Questions/Answers

Prior to 1970s, the majority of Thai populations lived in rural areas, being poor farmers. Although more than 80% of diseases were not complicated and could easily be prevented and cured, people could not access to basic public health services to inadequate number of public health facilities and health personnel. Less than one third of Thai population can access to basic health-care services. In late 1970s, Thailand adopted the Alma-Ata Declaration. This became the starting point of Thailand for Primary Health Care (PHC) development. The national policy aimed for rural development; the infrastructure development since 1970s led to full geographical coverage of PHC in particular in rural area. The PHC had been well functioning by adequate number of competent and committed health workforce together with Village Health Volunteers (VHV). The strength of Thai public health system lies in VHV network and community based activities in response to disasters and health issues. VHV is a link between people and health personnel and drive public health work at community level. As a result, the initiative not only enables healthy and safe communities, but also reduces vulnerabilities and strengthens resilience. The Department of Health Service Support (DHSS), having central and regional agencies, cooperates with provincial public health offices of each province and VHV of all levels. DHSS is responsible in strengthening the PHC system by improving competencies of more than 1 million VHV covering every village for handling health crises.

DHSS has been working with Health Network Association and various organizations to promote and support the strength of VHV system using VHV fostering mechanism. Currently, over 1,050,000 VHV are the focal point in taking care of people’s health, supporting health personnel in managing and handling health crises such as dengue fever, avian influenza, novel coronavirus 2019 and etc. DHSS advances VHV capacity through ‘VHV 4.0’ program so that they can deal with dynamic changes in technology and in patterns of illness – people in particular health risk-related diseases.

VHV contributes to achieving SDG3, ensure healthy lives and promote well-being for all especially target 3.3. VHV play active role for surveillance, prevention and control of diseases in communities. To prevent the spread of AIDS, the volunteers promote condom used for villagers and increase understanding of transmission. Additionally, the volunteers prevent the spread of liver fluke by find a risk group, planning and providing knowledge to people in communities, as well as visiting and taking care of patients at home properly. VHV also contribute to achieving target 3.8 to achieve universal health coverage (UHC), financial risk protection, access to quality essential health-care services and affordable essential medicines and vaccines for all by bridge villagers to health officers. Thailand has achieved UHC since 2002. All Thai people can access health-care services under the UHC schemes. Apart from SDG3, their contribution is to SDG11. During health disasters including COVID-19 outbreak, the VHV prevents and controls the diseases at the front line. They have conducted door-to-door visits for health education, active case finding, disease surveillance, quarantine, and even made cloth masks for the people. They have left no stone unturned in the quest to control COVID-19.

The VHV can catch up with societal dynamic, the implementation of VHV is specified in the Twenty-Year National Strategy. This strategy not only enhances digital literacy of VHV to become ‘VHV 4.0’ who can adopt advanced technology for their duties, but also strengthen health literacy to become a lead role in changing locals' health behavior. Therefore, the volunteers can encourage people to take care of their health and leverage local’s quality of life by utilizing community resources and the collaborative efforts among authorities of all sectors to achieve sustainable development, while leaving no one behind.

As a main mechanism for maintaining health and improving quality of life, with over 1.05 million VHV, each volunteer can take care of 15-20 households on average. As a result, all households in the country can access primary health care services thoroughly and equally. A local primary health care center is established as a workplace for the VHV to perform their duties and support health personnel to provide primary health care services such as first aid, screening for diseases, public health information, and health advice. Health leaders are selected by each household called ‘Family Volunteers’ as a representative of their family to take care of chronic non-communicable disease and bedridden patients together with VHV. View in this way, VHV acts as coach throughout the process. Recently, health volunteer systems expanded to migrant group. VHV collaborate with Migrant Health Volunteers (MHV) to take care of the health of migrants who live in Thailand. As a result, healthcare services are provided to everyone who lives in Thailand thoroughly and equally.

Among 1.05 million VHV, over 804,174 (78%) are female. It is easier to care among women and children, VHV search for new pregnant women in order to make a list and send it to health officers. Also, they give the advice on being under prenatal care within 12 weeks, as well as the advice on self-care during the pregnancy. Finally, after pregnancy, the VHV will give advice on and promote breastfeeding. As a result, women and girls have received PHC services thoroughly, particularly children and adolescents under the age of 15 who get pregnant unintendedly and pregnant women.

DHSS promote VHV to care disable people, underprivileged people with dependency, bedridden, chronic disease and non-communicable disease patients. VHV can provide appropriate information for patient to get access to health services as needed. Their advices, though basic information, cover various aspects including 1) physical care, for example, appropriate food, right medicine and exercise based on physical conditions; 2) mental care, for example, mental health evaluation using ST5, advisory services, suggestion of channels or tools for mental health care; 3) social relations, for example, having equal participation in social activities that are suitable for physical conditions; and 4) environment, for example, arrangement of appropriate physical surrounding for patients and infectious waste management. As a result, 92.43 % of target people have better quality of life and the total number of Family Volunteers throughout the country is 1,671,496.

The 1st period (1977-1996): VHV networks were developed so that people can access UHC. Community primary health care centers were promoted to use as a place to provide primary health care services and essential drugs to people in the community. The associations of Village Health Volunteers at all levels were formed. The 2nd period (1997-2016): the role of volunteers was advanced so that they could address chronic health problems and work with association networks to create healthy community. As a result, in 2015, the Department of Health Service Support won the award for the best participative government management. Family leaders were formed and developed to take care of fragile groups including 1.67 million of bedridden patients, disabled people and under-privileged people. The 3rd period (2017-present): the volunteers have been advanced to become ‘VHV 4.0’ who have skills of digital technology use and the abilities of CPR, be ready to handle health crises in communities. The volunteers can x-ray and screen risk groups to surveillance and prevent avian influenza. Since, the outbreak of COVID-19 occurred in Thailand at the beginning of 2020, the volunteers have a main role in handling the pandemic. About 7.5 million Thai people were instructed on how to maintain proper personal and public hygiene. About 3.6 million cloth face masks were made by VHVs, 14.07 million households across the country were called on to receive the COVID-19 messages. More than 1 million - or 98% of all – Thai people, who were newcomers to the villages during the said period, were isolated, home quarantined with daily monitoring for 14 consecutive days; and 3,200 cases were referred to hospitals due to developing symptoms suggestive of active COVID-19 infection.

The key obstacles while implementing the initiative are: The crisis cannot be predicted in terms of when and how it will happen. The crisis requires a swift response from various stakeholders to cope with it. Preparing essential human capital and tools is considers to be the best. DHSS handles the aforementioned problems by providing online platform to inform and communicate with volunteers and strengthen VHV to become VHV 4.0 who can use digital technology, obtain health literacy, shift mindset and be a leader of health changes. How to response crisis situations.

The application ‘AorSorMor Online (VHV Online)’, a collaboration between DHSS and private company (AIS), is Thailand’s public health application that was awarded the ITU & UN prize. This application indicates that Thailand has brought digital technology innovation to improve its public health system and raise people’s quality of life. It focuses on sustainable development of all sectors since community public health is necessary for local people who live in remote areas. The connection will be an important tool to raise the standards of people's life, and will promote the liaison among local health officers and VHV for better performance.

The inspiration of this innovation is to use digital technology as a tool to promote and maintain people’s health and well-being, improve the standard and efficiency of public health services, diminish inequality in the society and provide the access to public health services for people in remote areas. ‘AorSorMor Online’ Application, an online network for primary care units, staff at sub-districts’ health promoting hospitals (or health center) and VHV can increase efficiency of and improve their performance. With better health outcomes of people, this would decrease the government’s expenditure on health.

Using ‘AorSorMor Online’ Application as a tool to promote and maintain people’s health and well-being will lead to more efficient public health services. The goals of the Ministry of Public Health are healthy people, happy officers and a sustainable public health system. The Ministry focuses on applying technology to maintain people’s health in the form of services that implement the development of health information technology of Thailand. The collaboration between public and private sectors is needed so that Thailand’s public health system will be driven by beneficial innovation. That will lead to a solid eHealth and digital public health.

Thailand has used Primary Health Care’s strategies to adapt for various situations as follows: 1. Migrant Health Volunteers (MHV): Migrants in Thailand were important for driving the country’s economy. It was estimated that there was at least 3 million migrants in Thailand, so it was the destination country’s responsibility to give social and health care rights to maintain their health without any discrimination. MHV was formed in 2015 and has been constantly developed. They have worked with other volunteers to maintain good health of migrants in communities. Currently, there were 5,214 MHV in 18 provinces. In 2020, amid the COVID-19 pandemic, Thailand had MHV playing an important role in controlling the spread of the disease in border areas efficiently. 2. Prison Health Volunteer (PHV): An increasing number of inmates in limited space in prisons created overcrowded and unhygienic conditions which could eventually become disease reservoirs. Therefore, the Department of Health Service Support, together with the Department of Corrections, had made suitable inmates become Prison Health Volunteers (PHV). They have been trained and learned how to use primary health care strategies in prison areas and been able to monitor other inmates and prevent contagious diseases.

Concepts, models and performance lessons have been conveyed to other countries such as Laos that applying the Village Health Volunteer’s development pattern to its primary health care services in order to solve the problem of uncover health coverage, communicable disease surveillance and other public health problem solving. There was a discussion on the public health cooperation between Thailand and Laos and a memorandum of cooperation of the two countries was made on 16 September 2016 at the Royal Orchid Sheraton Hotel, Bangkok. In addition, ASEAN Institute of Health Development (AIHD), Mahidol University, together with Thailand International Cooperation Agency (TICA), Ministry of Foreign Affairs, arranged an international online training course entitled “International Online Training Public Health Measures and Adaptation of Thailand for Emergence of COVID-19” during 27 July – 14 August 2020 in order to convey the implementation of handling COVID-19 pandemic to 62 public health professionals at intermediate and high levels of various countries on the topic of “Village Health Volunteer as the Key Strategies to Prevent and Control for COVID-19 in the Communities”. It was indicated that the Village Health Volunteer was a main strategy for the prevention and control of COVID-19 in communities.

1. Manpower: 180 personnel under the Department of Health Service Support, over 1.05 million Village Health Volunteers, and over 12,000 local health officers 2. Budget: 46 baht ($1.5)/person/year including the COVID-19 allowance for 60 baht ($2)/person on average. 3. Instruments: mostly supported by local administration organizations and private sectors in the case of COVID-19 pandemic, by the way, the Department of Health Service Support purchased instruments to support the volunteers in the amount of 18 million baht. 4. Technology: digital technology was used as a tool for the volunteers’ performance such as the application ‘Smart VHV’, ‘AorSorMor Online’ and ‘PhonPhai’.

1. VHV were strong, trusted by the locals, ready to perform their duties when health crises occurred, well-developed continuously, and trained for the case a volunteer was passed away or resigned. 2. There was a local agency responded and solved crises according to the duties prescribed by the law including local administration organizations, local health officers and community leaders, as well as supported manpower, budget and instruments. 3.The government had a policy and agency responding for this directly that was DHSS that has developed the volunteers’ abilities and supported their performance.

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The study of factors related to avian influenza surveillance, prevention and control of VHV residing in Muang District, Suratthani Province was the evaluation of the volunteers’ roles in avian influenza surveillance, prevention and control. Suratthani Hospital conducted the cross-sectional survey research. The sample group was VHV who had been working for over 2 years, were able to read and write and willing to answer the questionnaire. The questionnaires were distributed to the sample – 380 VHV in Suratthani, and the performance data about COVID-19 surveillance and prevention of the volunteers.

An indicator of implementation achievement were Village Health Volunteers had the knowledge about handling health crises and their performance of it. The evaluation instrument was a questionnaire asking the volunteers about the knowledge on avian influenza surveillance, prevention and control and the belief on their ability to do so, social support, and the volunteers’ implementation of COVID-19 prevention. The instrument for data collection was the volunteers’ performance report. The volunteers would report their performance to local health officers so that the officers would record the data via the website: http://www.thaiphc.net/new2020/

The results revealed that the village health volunteers had good knowledge on the Avian Influenza’s surveillance, prevention, and control procedures (xˉ=12.34).The belief on their abilities showed at high level (xˉ=8.39). The social support receiving also appeared at high level (xˉ=2.66).The belief on their abilities had statistically significant with surveillance, prevention, and control the disease (p value = 0.018). Moreover, the social support receiving was moderately statistically significant related to surveillance, prevention, and control the disease (p value < 0.001). The results from this investigation will be used for considering guideline for surveillance, prevention, and control Avian Influenza by the village health volunteers. During the COVID-19 pandemic crisis, about 7.5 million Thais were instructed on how to maintain proper personal and public hygiene. About 3.6 million cloth face masks were made by VHVs, 13.8 million households across the country were called on to receive the COVID-19 messages. More than 1 million - or 98% of all – Thais, who were newcomers to the villages during the said period, were isolated, home quarantined with daily monitoring for 14 consecutive days; and 3,200 cases were referred to hospitals due to developing symptoms suggestive of active COVID-19 infection.

The success of the project caused by the collaboration of various agencies starting from the process of Village Health Volunteers’ potential development to prepare for handling crises. The Department of Health Service Support as a focal point has cooperated with relevant agencies to develop learning programmes and materials. The Department of Disease Control, National Institute for Emergency Medicine and Thai Red Cross Society developed an application to use as a tool for the volunteers to inform disasters and request for help. Also, Advanced Info Services Public Company Limited (AIS) developed the application “OrSorMor Online”, winning the WSIS 2017 Prizes Winner Award from ITU & UN, to use as a tool for the volunteers’ performance. In addition, there were the development of online questionnaires to survey people’s opinions and behaviours throughout the country every week during the outbreak for the consideration of easing measures, creation of memorandum of understanding, distribution of resources from donors to the volunteers, and regular teleconferences for following situations and supporting the volunteers’ performance. At a local level, local health officers, local administration organizations and community leaders gathered resources, issued community measures, managed crises, evaluated the performance and reviewed lessons gaining from their work.

Stakeholders have worked together systematically for the project’s implementation starting from 1) the Department of Health Service Support which have its affiliated agencies at both regional and district levels has developed the potential of Village Health Volunteers (VHV 4.0), founded the Emergency Operation Centre (EOC) to analyse the crises of the country in overall, designed and formulated strategies to handling problems according to government policies, made decisions, coordinated with other agencies, provided and followed up resources requested from local areas, collected, analysed and distributed information, followed situations and evaluated the project implementation, 2) public health agencies and the Village Health Volunteers Association at the provincial and district levels have participated in analysing problems, designing solutions based on central policies and situations in the area, providing necessary resources to the volunteers to evaluate the performance, and 3) the volunteers have solved the community problems with local agencies including local health officers, local administration organizations and community leaders, examined situations in the area, designed solutions according to local policies and conditions, gathered resources from different sources, performed the action of crisis prevention and control, and evaluated the implementation achievement.

What we have learned from the project implementation were factors of the success including 1) Village Health Volunteers who have been developed their potential continuously for over 40 years to prepare for handling health crises that may occur any times, 2) the collaboration among the volunteers who have been selected and trusted by villagers to form an association for the effective operation system, 3) the cooperation of various sectors at policy and operational levels consisting of local health officers, local administration organizations, community leaders, and villagers who shared the same problems, as well as measure issuance and its strong implementation to handle those crises, especially for the outbreak of avian influenza and COVID-19 and 4) the use of digital technology as a tool for the implementation leading to effective and faster problem management. The preparation of the project needed in-depth problem learning, management methods, appropriate strategies, clear communication, careful implementation, right, fast and reliable data and adequate resources, as well as the effective system of remedy and emergency operation centre (EOC) for those who were affected by their performance. It focused on the participation of relevant agents in order to create the strong and sustainable implementation.