Questions/Answers

The National Health Security Office (NHSO) is responsible for implementing the Universal Health Coverage to ensure all Thai citizens to have the right to get access to health services since 2002. Currently, almost 99.94% of Thais are officially identified and have UHC right. However, there are a small number of unreached people who extremely need helps to be certified as a Thai citizen. Among these vulnerable groups, Maniq is one of the ethnic groups in the south where they primitively live in remoting forest for more than one thousand years. However, due to the rapid deforestation, the struggle to search for adequate food is inevitable. Herbal remedies, which have been used for thousand years, has also been threatened. Some of them gradually expose local people for seeking helps. Some move to live in the forest edge and tend to adapt themselves to be able to survive. In addition, in some tourist spots, tourist agencies try to promote visits to indigenous lifestyle without the appropriate arrangement. They are very sensitive to confront the modernization and the adoption of modern living conditions. This interferes the daily living and sometimes brings about the severe health risk to expose some infectious diseases without immune system. All these occurrences would, more or less, threaten the survival of this indigenous group terribly. The objective of this project is to accommodate Maniq tribe to get the health security right. This could ensure them to get access to health services when needed and to enable them to perform proper basic essential health behaviours. The quality of life without the disturbance of their ordinary daily living is ultimately emphasized. This eventually would promote the social equality among this vulnerable group.

Acquiring the personal identification number, Maniq could get access to care and have the right to other social welfares. Moreover, the health facilities around those inhabitant areas are prompt to provide health care services no matter they have personal identification number (PID) or not. The intensive training course about the basic emergency health care and basic life support were provided. Immunization was implemented to control the outbreak. Moreover, NGOs give hands to these people to improve their settlement and teach agriculture for having enough food. All these activities aim to reduce social inequality and promote their quality of life.

a. The eligible acquirement of the health security right among the Maniq tribe would lessen the barrier to health care. The National Health Security Fund is directly and fully distributed to the hospitals and health centres with closed mutual monitoring and financial support. Moreover, the exemption to get treatment anywhere accommodates the convenience to care. Maniq will not be anxious to seek health services with financial constraint and the strict beneficiary regulation that stresses on following the referral system of medical services. Vaccination, health promotion and basic life support in case of emergency are also undertaken. All these would ensure their health need and promote the essential health care. In case of emergency, they could call for assistance that needs technically communication. This ensures Goal 3.8 to achieve universal health coverage with financial risk protection. In addition, Maniq will get access to safe, quality, convenient, effective and affordable essential medicines and vaccines. Healthy lives and the well-being which are the goal 3 of SDG are eventually promoted.

Gaining the opportunity to health care will certainly increase the chance of these people to get other welfares i.e. the monthly infant subsidiary, disabled subsidiary, and aging subsidiary. Economic constraint is minimized. The proper settlement and agricultural practice are voluntarily offered. They can improve their living conditions and adequate diets without disturbing their existing traditional lifestyle. To promote the goal 10 of SDG, its impact eventually reduces the social inequality of this most vulnerable group.

Prior to this project, the GPS to locate temporary sheds along the range for mapping Maniq population was introduced by UN staff in 2013. We called for some of their acquaintances to explain the advantages of the registration to them for the acceptance. First, appointments to bring them to the municipalities must be well arranged to pursue all procedures to get the PID card. The district chief officer (DCO) is the key person to accommodate this task. Prior to the process of registration, DCO must be informed in detail for the objective of this project. A closed collaboration between the health facilities and the regional NHSO office was the next step to register for the health security right. Gathering all Maniq clusters was another successful factor to convince the remaining Maniq to be willing to get PID cards. Within 33 months, 373 out of 500 got the PID cards and the following assistant activities were undertaken effectively. Moreover, the regional NHSO committee allowed Maniq to get services anywhere. This flexibility definitely responds to the actual lifestyle of Maniq. This initiative builds the trust among them and leads to the willingness for further social welfare activities.

It is certain that the right to get health services and other health-related activities is equal to all. Moreover, regarding their culture, the hierarchical social structure for food and health, children, elderly, and females are the priority, respectively. Males in the cluster take a leading role to protect their members in the cluster. It is evident that both Maniq boys and girls in Trang where this cluster seems to be adaptive to modern life are allowed going to school equally.

The target group of this project is Maniq at Banthat mountainous range covering 4 provinces in the south: Trang, Patthalung, Satun and Songkhla. The total estimated number of this population is 500. Currently, three-fourths (376) are the registered citizens. However, due to this extensive process for over a year, all the registered have the health security right and the capitation budget has been increasingly allocated directly to the hospitals where those Maniq were registered. This helps the hospitals to have more budget. Meanwhile, unregistered Maniq are not neglected. The regional NHSO committee allowed the bi-annual adjustment of the budget among all the hospitals in the region according to the data on health expenses of the hospitals that provided services to unregistered Maniq. Several patients have been referred to nearby hospitals and, if necessary, will be transferred to the higher level. Moreover, the basic life support and emergency care course could develop the skill to tackle life-threatening events. It is evident that an emergency call was successful to locate and take the patient to the hospital safely. In addition, the vaccination to all Maniq was operated right after a serious case of Diphtheria occurred. The disease outbreak was eventually controlled.

Regarding the NHSO strategic plan between 2016-2020, Strategy1 is to ensure coverage and access for vulnerable and underutilization groups. In January 2017, NHSO Region 12, Songkhla, indicated Maniq as a vulnerable group. The literature review and consulting experts for preliminary data were done. Dr. Pantip Kanchanachitra Saisunthorn, an expert from Thammasat University, and her team visited us for accelerating the process of Maniq to get PID cards. Three more meetings among local authority personnel, health staff, forestry officers, Maniq representatives and their intimates were conducted. Mapping of Maniq along the range was studied for locating their clusters. Eventually, the mobilization for PID cards was done. Prior to the project, there were only 126 out of the estimated total number of 500 got PID cards. According to the recent data in September 2019, 376 of Maniq have PID cards. They all were also enrolled to get the health security right. NHSO sets aside the capitation per head budget according to the number of registered citizens in each catchment area. The increasing number of registered will also increase the budget for hospitals. However, it is subject for the beneficiaries to visit the health facility where they register only. This does not get along with Maniq lifestyle. The regional NHSO committee thus had a consensus on the exemption of the strict treatment pathway. Non-registered Maniq are also eligible to get treatment free-of-charge. To cope with this exemption, the financial adjustment will be calculated annually to allocate to the hospitals where Maniq patients visit. A training course on basic life support and emergency service using the Local Health Fund was implemented and one child was successfully saved from this course. Moreover, when 2 children got Diphtheria, the surveillance was rapidly done and 139 Maniq in three clusters were vaccinated. The outbreak was completely controlled.

The obstacle to get the health security right is that the IT platform of the national household registry system and the NHSO system is different. The data cannot be automatically transferred for the new cases, except for newborns. The regional NHSO office periodically updates the list of new Maniq with PID and activate them for the health security right. Communication skill is another big barrier to understand each other. Tell-show-do is the powerful tool for learning. Demonstration enables Maniq to be confident to practice.

Mapping of Maniq along the range using google map is an appropriate technology to locate all clusters. Public hearing is a powerful tool for collective opinions and empower Maniq to express what they want. Deep listening accommodates nonjudgmental opinions and advancement. Multi-stakeholders from related organizations together with a few Maniq representatives were structurally organized to develop the recommendation submitted to policymakers. Emergency care training course is another interesting innovation. Basic life support; calling 1669 for transferring patients to hospital; and Cardio-pulmonary Resuscitation (CPR) were practiced. Even if Maniq cannot read and write, instructors successfully train them to perform accordingly.

The Treaty of Waitangi is a treaty signed by representatives of the British Crown and Māori chiefs from the North Island of New Zealand that empowers us not to judge by ourselves to provide what they actually need. The Bumiputra Policy of Malaysia recognizing Maniq as a category of Malaysians provokes us to take a closure look for Maniq in our area. These two legal regulations inspire us to urgently improve their quality of life for the sake of non-discrimination.

Maniq at Banthat Range originally are the same tribe as Orang Asli at Sankalakhiri Range. They have struggled similar conditions. Nowadays, with estimated total number of 319, only few have Identification Cards. The project has been expanded to this group through the Southern Border Provinces Administrative Centre, the crucial national integrated organization. The process has been at the initial stage. Moreover, the lesson learned is exchanged to interested parties who initiate another project for involving unregistered people. The rough number of this vulnerable group for the whole country is 50,000-60,000. The preparedness of the health security fund for unregistered people is currently under the NHSO Board Committee task. The short video clip of this project was shown in the Universal Health Coverage day, 12/12/2018. It is delightful that a few representatives from other countries and the Ministry of Foreign Affairs were interested in this task. It was shown in the Side Meeting in the Fifth session of the Economic and Social Commission for Asia and the Pacific, Committee on Social Development, Bangkok, November 2018. This clip is disseminated via YouTube under the title of “Thai UHC for Maniq: no one left behind สปสชคุ้มครองชาวมานิด้านสุขภาพ”.

Health personnel, forestry officers, and local authority staff are the key persons to mobilize PID registration. Financial adjustment of NHSO fund for the hospitals providing health services during the past two years and the first three semesters of the fiscal year 2019 was allocated directly to the hospitals. The amount of budget (30,000 $) was calculated from the actual service expenses provided for Maniq. This amount came from the annual global budget of all hospitals under the Ministry of Public Health in the region. Moreover, a local health fund funded the emergency care project for 1,000 $.

Due to rapid deforestation and starvation, it is convinced that a majority of Maniq will not deny the adaptation of their daily lives from deep forest to semi-permanent settlement. The requests from Maniq clusters regarding the agriculture, housing, earning money and education are focused and developed with the closed multi-collaboration. The Thai Health Promotion Foundation subsidizes the projects on agriculture; farming; check dam for clean water; and waste management. The self-reliance projects in fundamental and basic needs are highly expected to serve as the essential tools for the sustainability of their lives.

Yes

Concerning the external evaluation, the Public Sector Excellence Award (Lert-Rat) Thailand of 2018 in Effective Change (Participatory Engagement) was granted by the Office of the Public Sector Development Commission (OPDC). Three dimensions of the evaluation are 1) the potential of organization to engage people to participate (20 scores); 2) the participatory implementation: model development, processes, and stakeholder roles and actions (50 scores); and 3) the achievement and model of good practice (35 scores).

The internal evaluation of the achievement of this project came from 2 main parts: 1) the number of Maniq who got PID and Health Security Right and the data on health services provided including treatment, vaccination and health promotion activities, the budget expenses and its allocation adjustment and 2) the satisfaction assessment of stakeholders who got involved into this project.

Within only 3 years, two folds of the previous number of Maniq got PID and the health security right. Currently, more than three-fourths of Maniq have access to health care. During the first semesters of 2019, 201 visits of Maniq that got services outside the catchment area were reported. Twenty-five severe cases were referred to the provincial hospitals. The regional budget adjustment for additional allocation to the hospitals that provide services for Maniq patients was undertaken. During the first period of 2016-2018, 6,333 $ was additionally allocated, In the first three semesters of 2019, 23,666 $ was allocated. The regional NHSO committee has the consensus to continue this adjustment once a year. This indicates the mutual accountability of all hospitals in the region in terms of finance to take care of Maniq. The satisfaction level of project implementation from stakeholders involved was high (4.22 of 5). In addition, the satisfaction of public hearing process for Maniq was rather high (3.87 of 5). This illustrates the effective participation of stakeholders for model development. The involvement of Maniq representatives along the process and hearing their voices are the key success factors of this project.

The National Health Security Office takes charge in ensuring all Thai citizens to get access to health care according to the National Health Security Act. After 15 years of implementation, the effective coverage has been considered as a vital indicator. The vulnerable groups are very much concerned as they have extreme barriers to be covered. To search for these groups, identifying and approaching are the basic processes that need the coordination from various parties. Initially, the Faculty of Law, Thammasat University is the academic institute addressing the obstacles of Maniq to get PID. They called for action to collaborate among the relevant organizations in the area. The local authorities in Pabon and Kongra District, Pattalung; Langu, Tungwa and Manang District, Satun; Palian District, Trang; and Rattapoom District, Songkhla together with officers from the Royal Forest Department were the organizations that look after Maniq in a daily basis. Health personnel from hospitals and health centres act as key actors on health conditions. Regarding health care financing, the Regional NHSO committee and the working group between the executives from the main providers (MOPH region 12) and the main payer (NHSO region 12) are the key decision makers for financial adjustment and allocation.

The NHSO headquarter fully supports due to the present NHSO strategic plan. Staff of the Faculty of Law, Thammasat University academically supports at the initial stage. They instructed locals to prepare family trees which are fundamental tools for personal verification. They also facilitated all official documents needed for ID registration. Three parties: forestry officers, local authorities, and chief district officers in each area closely collaborate and take part in the process of PID registration. Health personnel from the hospitals and health centres promptly take the next step to register for the health security right. In addition, the regional NHSO committee and relevant working groups totally agreed upon subsidizing the hospitals that take care of Maniq. The local authorities also play an important key actor to take care of Maniq in a daily basis. The Royal Forest Department is also another backbone supporter of their settlement in the forest. The engagement of these two institutes would encounter such barriers to their living conditions and the quality of life. This project not only shows the respect to the marginalized ethnic groups, but also engages them to be a part of inclusive society and contributes to the preservation of forest.

The first step was to search for good fieldwork reports and key local persons. Brainstorming key local persons from all areas involved and locations of Maniq sheds using google map were a proper preliminary process of planning. Experts are the essential support for the preparedness step. Snowball technique and non-structural procedures are apparent in this project. However, the most important success factor is trust and sincerity. Maniq generally build up strong relationship with outsiders whom they trust. Communication with Maniq via these persons is an entry point to learn how to perform such activities. Anyhow, we must keep in mind that our development will not disturb their traditional way of life. Public hearing is another critical factor that made their voices heard publicly. Their expressed wants should accommodate relevant organizations to make it done. This strengthens the trust and eases following activities. The regional NHSO committee made decision to permit Maniq to get health services anywhere. This will align with their movable daily living. The project has been expanded to Orang Asli, another Maniq group, at the Sankalakhiri Range along the Thai-Malaysia border. Moreover, the lesson learned is exchanged to interested parties who initiate another project for involving unregistered people.