, according to the data from the United Nations. By 2025, the number of working-age adults potentially available to support the population aged 65 years or more will be reduced by half, compared to 2006.

Ms. Somphaan [here standing with her daughter] spends most of her day working in the fields, but every two hours she stops what she is doing to care for her elderly mother. Her mother’s hand is tied to the bed so that she does not rip out her feeding tube. Most VHVs work a separate full time job and only spend a few hours a week volunteering. Thailand’s Potential Support Ratio is rapidly falling, according to the data from the United Nations. By 2025, the number of working-age adults potentially available to support the population aged 65 years or more will be reduced by half, compared to 2006.

This role as a bridge is especially profound for Somphaan Sonphromma, a 50-year-old resident of Khok Si, a village eight kilometers outside of Khon Kaen City. She is one of the village’s twenty health volunteers educating people on how to prevent mosquito-borne illnesses, such as dengue. One of Ms. Somphaan’s weekly tasks is to visit her assigned families and distribute fish and chemicals that destroy mosquito larvae.

“VHVs and villagers live in the same community, so volunteers know people’s problems better than the doctor and can work to help one another” says Jitti Chertchoo, the headman of the slum community Theparak 5.

The localized volunteer service model is effective in Thailand because it mirrors what is already culturally practiced – villagers taking care of family members and supporting the well-being of the community.

“My life is hard but then I look around and see that other people have it worse than me,” says Ms. Uthumporn. Her budget request letter to the municipality did not ask for much in the way of resources. She knows that the most valuable thing she can offer is her time. Here, she checks to make sure the food that the school donates will not be too spicy for her patients. Amphon Phosanit used to work transporting and selling vegetables in remote provinces. Five years ago he lost his left arm in a car accident when he swerved to avoid a shipping container that fell off an eighteen-wheel truck in front of him. Now he drives Ms. Uthumporn to the places she volunteers. He earns 50 baht to cover the cost of gas, and 5 Baht for every meal they deliver. Knocking on the door of each patient's house every day can take a long time, but that closeness is what Ms. Uthumporn thinks makes this program important. “We are closer to each other than we are to doctors. We see the real conditions of the community, but doctors and nurses see the patient only at that moment,” Ms. Uthumporn says. Ms. Uthumporn smiles, saying “seeing people in the community healthy makes me happy. If I had to choose between helping the community or helping myself, I would help the community.” Phanom Seemuang, 76, has problems with her vision. Like many of Ms. Uthumporn’s patients, she lives alone and doesn't have family around to take care of her. In the corner of the house, Ms. Phanom has a small stove for cooking on days when Ms. Uthumporn cannot bring her meals. Ms. Phanom lives here alone. The railroad connecting Nong Khai to Bangkok runs 15 yards outside her front door. Many houses here are dilapidated structures made of plywood and sheet metal, but the community has made some improvements. After petitioning the government to be recognized as a legal settlement, the community was granted legal status ten years ago. Jitti Chertchoo, the headman of Theparak 5 community, says the challenge these days is “the government thinks that children should not be here in the slum.” Mekhala Nonsiri’s husband works as a gardener in downtown Khon Kaen and her children work at a store, so Ms. Uthumporn helps take care of her during the day. With Ms. Uthumporn’s assistance she is in the process of registering for a disability card and received money to buy a wheel chair. Many of Ms. Uthumporn’s patients receive 800 baht in disability benefits a month from the municipality. Sustained declines in birth and death rates during the last three decades of the 20th century have left Thailand facing a rapidly growing population of older persons. Almost a third of Thailand’s population will be over the age of 60 by the year 2050. Women constitute the majority of Thailand’s older population and face disadvantages relative to men, including lower levels of literacy, longer periods of widowhood, living alone with significantly lower household income, higher levels of morbidity and disability, and lower likelihood of receiving formal retirement benefits or social security support, according to the United Nations. 
[Pictured above Ms. Uthumporn visits her patient Amphorn Khanwijit] Diabetes is a growing problem in Thailand; according to the WHO,  one in 13 adult Thais has diabetes. Udom Majundaeng, the president of the VHVs in Theparak 5, does what he can to continue to help the community - such as providing health consultations and helping residents document their conditions - despite his own struggles with the disease. Basket weaving is a common source of income for the elderly and disabled of Theparak 5. A basket takes a whole day to make and might sell for 50 baht, less than $1.50. For elderly residents living alone, like 75-year-old Samai Moongjuaklang, these baskets are means to a livelihood. “After I got in the car accident, I didn’t want anyone in my family to take have to care of me, so I moved here to Khon Kaen. I would be a burden to my family and I didn’t want my grandma taking care of me and washing dishes for me - I wanted to take care of myself” Mr. Amphon says. Encouraged by Ms. Uthumporn, Mr. Amphon took up singing. Some nights he can make up to 1,000 baht singing in the market for coins. A true caregiver, Ms. Uthumporn sees the potential in everyone she works with. Despite living in the center of the city's activities along the rail road tracks, access to public services can be confusing, especially for those not living near extended family.
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Sustained declines in birth and death rates during the last three decades of the 20th century have left Thailand facing a rapidly growing population of older persons. Almost a third of Thailand’s population will be over the age of 60 by the year 2050. Women constitute the majority of Thailand’s older population and face disadvantages relative to men, including lower levels of literacy, longer periods of widowhood, living alone with significantly lower household income, higher levels of morbidity and disability, and lower likelihood of receiving formal retirement benefits or social security support, according to the United Nations. [Pictured above Ms. Uthumporn visits her patient Amphorn Khanwijit]
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