Community Medical Sciences to resolve steroids-containing traditional medicines in Thailand
Department of Medical Sciences

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Steroid hormones play many important roles in human health related functions such as control of metabolism, immune functions, inflammations, etc. Steroids used in medical treatments are synthetic substances for curing many diseases including dermatitis, allergies and serious rheumatoid arthritis. As steroids have an impact on most body systems, using steroids in a large amount or continuously for long time can cause many serious adverse effects such as infection, high blood pressure, Cushing syndrome, etc. Moreover, it can also interfere with child growth development and in the worst case, cause death. Therefore, in Thailand, medicines containing steroids are regulated as controlled drugs which can be used only under the supervision of physician. However, steroids are still added in many products because of lack of awareness or greediness of the producers. Currently, due to the national policy in promoting the use of local wisdom, many traditional medicines has been produced and directly sold without license. There was a report in the National Health Assembly 2014 showing that 93:1000 of Thai population had suffered from using steroid medicines inappropriately and 6.4% of them died because of steroid induced symptoms. The length of hospitalization of these patients was 2.19 days longer than the days needed for treatment of the same symptom. The estimated total cost for treatment of these patients was 57.6 million USD per year. The Department of Medical Sciences (DMSc), Ministry of Public Health in Thailand, which is responsible for surveillance and risk analysis of health threats and conducting research and development of innovations to support disease prevention, control and treatment, recognized this steroid problem. Therefore, in collaboration with other relevant units, DMSc by the Regional Medical Sciences Centers (RMSC) conducted the surveillance of steroids or other medicines illegally adding in the traditional medicines, food, and beverages. From the surveillance conducted by the 8th RMSC, Udon Thani, during 2007-2010, the results showed that 17.9 % of the traditional medicine samples containing steroids and the root cause analysis showed that most of the high risk population was living in the rural areas far from the hospital or health care center with limited public transportation. Most of them were farmers or labors and elderly that were credulous. When they had health problems such as muscle pain or other illness, going to a health center was quite expensive and the treatment took time because the physicians had to control the appropriate amount of medicine to avoid adverse events. Therefore, these patients could be victim of buying the traditional medicines containing high quantity of steroids from peddlers or direct sell easily. When they recovered quickly, they told the others about this excellent efficacy of the medicines by word of mouth without realizing their bad consequences. Although many levels of health units has provided the knowledge through different types of social media, this problem remained and it had a bad impact on the health status at both society and family levels. The initiative for sustainable solution of this problem must be established and implemented.

B. Strategic Approach

 2. What was the solution?
Innovative approach for sustainable solution of the inappropriate use of steroids in traditional medicines and other health products was working in collaboration with the communities and relevant local government organizations in order to empower the communities in surveillance and risk management of consuming steroids inappropriately. DMSc has used the concept of Community Medical Sciences to increase awareness of communities in the deleterious effect of consuming traditional medicines containing steroids by transferring them the knowledge and supplying them the in-house developed steroid diagnostic kit. In addition, to make sure that the communities can solve the problems appropriately and on time, DMSc also provided the technical advices continuously as well as using information technology to improve communication via the developed “Single Window: Unsafe Product Alert” application.

 3. How did the initiative solve the problem and improve people’s lives?
The main objective of this initiative approach is to reduce the number of steroid chronic patients in the group of poor and low educated farmers and laborers as well as the elderly who are living in the rural areas. The concept of Community Medical Sciences has been applied in order to strengthen capacity of the communities in the rural villages in Thailand in detecting and solving their problems themselves. Following this approach, DMSc has developed and transferred the knowledge and technologies to the communities. The work performance has been conducted by focusing on networking with the communities and relevant organization in all levels. During 2011 to 2015, the 8th RMSC, Udon Thani, DMSc, led by Dr. Worawit Kittiwongsunthorn, the director of the 8th RMSC at that time, had applied this initiative in Na-Muang Subdistrict, Prachaksinlapakhorn District, Udorn Thani in where the people who was living had difficulties in accessing the health services because there was no public transportation in this area. The patients had to rent a car for going to the nearest hospital or health care centers to get the treatment. This was very costly and most of them were poor and low educated. Therefore, they preferred to buy the medicines from peddlers in the villages. Most of these medicines were traditional medicines containing steroids illegally and the consequence of consuming these medicines was inducing steroid chronic sickness in these vulnerable people in the communities. The main strategies in this initiative are as follows: 1) Adjust attitude and beliefs of the people in communities by providing knowledge and information through the communities’ leaders in order to raise public awareness on the detrimental effect of inappropriate consumption of steroids which may contain in the traditional medicines sold in their communities; 2) Establish networking and share responsibilities between DMSc and relevant local organizations including local governments, Subdistrict Health Promoting Hospitals (SHPHs), communities and their partner network in order to empower the communities in surveillance and risk management of health threats from consuming products containing steroids including traditional medicines, food and beverage, as well as modern medicines; 3) Solve problem of patients who have had chronic sickness because of consuming the products containing steroids inappropriately by providing them the appropriate treatment as well as knowledge to ensure that they would not use those products again; 4) Develop the communication channel for the communities and relevant organizations to be able to access the information of the products found contamination of steroids easily and quickly in order to timely prevent and control inappropriate use of the products containing steroids. In conclusion, these strategies are not only for solving the problem of chronic steroid patients in the communities but also inducing strength of the communities to be sustainable self-reliance in risk management of consumer products containing steroids.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
DMSc by the 8thRMSC, Udon Thani has applied the concept of Community Medical Sciences (Com Med. Sciences) to solve the health problem of the villagers from benighted using the traditional medicines containing steroids. This initiative focused on participation of people in communities. The first pilot model was developed at Na-Muang Subdistrict, Udon Thani. Then the success model has been extended to cover broader areas. The initiatives to support the achievement of this project were as follows: 1) Development of test kit for screening steroids in traditional medicine samples that can be used easily in the rural area by the trained district volunteers without any need of scientific equipment; 2) The appropriate community system for surveillance and risk management of traditional medicines containing steroids established and implemented by the community under auspices of DMSc and local governments ; 3) Development of “Single Window: Unsafe Product Alert” application (http://www.tumdee.org/alert/) which can be accessed via the Internet and mobile phones by all levels of health officers including the district health volunteers for sharing and accessing information in order to perform further action to solve the community’s problem precisely and in time.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
DMSc was a main player of this project and responsible for the following activities: 1) Support and providing knowledge to the community leaders, villagers , and all levels of relevant government organizations by direct communication and training to initiate Community Medical Scientist Volunteers and Unsafe Product Alert System of the villages; 2) Development, production and supply of the test kit to the community for surveillance of steroids in traditional medicines; 3) Development of the “Single Window: Unsafe Product Alert” application for free access via internet or mobile phone to all levels of health officers and volunteers to the information of test for steroids in traditional medicines a s well as in other consumer products; 4) Conducting laboratory testing for confirmation of steroids detected in the samples of traditional medicines, food and beverages by test kit; 5) Development of training materials and providing training to strengthen the capacity of Medical Scientist Volunteers of the villages to be able to use the test kit and send the positive samples for laboratory confirmation correctly. In addition, providing training to the health officers in all levels to be able to use the “Single Window: Unsafe Product Alert” application efficiently. The outcome of this project conducted during 2011 to 2015 have affected to all 14 villages in Na-Muang Subdistrict. Every village has established its own surveillance and risk management system which has been being implemented continuously by the community in each village. Therefore, risk of using traditional medicines containing steroids inappropriately which could cause health problem in about 10,683 populations has been reduced. Moreover, in 2016 the concept of Na-Muang model has been applied to 90 more Public Health Centers and it was planned to extend this model across the country in 2017.
 6. How was the strategy implemented and what resources were mobilized?
During 2007- 2010, DMSc by the 8th RMSC, had conducted surveillance of steroids containing in traditional medicines distributed in the areas under its responsibilities and found 17.9 % of traditional medicines containing steroids illegally. In March 2011, the 8th RMSC started the integrated project with the relevant organizations including local governments, SHPHs, and District Health System (DHS) on community empowerment for surveillance and risk management of consuming steroids containing in traditional medicines distributed in rural areas. The first strategy was adjustment of attitude and belief of villagers on using the traditional medicines and raising their awareness on hazardous steroids containing in those medicines. The first target group was the community leaders. The assigned coordinator from DMSc had provided them the problem of steroids in traditional medicines detected by DMSc, causes of problem, and seriousness of steroids chronic diseases occurred from consuming these medicines. Then, the community leaders called for meetings with the villagers to convey them those information and convinced them to participate in establishment of system for social awareness and control of these products in their community. The second strategy focused on networking between DMSc and the relevant organizations to solve this steroids problem in the villages. Agreement on sharing responsibilities and fundraising by different partners was made. In 2012, public health centers started working with the community to select 2 to 3 health volunteers in each village to be trained and certified by DMSc on health deleterious effect of steroids and using DMSc’s test kit for screening steroids containing in traditional medicine samples. These trained and certified volunteers were assigned as the Community Medical Sciences Volunteers responsible for surveillance of steroids in traditional medicines, providing unsafe product alerts to their community and sending the suspected samples to DMSc for laboratory confirmation. DMSc had used its own budget and human resource for capacity building of the volunteers and communities, test kit development, and laboratory confirmation. The communities had used budget from Subdistrict Health Fund for procuring test kit, sending samples for laboratory confirmation and compensation for the Community Medical Sciences Volunteers. In 2016, in order to extend results of “Na-Muang Model” to the other 90 Health Centers, Health Consumer Protection Program, Chulalongkorn University supported 1.2 million Baht for procuring DMSc test kit for these Health Centers and 1.7 million Baht in 2017 for supporting capacity building program for the Community Medical Sciences Volunteers. The third strategy focused in solving problem of the steroids chronic patients in the communities. Since 2011 the Community Medical Sciences Volunteers had worked with family care team and SHPHs in searching for the chronic steroids patients, provide them treatment and knowledge, and follow up to make sure that those patients had completely recovered and would not use traditional medicines containing steroids again. Moreover, in 2014, the initiative for treatment of these patients using traditional medical services was developed including pain reliever made from local medicinal plants, five parts of Senna siamea formulation, and the Thai Hermit Exercise for rehabilitation. The budget used for the patient treatment and follow up as well as development of traditional medical services was from the Subdistrict Health Fund. The fourth strategy was enhancing the communication channel. From 2011 to 2013, the risk communication and unsafe product alert were conducted through village broadcast towers. In 2014, DMSc had worked with Health Consumer Protection Program to develop “Single Window: Unsafe Product Alert” application via mobile phone and internet. Moreover, the Unsafe Products Alert Center in each village was established. These centers have been controlled by SHPH and their quality was ensured by DMSc.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The stakeholders involved in this project and their responsibilities are as follows: 1) DMSc was responsible for project design, development , production and supply of test kit, transferring knowledge and technology to the community and health volunteers through several training courses, support the technical information, development of the “Single Window: Unsafe Product Alert” system and announce the unsafe product alert via this system; 2) 60th Anniversary Chaloem Phra Kiat Navamintarachinee Health Center, Na-Muang, was acting as the Subdistrict manager working in collaboration with the community in establishment of the Unsafe Product Alert Center and selection of Community Medical Sciences volunteers who would be responsible for surveillance of steroids in traditional medicines; 3) Chief Executive of the Subdistrict Administrative Organization (SAO), Na-Muang and community leaders including Village Headman, Subdistrict Headman and the Community Medical Sciences Volunteers were responsible for communication with villagers in order to adjust their attitudes in using traditional medicines inappropriately and receiving complaints about the steroids detected in the testing samples; 4) The Community Medical Sciences Volunteers had worked with family care team and SHPHs in searching for the chronic steroids patients, provide treatment and knowledge for them and follow up to make sure that those patients had completely recovered and would not use those medicines containing steroids again; 5) Health Consumer Protection Program, Chulalongkorn University had supported budget, provided technical information and worked in collaboration with DMSc in development of database of the “Single Window Product Alert” as well as supported the budget for training of Community Medical Sciences Volunteers; 6) Queen Sirikit Health Center Foundation had announced its policy to extend results of Na-Muang Model to all 90 Health Centers under the Foundation across the country.

 8. What were the most successful outputs and why was the initiative effective?
The important outputs of this project were: 1) Community leaders and villagers living in Subdistrict Na-Muang including vulnerable citizens have received the information and knowledge and were well aware of the health hazard of steroids containing in traditional medicines. The communities were empowered under auspices of DMSc and local government in surveillance and risk management of traditional medicines containing steroids. Moreover, the community had declared their public policy for all local merchant to stop selling these high risk products and investigated all peddlers coming in their community. 2) “Na-Muang Model” as the community empowerment model in solving problems of the communities by using the concept of community participation under this system could be modified accordingly to type of problem, life style and attitude of the population in each area. The community could follow this model by using its own budget, human resource, and mechanism of social control appropriately and efficiently. Fourteen Unsafe Product Alert Centers were established. Three Community Medical Sciences Volunteers from each of 14 villages were trained and have worked on surveillance and screening of steroids in consumer products in their community. 3) “Na-Muang Model” had been applied in other rural areas. Ninety Health Centers had established the system following “Na-Muang Model”. Besides extending results of “Na-Muang Model” to broader area, they were also extended to the surveillance and risk management of other health hazardous agents such as antifungal in fermented vegetables, formalin in seafood, ammoniated mercury in cosmetics, etc. 4) The people and relevant organizations could access to the information of unsafe product alert via many communication channels including appropriate public media established by the community, “Single Window: Unsafe Product Alert” application via mobile phone and internet. Database was established. Trend analysis using the database was used in planning of future surveillance and solving problem in time. Moreover, the regulator had used the information from “Single Window: Unsafe Product Alert” in investigation and arrest of the person who produced traditional medicines illegally in many provinces such as Khon Kaen, Kalasin, Maha Sarakham, Nonthaburi, etc. 5) Sixty six out of 67 patients (98.5%) on chronic steroids found in Subdistrict Na-Muang had recovered and no new patient was found. Alternative traditional medical services in order to replace use of traditional medicines containing steroids were developed. These included pain reliever using five parts of Senna siamea formulation and rehabilitation of the patients by Thai Hermit Exercise.

 9. What were the main obstacles encountered and how were they overcome?
The main obstacles encountered and the performances to overcome them were: 1) Attitude adjustment of community leaders and villagers to stop using traditional medicines containing steroids required appropriate communication skill. The communication in the area of medical sciences technology to the villagers who had no background knowledge in this area was very difficult. Therefore, the person knowledgeable in the local culture was assigned to communicate with community leaders. Then, the community leaders convinced the villagers to participate in design of their own system suitable for solving problems in their community. 2) At the beginning, establishment of networking moved very slowly because all stakeholders did not understand the importance of this project and did not provide any support. The scientists from the 8th RMSC had to provide them periodically with the actual evidences from laboratory surveillance and explained them about importance and benefit of this project. Negotiation and agreement on sharing responsibilities and budget appropriately to work together efficiently was also done. 3) Although the technique in using DMSc test kit for screening steroids containing in traditional medicines was very simple, most of Community Medical Sciences Volunteers had no basic scientific knowledge. Therefore, the community had no confidence in their results of the steroid screening. The training course and competency testing for these volunteers had been established and implemented by DMSc to increase confidence of the volunteers and to build the community trust. 4) The villagers did not want to stop using traditional medicines containing steroids because these medicines could relief their pain quickly and they were not aware of their deleterious effect. Therefore, in order to provide the villagers the other affordable and effective treatment options, DMSc and Na-Muang SHPH had developed the other pain relief methodology using local medicinal plants and Thai Hermit Exercise.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
This project focused on solving the health problem of the villagers who were poor and had difficulty in accessing to the appropriate and affordable treatment in time. They also lacked of the precise information/ knowledge on the health hazards of using steroids inappropriately. Therefore, they were easily convinced to use the traditional medicines or other consumer products containing steroids continuously in order to solve their health problems. Serious chronic steroids illness in this group of people had been discovered. In this project, 67 chronic steroid patients were detected and treated. Sixty six patients recovered well and none of them have ever used the traditional medicines containing steroids again. Up until now, no new chronic steroid patients were detected in Na-Muang Subdistrict. It was showed that this new approach could prevent many poor people in the rural area from suffering from chronic illness and the family and government expenses for their treatment could be saved for at least one million Baht per patient. Altogether, from detecting and treatment of chronic patient in Na-Muang Subdistrict, at least 66 million Baht was saved. This success also brought back the family happiness of these poor peoples. In the long term, the most benefit that the people in rural area, particularly poor and elderly people, had received from this project was knowledge and tools that empowered them to prevent themselves from consuming unsafe products advertised in local social media, peddlers or sold in local stores or by direct sell. The strategies on community empowerment by encouraging participation of community leaders and villagers to develop their own system suitable for community environment and their life style in surveillance and risk management of unsafe products efficiently worked very well in the rural area. This social integration approach of “Na-Muang Model” which responsibilities and budget was shared among stakeholders in all levels was not only helping in solving problems quickly but also being proved as an excellent model in term of cost benefit and sustainability. The success of this model could be applied for solving other health problems in communities in a long term.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
This initiative improved integrity and accountability in public service because it emphasized on the participation of people and the other stakeholders in every activities including problem identifying and designing mechanisms to solve the problem in communities. DMSc and other government organizations only initiated the projects and were mentors for the communities. This approach was to empower people in the community and build their confidence in establishment and implementation of suitable surveillance and risk management systems for unsafe products in their community. At the end of this project, the people in the communities were main players in controlling budget and doing the activities under auspices of the government organizations. In addition, one of important objectives of this project focused on enhancing the accessibility of the risk group of people in rural areas to the precise information/knowledge and appropriate treatment in time. Even though the government organizations such as hospitals or health care centers played major role in treatment and rehabilitation of steroids chronic patients as well as development of medical service innovations, the community participation through Community Medical Sciences Volunteers in identifying and educating the patients was important success factor of this project. The outcome of “Na-Muang model” showed excellent success as it was extended to be integrated in the performance of District Health System (DHS) in order to establish mechanisms for consumer protection, health promotion, and health rehabilitation by people participation. The impact of this project could be also measured by the community capacity in efficient and sustainable problem solving. The other important outcome of this project was getting budget and human resource support from not only the communities but also various organizations. Moreover, the results of “Na-Muang Model” had been extended to 90 Public Health Centers in 2016 and across the country in 2017. From these outcomes, it was proved that the public and government had confidence in the efficiency and sustainability of “Na-Muang Model”.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
As stated previously that the rationale of this project was from the health problems detected in the poor villagers in rural areas. Therefore, in addition to work in collaboration with the relevant organizations to solve their problems, this project focused in community empowerment through education of the people living in the villages (particularly poor farmers, labors and the elderly), who had difficulty in accessing appropriate health care, treatment, and knowledge/information, to prevent them from using unsafe consumer products and to get the appropriate treatment. Even though this project was applied to solve the health problems for all genders, in practical most of main target group to be educated was housewives who became victims of false advertising through many channels easily because they were low educated and vulnerable in accessing the precise public health information. The other important target group in providing precise information and knowledge was students in primary schools. The knowledge they gained was not only empowering them to prevent themselves from the health threats in the future but also encouraging them to support social control of suspicious unsafe products in their community.

Contact Information

Institution Name:   Department of Medical Sciences
Institution Type:   Government Department  
Contact Person:   Worawit Kittiwongsunthorn
Title:   Executive Management  
Telephone/ Fax:   +6681 7185154/+662 9511026
Institution's / Project's Website:  
E-mail:   kworawit@gmail.com  
Address:   88/7 Soi Bamradnaradoon, Tivanond Rd.
Postal Code:   11000
City:   Nonthaburi
State/Province:   -
Country:  

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