Questions/Answers

Ethnic minorities in Thailand have been struggling to be recognized by law as Thai citizens. Although Thailand has given legal statuses to some ethnic groups, they are still left ostracized as “others” or “second-class citizens” whose rights are unequal to those with Thai citizenship, due to their ethnicities, language and cultural barrier, physical distance, and prejudice. Women of ethnic minorities are faced with even more complex and severe issues as they are more socially excluded due to their gender. All of these factors are social determinants of health that affect the livelihood of ethnic women. According to a study on ethic women’s experience and access to justice conducted by the Law Reform Commission of Thailand, it was found that women of ethnic groups suffered health problems as they had difficulties in accessing health services due to their legal status and language barrier, while many fell victim to human trafficking. With the goal to reduce or even eliminate social exclusion factors that spawn inequality in health for ethnic women, ThaiHealth, together with Pang Mapha Hospital, Faculty of Public Health, Thammasat University, and community leaders of ethnic women, has developed a health service model that is friendly to ethnic women, taking into account gender sensitivity and ethnic diversity, which was piloted in Pang Mapha Hospital, Mae Hong Son Province.

Our user-friendly health service model for ethnic women aligns with Category 5 of the UNSPA (Promoting gender responsive public services to achieve the SDGs). We focus on developing a user-friendly health service model aimed to be scaled up to other provinces or nationwide, in order to ensure equality in accessing public health services friendly and sensitive to ethnicity and gender diversity, by enhancing the capacity of hospitals and other healthcare institutions on providing health service for ethnic women as well as engaging them into the process of model development.

Our user-friendly health service model for ethnic women prevents ethnic women from being discriminated based on their gender, nationality, ethnicity, language, or culture. This is in line with the SDG 5: achieving gender equality and empower all women and girls. By engaging ethnic women to be part of capacity building programs for healthcare institutions, it is further ensured that they would have equal access to sexual health and reproductive health service as ethnic men or women with Thai nationality.

The model is socially, economically, and environmentally sustainable. On the social aspect, the process of model development engaged multi-sectoral stakeholders including healthcare providers, ethnic women, and civil society organizations, with a strategic plan to create momentum for policy advocacy on the national platform. Economic-wise, the model helps reduce cost of transportation for ethnic women, usually living far away from healthcare institutions, by expanding health promotion and preventive care more into their neighborhood. Lastly, the model requires modifying the environment of hospitals to fit ethnic women’s needs, e.g. providing private space for breast-feeding or performing postpartum rituals according to their belief.

Ethnic minorities’ accessibility depends hugely on public health personnel’s understanding of their languages and culture. For a long time, there had been no practice guideline for ethnicity- and gender-sensitive healthcare, while many modern medical services are opposed to their traditions and ethnic women could not communicate in Thai, the official language of Thailand. Therefore, user-friendly health service model for ethnic women has been developed in order to help enhance capacity of hospitals as organizations as well as healthcare staff, while also deepening their understanding towards ethnic women to ensure their accessibility to decent and equal healthcare services.

Due to their cultural beliefs along with their gender as women in their cultural context, most ethnic women usually would not seek healthcare service from formal healthcare institutions. Therefore, we focused on facilitating friendly environment and service for ethnic women, with hopes to eliminate barriers and attract them to hospitals. Such attempts include sensitizing workshop for healthcare personnel as well as capacity building programs, creating practice guidelines, developing ethnic interpreters to help with communication between ethnic women and hospital personnel.

As we piloted the model in Pang Mapha district, 609 ethnic women who has been in the program were satisfied with the service. They also showed to have better understanding in general health and reproductive health, through our education model which incorporate both modern medical and traditional healthcare approaches in order to reduce friction between the two.

Thai Health Promotion Foundation (ThaiHealth), together with Faculty of Public Health Thammasat University, Pang Mapha Hospital, and community leaders of ethnic women, has developed a health service model that is friendly to ethnic women, in order to eliminate obstacles, which prevent ethnic women from accessing healthcare services. Such barriers include differences in language and culture between service providers and ethnic women, physical distance between healthcare institutions and where ethnic women live, and healthcare personnel’s negative attitude towards ethnic minorities. In order to solve the problems, we have adopted the “Tri-power strategy” which includes (1) knowledge creation, (2) social mobilization and (3) policy advocacy, to guide our implementations: 1) Conducting a survey on ethnic women’s access to general health and reproductive health services to generate baseline data. 2) Developing capacity building program for ethnic interpreters and community leaders to be able promote proactive preventive healthcare and health promotion in their communities, as well as to coordinate between healthcare personnel and ethnic women. So far 79 ethnic interpreters/community leaders have been in the program. 3) Enhancing capacity and sensitizing healthcare personnel. So far 44 healthcare workers have been in the program. 4) Developing a standard operation procedure (SOP) sensitive to gender and ethnicity for health practitioners and other staff in hospitals. 5) Producing communication tools, e.g. health education posters, audio media for ethnic women, and signs and notices to assist ethnic women in hospital. 6) Conducting proactive outreach health promotion activities and preventive health care in remote area. 7) Modifying the hospital’s environment to accommodate ethnic women’s needs, e.g. private space for breast-feeding or performing postpartum rituals according to their belief.

Ethnic interpreters play an important role in healthcare service for ethnic minorities. Currently most ethnic interpreters in hospitals are volunteers, although there are costs incurred from providing such service, e.g. transportation fee, communication fee, or opportunity cost, etc. We have developed policy recommendations based on lessons learned from ethnic interpreters’ volunteer activities, which will be utilized to advocate for budget allocation for ethnic interpreters.

The Ethnic Women Friendly Health Services was developed to fill in the gaps, eliminate obstacles, and accommodate ethnic women’s needs to have equal access to health services. Adopting the bottom-up approach, we conducted a participatory action research (PAR), engaging women of four ethnicities: Karen, Lisu, Shan (a.k.a. Tai Yai), and Hmong. The collected data from the research was then used by researchers, Pang Mapha hospital’s executives and staff to develop the user-friendly health service model for ethnic women. Principal components of the model include working groups, practice guidelines, sensitized healthcare workers and staff, ethnic interpreters, communication tools, and friendly environment.

This user-friendly health service model for ethnic women was developed based on existing friendly health service models for other target populations adopted by public hospitals, which, however, have not addressed the complex issues relating to intersectionality of gender and ethnicity.

The model has not been implemented in other contexts/areas yet.

After piloting the model in Pang Mapha hospital, we found that the model increased the number of ethnic women who went to receive health service at the hospital by 22.2% or 358 persons (data as of 31-05-2019). The overall satisfaction of ethnic women also prompted formation of a technical working group under Pang Mapha district’s Quality of Life Development Committee, to synthesize lessons learned and develop policy recommendations regarding expansion of model implementation to other areas or contexts with similar issues.

The process of developing user-friendly health service model for ethnic women took 24 months and costed 2,259,000 baht, which was spent on the participatory action research, community members’ capacity building program, healthcare workers and staff’s capacity building program, developing practice guidelines, developing communication tools, and modifying the hospital’s environment. The process of the project also ensures participation and engagement of ethnic women leaders, community leaders, Pan Mapha hospital’s executives and staff, civil society organizations which work in the areas, and Faculty of Public Health, Thammasat University.

On the demand side, the bottom-up approach which take ethnic women’s voice into account ensures that the model truly accommodate their needs, and thus enhance sustainability of the model. Moreover, on the supply side, the hospital’s executives and staff members understand the importance of the issue and want to improve their service to ensure equal access to health services for ethnic women. Additionally, Pang Mapha district’s Quality of Life Development Committee also understands the importance of the issue and desires to utilize lessons learned from the pilot project to develop the district policies to ensure the sustainability of such services.

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The pilot project was evaluated by a lecturer/researcher from Boromrajonani College of Nursing Nakorn Lampang, using the 4P model and empowerment evaluation approach to collect data according to the project indicators on output, outcome, and impact level. Data on contextual factors and implementation were also collected and analyzed to indicate success factors, while also empowering the project’s staff members.

The evaluator adopted the 4P model to evaluate the pilot project. Data were derived from empirical evidence, in-depth interviews, and focus-group interview. Important indicators include increase in number of ethnic women who had access to public health service and social welfare, number of healthcare workers and staff members who took part in sensitizing workshop, etc.

According to the evaluation result, it was found that the pilot project’s performance exceeded its goals. Overall 44 healthcare workers and staff members now understand gender norms and cultural factors that affect ethnic women’s lives, and understand what user-friendly health service for ethnic women means. 79 ethnic interpreters were trained to be able to conduct health promotion activities and preventive health service in remote area, and to coordinate between healthcare providers and ethnic women who cannot speak Thai. As a result, the number of ethnic women who had access to health service was increased by 22% or 358 persons (data as of 31-05-2019).

This user-friendly health service model was developed with cooperation between organizations from various sectors: Pang Mapha district public health office was in charge of policy advocacy; Pang Mapha hospital was responsible for developing tools and facilitating mechanisms for the health service; Faculty of Public Health, Thammasat University along with civil society organizations such as Ethnic Minority Development Foundation (มูลนิธิพัฒนาชนกลุ่มน้อยและชาติพันธุ์) conducted research and develop capacity building programs for ethnic women leaders and healthcare workers, while ethnic women and community leaders also took part in the research and help develop communication tools.

To ensure equal access to health services for ethnic women in Pang Mapha district, ThaiHealth together with Pang Mapha hospital, Faculty of Public Health, Thammasat University, and other partners, formed a working group to develop user-friendly health service model for ethnic women by engaging ethnic women and their community leaders throughout the process: (1) Faculty of Public Health, Thammasat University was in charge of synthesizing knowledge, developing capacity building programs for ethnic interpreters, conducting PAR, facilitating public health activities, as well as sensitizing healthcare workers and staff members on gender and ethnic diversity. (2) Ethnic women leaders and community leaders participated in the PAR in order to indicate the gaps, obstacles, and needs of ethnic women in accessing healthcare services. They also took part in developing practice guidelines for healthcare workers and communication tools. (3) Pang Mapha hospital’s executives and staff members, along with the district public health officer were responsible for developing practice guidelines and communication tools, as well as conducting capacity building program fore ethnic interpreters on conducting health promotion activities and preventive health service. (4) Civil society organizations, e.g. Ethnic Minority Development Foundation, together with ethnic women leaders, helped advocate policies through Quality of Life Development Committee.

The pilot project can potentially be scaled up and expanded to other healthcare institutions and hospitals to ensure equal access to health service for ethnic women in the area. Looking back, we learned that these factors/approaches played important roles in improving health service to be more friendly and sensitive to ethnic women, which led to ethnic women’s satisfaction of the services: (1) Tri-power strategy: (knowledge creation, social mobilization, and policy advocacy). (2) Engage target population (i.e. ethnic women and community members, in this case) throughout the process, and listen to their voices to understand their needs and problems. (3) Identify common interests with health service institutions and work on those issues. In this case, Pang Mapha hospital wanted to proactively alleviate unequal access to health service in the area. (4) Engage local stakeholders and create sense of ownership.