Questions/Answers

Thailand is a developing country which comprises of 65 million people. 95% of Thais believe in Buddhism. There are 39,481 temples and there are 348,433 monks and Buddhist novices. In the past, temples owned traditional medicine textbooks for people in the community to learn, and the temples also provided herbal medicines to patients. Therefore, temples were like hospitals, since people went to temples when they got sick. “Temples and monks” played vital roles in providing health care to communities. They make health care services equally and inclusively accessible for underprivileged and poor people, regardless of gender, race, and religion. The Population structure has changed due to an aging society. People’s lifestyle transforms to an urban society. Spiritual anchors have become weak within communities. Poverty has become a consideration when obtaining medical services. Hence, supports and developments for temples are improving community spirit. Thai society has been well-known as “a peaceful society” and Thailand has been called “the land of smiles.” This is due to the depiction of temples being a spiritual support for the locals. Department of Health developed the “Health Promotion Temple” project, which has built and developed the “health promotion volunteer monks of the temple, or so-called Phra Khilanu Patthak meaning nursing monk,” to know, understand and have skills in health care service according to their monastic discipline. They can give advices on health care and take care of monks in their temples, as well as communities. Temples became health centers that serve health care to monks and the elderly in the long run, as most of the monks are elderly. Furthermore, this was a project that develops the potentials of leader monks who are spiritual leaders and health care leaders for communities and societies that connect the government, the private and the civil sectors.

"Strong Monks, Stable Temples, Happy Communities” was a health care promotion system emphasizing on connective and integrative self-care in communities. The Department of Health was the major organization driving the policy, developing the knowledge, supporting the operations, and improving potentials of personnel. Monks were coordinators, volunteers, and spiritual leaders who led in providing physical, mental, psychological, social, and environmental care, in order to promote the locals’ well-being. This “monks and locals”-centered project offered healthcare through networks, especially in the areas where the locals could hardly get any medical service, so that inequality is eliminated and social equilibrium is well balanced.

Goal 3 (Good Health and Well-being) and Goal 10 (Reduce Inequality within and among countries) of 2030 Agenda were concerned about. The Department of Health carried out the health promotion temples and followed National Code for Monk Wellness to reinforce good health among monks all over Thailand, underlying the National Health System Code, and goals set by the National Health Assembly. More importantly, monks’ roles as community and society health leaders require five factors including knowledge, information, development, health service, and researches that promote monks’ physical, mental, intellectual, and social well-being, managing the environment to be supportive for well-being, and enable temples to bond with communities. That eventually makes strong monks, stable temples, and happy communities.

(1) Cooperating with agencies involved in “National Code for Monk Wellness” (2) Revising, analyzing, and synthesizing social health problems and roles of monks as the center of community well-being (3) Identifying main objectives and operational strategies for the project, and giving priority to creating “health promotion volunteer monks of temples” (4) Planning and carrying out strategies into practices through workshops, curriculum and training development, and creating primary trainers from every province (5) Frequent visits, outcomes report, and advocating “health promotion volunteer monks of temples” as a project that drives “One Temple, One Hospital/Sub-district Health Promotion Hospital”, the government’s key policy.

“Strong Monks, Stable Temples, Happy Communities” has monks as health care coordinators which makes Thailand able to utilize monks’ health promotion systems and to ease the poor to receive seamless health care, or to ease health care services in every process. “Health promotion volunteer monks of temples” fulfill health care systems that still lacks personnel, service resources, and instruments. This volunteer system provided at temples and in communities reduces the government’s expenses and the locals’ household expenses. Moreover, it makes a positive and supportive environment for communities when temples are perceived as “Temple areas are tranquil areas.” since the locals can do health promotion activities in temples. The locals can exercise, meet fellow elderly people, and spend time in temples during the day, as day care centers. No doubt, when monks are healthy and maintain desirable health behaviors, regarding the monastic discipline, it was strongly expected by the Department of Health that NCDs (Non-Communicable diseases) and morbidity rate among monks and the locals decreased. This caused the department to move the project forward with great hope.

In Thailand context and in Buddhism, monks are clergymen. Monkhood is detailed and there are limitations for their health care service. Monks’ daily lives are based on monastic practices. They do not live in their houses. After they are ordained, they live in temples. So, when they are sick, they do not have a family member to take care of them. They cannot cook by themselves. They do not have income. To eat, they have to receive food from the locals. That means they cannot choose what to eat. As a result, their health promotion is restricted.

- Monks and leading monks were equally encouraged to have good health, skillful and knowledgeable in health care, as well as to be leaders in carrying on Buddhism, developing and teaching morality and ethics, improving the society and communities, being role models for self-care and temple environment, and expanding to the development of community well-being. This will bring the country to security, prosperity, and sustainability. - Local people in each temple’s neighborhood and, particularly, temple cooks were taught about how to cook healthy food with slight sweet, greasy, and salty flavors for monks, to avoid the risks of NCDs. - Temples have health promotion systems and mechanisms that create a healthy environment, to protect temples from health risks and hazards, emphasize on proactive approaches, keep assessing and improving itself to be more effective, centralizing health promotion activities to uphold community health, and helping communities understand health facts and to appreciate good health. - Public medical service centers have a reduced number of bed occupancy rate, so that they can take more emergency patients and more serious patients. - Monks concretely and widely lead their communities in fulfilling and supporting health care learning and wisdom seeking from birth to death.

Phase 1: Many monks suffer from diabetes, hypertension, ischemic disease, and dyslipidemia caused by foods offered by the locals who lack knowledge and understanding about health and are not aware of monks’ health conditions. Also, the monks’ behaviors put them at risk, such as smoking. Accordingly, monks’ main target is to reinforce their life skills and long-life learning skills. The Department of Health, Thai Health Promotion Foundation, Mahachulalongkornrajavisyalaya University, and associate networks worked together to run this project. Phase 2: (1) Coordinating with associate networks, appointing teams for the implementation of well-being development for monks’ activities and for the integrated works with health promotion temples’ sub-committee and nursing monks. (2) Formulating strategies: 2.1 Operating activities for well-being development for monks and health promotion volunteer monks of temples 2.2 Developing monks and novice database 2.3 Implementing Health Literate Temple activities (3) Planning 3.1 Arranging workshops to develop a curriculum for health promotion volunteer monks 3.2 Establishing a press conference to advance and promote 3.3 Organizing workshops to enhance capability of monks from every province 3.4 Encouraging district health centers and health regions to apply the nursing monk training curriculum 3.5 Publishing training guidelines for every province (4) Tracking and evaluating the project to reveal results and support the policy to consider the nursing monk training curriculum a successful project that drives “One Temple, One Hospital / Sub-district Health Promotion Hospital” policy into the government’s 2018 – 2019 Quick Win Projects. Phase 3: Results 1) 17,970 monks were screened. 2) 5,589 temples passed the criteria of health promotion temple screening. 3) There were 4,525 health promotion volunteer monks (nursing monks). 4) Each temple was paired with one hospital / sub-district health promotion hospital. There were 9,753 temples working with 9,504 hospitals / sub-district health promotion hospitals. 5) Moral Communities and the Hands of Home-Temple-School-Medical Service Centers Project was launched in 2,232 temples. 6) Information of 174,091 monks was recorded systematically.

(1) Conducting project and developing the nursing monk training curriculum were challenging. Integrative works with monks, the Sangha Supreme Council of Thailand and associate networks were also applied to create sense of ownership. (2) Many limitations on selecting monks for training were identified, as the operations must be done through the Sangha Supreme Council of Thailand and the National Office of Buddhism. (3) Quality of health care services provided to sick monks, or temple and bed-bound monks was restricted. (4) Nursing monks were sometimes discouraged to work. Related authorities visited the monks for encouraging and improving their skills.

Health promotion temples have the notion of temples as the center of community according to 1T2HC (Tranquility, Hygiene, Health Promotion, Culture, and Cooperation) concept. The 1T2HC strategy consists of the following: (1) tranquility undertaken by preaching and spreading Buddha teachings, (2) hygiene by making temples and temple areas clean and hygienic, (3) health promotion for monks, novices, temple personnel, and the locals, (4) culture, arts, traditions, local wisdom and natural resources and environmental reservation conserved and inherited by the locals, and (5) cooperation from the locals as well as cooperative administration, management, planning, responsibility, and true friendship.

In Buddhism, monks are encouraged to take good care of their health, as said in a Buddhist proverb, “God helps those who help themselves.” In Thailand, Buddhism teachings were the basis of Thais’ ways of life and foundation of our culture and traditions. Monks are the medium for sending Buddha’s teachings, developing moral and ethics learning as well as developing societies and communities. Monks are also crucial to develop temples to be supportive for health promotion and be Health Literate Temples. That means, temples are centers for community health and led by nursing monks.

Conductions of health promotion temples, integrative development for monks’ well-being based on the National Code for Monk Wellness, seamless health care for monks—the specific target group, and operational processes were integrated and transferred to pilot areas and leading monks. The operations within health promotion temples were integrated according to the National Code for Monk Wellness and seamless healthcare. The outcomes of the project were expanded in every health region in Thailand (health region 1 – 12 including Bangkok) and in every region of Thailand; for example, Chiang Mai, Chiang Rai, Lampang, and Sukhothai provinces in the North, Nakhon Nayok and Nonthaburi provinces in the central region, Songkhla and Trang provinces in the South, and Nakhon Ratchasima, Surin and Ubon Ratchathani provinces in the Northeast. Moreover, the project was also developed and applied internationally, such as in Singapore, Vietnam, China and Japan, although there were contextual differences.

Thailand is one of the global Buddhism centers. We formulated the National Code for Monk Wellness. There are a lot of Buddhism organizations in government and civil sectors where scholars, including laymen and monks, move the organizations. We launched a curriculum and a guideline for nursing monk training. We established training centers to convey knowledge and technology. We have model temple for the operations and leading monks for transferring and exchanging skills and knowledge to develop potentials of personnel and associate networks. Training programs and guidelines for the nursing monks as well as knowledge dissemination to develop the relevant participants were provided. Database of nursing monks was developed to be systematic and accessible to the nursing monks and experts to communicate, exchange information and give advice via online channels, such as Line and Facebook, so that they all are well-prepared to give the knowledge and share their skills to any countries that are interested in the implementation of the project.

Budgets were allocated from Thai Health Promotion Foundation, National Health Commission Office, and monastic public and private organizations.. Department of Health also proposed the project to the government for financial support. Regarding human resources and management, a committee of leading monks, monastic networks, and government and civil sectors conducted health promotion temples.. Academic development was supported by universities, such as Mahidol University, Chulalongkorn University, Mahachulalongkornrajavidyalaya University, and Mahamakut Buddhist University. There were training programs in the central and regional levels where experts from Department of Health, Ministry of Health, and other related organizations trained and mentored nursing monks.

Policy advocacy is the main factor driving the project. In addition, the following aspects made the project sustainable: having model areas, leading monks, exchanges of lessons learned, extension of results, personnel and associate networks development, supports of guidelines for the operations, supports in planning operations in local areas, provinces, and health regions, proposing integrative plans to the government for life-long human development and policy for aging society, developing nursing monk database system to be accessible, communication channels for information exchange among nursing monks including Line and Facebook, and formulating integrative operational controls and direction, and evaluation.

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Department of Health and experts from health promotion temples committee assessed the following aspects: (1) duration of and content for the curriculum and training were examined by associate networks; (2) satisfaction of nursing monk training and the curriculum were also evaluated; (3) policy evaluation brought about positive outcomes. The nursing monk training became an essential issue driving the National Code for Monk Wellness, and became a government’s Quick Win which was reported to the government monthly; and (4) evaluations conducted by nursing monks in terms of self-care and health care services to sick monks.

Questionnaires and interviews were used. Questions were examined and tested by experts from health promotion temple committee, regarding content validity. The questionnaire and interview questions covered health condition screening and evaluation before and after trainings, and health promotion operations in practice in communities. Below were indicators: 1) Percentages of satisfaction of the curriculum 2) Percentages of nursing monks’ desirable health behaviors 3) Percentages of health knowledge in various dimensions 4) Number of monks receiving health screening 5) Number of health promotion temples that passed criteria 6) Number of trained nursing monks from all over Thailand

(1) On development of the curriculum, it was suggested that training duration should be separated since it was not practical for monks to stay in some settings for 70 hours at once. The training was 18 hours, and 35 hours, before the monks got back to take the real steps in their areas. Later on, they continued the training until 70 hours were completed. (This depended on readiness in each area.) (2) From questionnaires, most monks were satisfied with the training. When their health competence was examined, it was found that that 71.43% of monks could access to health information 76.19% understood health information; 57.14% could revise and question health information; 59.18% could make decisions concerning health information; 41.61% could get to health behavior changes; and 39.94% could convey health information. (3) Policy evaluation and the training for nursing monks were well-accepted. It became an important policy to push forward the National Code for Monk Wellness, and a Quick Win. The progress must be reported to the government monthly. (4) 17,970 monks’ health were screened. (5) 5,589 temples passed criteria of health promotion temples. (6) 4,525 nursing monks participated the training and the extension is being pursued in every district.

The innovation of nursing monk training curriculum focused on community health promotion. It integrated operations from the policy level to the regional level. Agents getting involved in this project were Department of Health, the Ministry of Health which developed the curriculum, organized training to pass down the policy in health regions, provinces, and local areas. The task to pair “one temple, one hospital/health promotion hospitals” was directed by Department of Health, the Sangha Supreme Council of Thailand, and Thai Health Promotion Foundation. The organizations designed a structure for health promotions and health care services for monks in temples and communities, and supported activities of health promotion temples. The National Office of Buddhism, Department of Provincial Administration, and The National Health Security Office set up a database of monks in each temple and made ID cards while Department of Medical Service, Office of Permanent Secretary Ministry of Public Health screened monks’ health, and National Health Office supported and drove 2017 National Code for Monk Wellness. Health region offices, and provincial public health offices implemented “one temple, one hospital/health promotion hospitals” by selecting temples and hospitals to join the project, arranged training in their areas, gave advises, and supported their works.

This development of service innovation “Strong Monks, Stable Temples, Happy Communities” was achieved by adapting PIRAB health promotion strategy of the Bangkok Charter: 1) P: Partnership: Persuading alliances from every sector and level to be aware of the importance of sustainable health promotion for monks and all groups of Thai people, especially identifying health issue as a crucial issue included in every health policy. 2) R: Regulations and legislation were imposed to protect citizens from any health risks, particularly in this project, the National Code for Monk Wellness was the core. 3) A: Advocating, guiding and encouraging every level of politics to place importance on health promotion as regards human rights, equality, and cooperation from every sector. 4) B: Build capacity of personnel in every sector to be capable for developing policies concerning about health, doing research and giving knowledge to citizens to make them knowledgeable about health and health care for monks and for themselves, so that communities are able to promote monks’ well-being in accordance with the government policies.

- Training should prioritize religious matters over mundane ones, and time flexibility. - Health services and social welfare for monks should be done with respect to nursing monks’ way of life, their backgrounds and communities, and also environment that harmonize with their lifestyle. - Service provisions must be integrated with different fields, such as traditional Thai medicine wisdom and massage, and supported using herbs that are useful and easily found. - Innovations should encourage cooperative learning, rather than giving, so that citizens, especially vulnerable, understand and can help themselves. Also, communities can take parts, which was agreeable with the SDGs. Development leading Thailand to “Security, Prosperity, Sustainability” through “Strong Monks, Stable Temples, Happy Communities”