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Symposium Paftnens and SuPpofters

lrlahidol University gratefully acknowledges the paftnerc and supporterc of the International Symposium on 'Global Health: Borderless Movement of Diseases"
The ASEAN Institute for Health Development (AIHD),

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tapan International Cooperation Agency

World Health Organization Regional Office for South-East Asia

lletwork for World Health Organization Collaborating Centres and Centres of Expeilise in Thailand (ilEw-CCFr)
ASEAil Foundation (through the Japan'ASEAN Solidarity Fund)

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THAILAI|D Convention and Exhibition Bureau

Commission on Higher Education, Thailand

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the 25h ann the

Table of Contents
Schedule of the International Symposium on "Global Health: Borderless Movement of Diseases"
1

Poster presentations Report to Chairman Welcome Address Opening Address

6 7

I
10

The

21* Annual Natth

Bhamarapravati Special Lecture

11

Professor Natth BhamaraPrauati

12

Professor Yasuhide Nakamura

Intemational Collabontbn leading to
Honorary speech

t4 Halth
for

All

L7

IntemationalHealth S*urity: A Bridge for

Keynote Speech

Peace

25

Health, Poverty Alleviation and the Sufficiency Economy

in Thailand

29

The 120h Anniversary of Japan-Thailand Diplomatic Relations:

Emergence of Community Eye Care in Thailand
AIHD'S 25 Years of Success: Health for All 51 73 77

Section

Infectious Diseases

Section 2 Health Care and Management Emerging and Reemerging Diseases: Threats and Challenges Delegates, Participants and Contacted Addresses Organizing Committee

r27
195 199

209

Schedule cf ttre Intermatisnatr Symposium cm "Gfsbal Health: B*rderless Movement of Diseasesu'

N*vernber 2**3$, 2**7
Thursday 29*, November 2007

07.30-08.30 08.30-09.30

Registration

Opening CeremonY
Chairman

Professor Pornchai Matangkasombut

RePoft to the Chairman

Assaciate Professor Sirikul fsaranurug

Director, ASEAN Institute for Health Development Welcoming addresses bY

Ambassador Extraordinary and Plenipotentiary of Japan to the Kingdom of Thailand

His Excellency Mn Hideaki KOBAYASHI

&

Permanent Secretary, Ministry of Public Health

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Director-General, TICA

Dn Prat Boonyavongvirot

y'chi:r.i:

-Pin'n":! Former WHO Regional Country Representative to Thailand

Dr, Brian Doberctyn

Opening address by the Chairman

Professor Porncha i Matan gkasombut

President of Mahidol UniversitY

09.30-10.00 Honorary speech

International Health Security: A Bridge for Peace
Dr. Samtee Ptianbangchang
WHO Regional Director of the South-East Asia Region To be delivered by

Associate Professor Dr' Orapin Singhadei

Secretary-General Network for WHO-CC and National Centre of Expertise in Thailand

Thursday 29s, November 2(Xl7

10.00-10.30

CoffeeBrealVPoster Presentations

10.30-12.00 KeynoteSpeech Health, Povefi Alleviation and the Sufficiency Economy

in

:::::11 Dn Kraae Chanawongse Prcfessor a- .,__ * _ ,,-__Ramon Magsaysay Awardee for Community Leadership

12.00-13.00 13.00-13.45

Lunch

The 120th Anniversary of Japan-Thailand Diplomatic Relations

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Associate Professor, School of Medicine, Juntendo University

13.45-14.30

AIHD'S 25 Years of Success: Health for All

:*""on :::":": for Health Development Director, ASEAN Institute

14.30-15,00
CoffeeBrea(PosterPresentations

on siri*a! rTranurus

15.00-17.00 Breakout Sessions

Section

Infectious Diseases

Chairpersons:

Dr. Khine SabaiLatt Dr. Donald Persons

Integrated Health Delivery System in the District Health System Based on Primary Health Care: A Case Study of Thailand
Experience

Dr. Jumroon Mekhanoon

HIV/AIDS Awareness and Risk Behavior Among the Tea Garden Workers of Bangladesh
Associate Professor Dr, Giasuddin Ahsan

Channeling Mataria Information: Local to Global Implications

Dr. Tin Oo
Long-Term Protection against Japanese Encephalitis by Using a Single Dose of SA 14-14-2 Vaccine: A Case-Control Study in Nepalese Children. Dn J,B, Tandan Gender Sensitlve Tuberculosig Control Rural Bangladesh Associate Profecsor Dr. Giasuddin

Interention Study in

Ahnn

Thursday 29s, ilovember 20O7

15.00-17,00 Breakout

Seseions

Section 2 Health Care and Management

ChairPersons

Associate Professor Dr. Boonyong Keiwkarnka

L

ecture r Sa kes n SiriPh a du n g

An Assessment of the Perception of Remote Communities about

Indigenously Developed Human Resources in Health

Dn fmran Hameed
Assessment of Nutritional Status of Under-Five Children and

so""ritv n"friUifit"iion Program (FSRP) in n-ukum District, Nepal Associate Prcfessor Jagat l{an Shrestha
A Collaborative Training Programme on Leadership and Ms. Nguyen Bich Luu

Pregnant Mothers in Communities Benefiting from the Food

Management Devetopment for Nurses in Vietnam, 2004-2006 Perception of Active Listening among Doctons
Dn fmran Hameed

Promoting a smoke free regutation in the National University of

Laos

Dn Angkham Ounavong

oflrlutrition through nfmaV Health Care and Ilp1_oyeA"nt Nutrition Education/Public Awareness
Dn Zahid Larik

17.O0-onward AlumniMeeting

18.00-21.00

Welcome Dinner

Frlday 3On, ltovember

20bl

The 21* Annual Natth Bhamarapravati Special Leture

International CollaboraUon Leading to Health for All Prcfessr Dn Yasuhide Nakamura

Professor, Graduate School of Human Sciences, Osaka University

10.00-10.30 Coffee Break/Poster Presentations 10.30-12.00 Emerging and Reemerging Diseases: Threats and challenges Dn Chaiyos Kunanusont
Advisor, UNFPA CST Bangkok

12.00-13.00

Lunch

13.00-14.00 culture, Migration, and the Bordedess Movement of Diseases Dn David Feingold
Directror, Ophidian Research Institute

International Coordinator for HIV/AIDS and Trafficking, UNESCO Bangkok

14.00-14.30 Coffee BrealdPoster Presentations 14.30-15.30 HonorAwardsCercmony

15.30-16.00 Closing Ceremony

Prcfessr Krase

Cha na

wongre

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paper

1 2

Current Situation of Nosocomial Infection (NI) Management in China Analysis

Wang Shuhui

paper

Investigation on complying with medication regimentf - . receiving health education and life style of patients with hypertension in hosPital and communitY Chen Ai ping
A way

Paper

3 4 5 6 7 8 g

to success of BRAC TB Program in Afghanistan

Taufigur Rahman

paper

primary health care as a bridge for peace in delivering health care in conflict situation Dr Babu Ram Marasini
Evaluation on Management of Day Care Services Provided by Local Government Organization ASEAN fnsfitute for Heatth Development (AIHD)
Condom Use Among Most at Risk Population in Bangkok' 2O07
ASEAN

paper

Paper

Institute for Heatth Development (AIHD)

Paper

Condom UseAmong BangkokStudents, 2002-2006

ASEAN

Institute for Health Development (AIHD)

paper

Emotional Developrnent and Nutritional Status of HIV/AIDS Orphaned Children Aged 6 to 12 Years Old in Thailand ASEAN fnstitute for Health Development (AIHD) Promotion of Utilization of Maternal and Child Health Handbook by Village Health Volunteers ASEAN Institute for Health Development (AIHD)

paper

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I-[onored President of Mahidol University, Professor Dr. Pornchai Matangl<asombut, His Excellency tlre Arnbassador of Japan, His Excellency Mr. Ilideaki KOBAYASIIt, Former WFIO Regional Country Representative to Thailand, Dr. Brian Doberstyn, E,steemed Permanent Secretary of the Ministry of Pubic Flealth of Thailand, Dr. Prat Boonyavongvirot, Japan International Cooperation Agency (Thailand Office) Resident Representative, Mr. Katsuji ONODA, Thailand International Cooperation Agerrcy Director-General, Mrs. Chitriya Pinthong, Honored Founder of the ASEAN Inslitute fbr Health Developnrent and Ramon Magsaysay Awardee, Professor Dr. Krasae Chanawongse, esteemed colleagues at the ASEAN Institute fbr Health Developrnent. faculty, alumni and current students, Flonored benefactors and donors, honored guests, ladies and gentlemen.

It is my great honor to welcotne you to the ASEAN Institute for Health Development's International Symposium on Global Health: Borderless Movement of Diseases. During the past 25 years, the ASEAN Institute for Health Developrnent has played a significant role in human capacity bLrilding for primary health care management. The successlirl work of AIHD has prodLlced graduates and training courses for participants playing important roles in policy development, prirnary health care management, and health leadership in government and non-government roles and in national and international contexts as well. During that tirne the ASEAN Institute for Health Developrnent has been at the fbrefront of education and research on integrated development for primary health care in the region and has been recognized for its role and standards by the World Health Organization and by the Japan International Cooperation Agency ol' the Government of Japan. Through the support of our partners across Asia and irrdeed the
world, we have contributed significantly to each nation's pubic health infiastrr,rcture and
development. We are pleased to hold the international sytnposiuur in commemoration o1'the celebration of the 25rr'Anniversary of the ASEAN lnstitute for Heatth Development and the 120'r' Anniversary of Japan-Thailand Diplomatic Relations. The therne of this symposiLrrn is very tirnely. 'T'he challenges of health we knew 25 years ago have been reliamed by the global movement of people and goods, and with it, the global rnigration ol'diseases. We found that disease rnigration as a significant clrallenge for 2l't Cenlury cpidenriology which requires close cooperation, sharing of information arrd cven.joint nranagcrnent in regional and global health structures that respond to these challcnges.

Therefore AIHD has organized this symposium to strengthen local-global health networking and to create a platl'orrn lbr exchanging experiences. to explore diseasc transmission in global health in an acadernic setting involving health and development
scholars and practitioners.

During this syrnposium over 200 participants have gathered fi'om all aspects of our international network. We will hear from rrany renowned international leaders irr health development and have a few precious days to exchange and network in global health developnrent. I hope that all participants will rnake rnuch of this opportunity and wish you all a meaningfirl and enjoyable stay here in Thailand.

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On behalf of the Government of Japan, I would like to offer rny hearty congratulatlons on the 25''' Anniversary of the ASEAN Institute for Health Development: AIHD. I sincerely

appreciate the persistent efforts of all the people who have been involved in the establishment and development of AIHD for the past 25 years. I should also like to pay high tributes to all of those who have worked so hard to organize this symposium.

This year, we are also celebrating the 120'h Anniversary of Japan-Thailand Diplornatic Relations as well. The contacts between the peoples of Japan and Thailand date back more than 600 years ago. Ever since modern bilateral relations were established in 1887, the two countries have built up friendly and mutually beneficial relations in a number of fields irrcluding health. The closeness between the Imperial Farnily of Japan and the Royal Farnily of Thailand symbolizes tlre amicable relationship enjoyed by tlie two countries and we congratulate His Majesty the King of Thailand on his majesty's 80'r'
birthday.

Throughout this year, many events and programs commemorating 120'' Anniversary have been, and will be carried out. This International Symposium is one of such programs, and also is another important Japan-Thaijoint effort in the health sector.
Japan has been making untiring efforts in the area of global health. The Governrnent of Japan has raised the world's awareness of the importance of health issues, for example, by putting global health issues, especially infectious disease control, high on the agenda at the Kyushu-Okinawa G8 Summit in 2000. For many years, Japan has worked together with Thailand in both public and private sectors in implernenting various sorts of health

programs such as human resources development, academic research, infectious diseases control and the development of health security schemes, responding to the current needs in Thailand and the Asia-Pacific region.

In the history of cooperation between Japan and Thailand in the health sector, AIHD was established in 1982 underthe Japanese grant aid scheme. AIHD has played an imporlant part in human resources development in the health sector and also in the developrnent of prirnary health care. In the last 3 years, AIHD has made a great contribution to HIV/AIDS control in neighboring countries through the HIV/AIDS Regional Coordination Center Project that was jointly implemented by the Government of Japan and the Royal Thai Government. I sincerely hope to see the further developrnent of AIHD as the core of its kind in the ASEAN countries.

In concluding, I should like to express my hope that this symposiurn will enable all the participants from Japan, Thailand, its neighboring countries, international organizations and non-governmental organizations to promote mutual understanding and strengthen their collaboration for the future.

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Honored President of Mahidol University, Professor Dr. Pornchai Matangkasombut, His Excellency Mr. Hideaki KOBAYASHI, the Ambassador of Japan, Dr. Brian Dobcrstyn, Former WHO Regional Country Representative in Thailand, Assoc. Prof. Orapin Singhadej, Delegate of the WHO Regional Director of the South-East Asia Region, Japan International Cooperation Agency (Thailand Office) Director Mr. Orroda KatsLrii, Thailand International Cooperation Agency Excoutive Director KhLrn Chitriya Pinthong, Ilonored Founder tnember of the ASEAN Irrstitute for l-lealth Development and Ranron Magsaysay Awardee Professor Dr. Krasae Chanawongse, I lonored berrefactors arrd donors, esteemed colleagues at the ASEAN Institute for tlealth Development, alumni and current students, honored guests, ladies and gentlemen.

It is an honor and tny pleasure to bring greetings on tliis occasion of the 25'r'Anniversary of the ASEAN Institute for Health Development. AIHD has broLrght togcther ministries of public health from many nations, academicians and health professionals to focus on the many challenges we have in public health. AIHD has been at the forefront of the region's efforts in primary health care research ancl training efforts since 1982, only a few years after WHO and UNESCO embarked on the health for all carnpaign based on the Alma Ata Declaration in 1978. On the part of Thailand, prirnary health care is the responsibility of individuals who live in communities and have access to health inforrnation, infrastructure and fbcilities. Our local administrative authority or l-ambol is now becorning the primary manager of'the clinics and hospitals that make up the primary health care infrastructure. In all of this the partnership ol'the Ministry of Public Ilealth and AIHD has supported Thailand's goal of achieving health for all, irnproving the health of rnothers with children, the elderly and populations at risl< of a variety of epidemics, diseases and other health concerns. This has also meant that we rely upon the creative training and research programs of AtHD. We have made great strides together in health promotion and prevention aotivities. AIHD has also assisted the nation with respect to research arrd monitoring activities. Participatory action research initiated by AIHD in various locations is helping to bolster people's participation in their health through these structures, to monitor HIV/AIDS in
key popLrlations and prorlote health.

AII of this work has been done in the context of the production of graduates through the international MPFIM Degree Program. This has further prepared the Ministry of l)ublic Health of Thailand for the challenges of networking with other nations fbr a healthy
future.

It

is theretbre with deep pride in the past acconrplishments of AIHD and with confidence in our future partnership that Icongratulate AIHD and all of us on lasting friendships that ter health for all.

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Mahidol University is pleased to witness this Jubilee Anniversary celebralrng 25 years since the establishment of the ASEAN Institute for Flealth Development' Through the important work started at that time, new models of training and active 1..r.urrh in Primary Health Care have emerged, effecting not only prirnary health
care management in Thailand, but across the region'

The networks established through AIHD represent some of the cutting edge areas of the university's renowned contributions to health. The WHO Coordinating Center located at AIHD is one of 9 such WHOCC centers at various faculty and institutes in Mahidol University. The HIV/AIDS Regional Coordinating Center demonstrates Mahidol University's commitment to the prevention, treatment and care of people living with HIV/AIDS which provides leadership to HIV/AIDS programs in the area of teihnical support and human capacity building which has made possible by the technical cooperation agreement between the Government of Thailand and the Government of Japan.

The significant development of a graduate degree offering in Prirnary l-lealth Care Management has been a major factor in the development of community health care and research throughout Asia. A variety of other training programs. international conferences and database development in health care have been the hallmarks.
Sustaining the development of such an important institute such as ASEAN Institute for Health Development over these years could only have been possible by the cooperation and support of very important national and international agencies. This International Symposium and gathering of the partners of AIHD is only a small way of marking the heartfelt thanks we have for your involvement and support.

The past has brought so many good things to fruition as demonstrated by the comments of previous directors and partners in the documents of this Symposium. The future will of course bring changes to Mahidol University's structure. However we stand as committed as everto our organizing principles of valuing all hurnan life, the pursuit of excellence and clarity in the mission and management of health care at all levels and the application of research and production of graduates wl-ro will be engaged in management, human capacity building and technical developntent iu
nrimarv health care.

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Professor Natth BhamaraPravati

Foundinu Director of the ASFAI\ Institute for Health Development

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and Fcrmer President of Mahidol University

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Professor Dr. Natth Bhamarapravati received the

M.D. from Siriraj Medical College of Mahidol University and the D.Sc. from the University of
Pennsylvania. He chose Pathology as a specialty

and was certified by the American Board of Pathology. He served as a pathologist for two years at the Armed Forces Institute of Pathology in Washington D.C. before returning to the Faculty of Medicine and Siriraj Hospital in 1959 as a lecturer in the Department of Pathology. His positions included Chairman, Dean and President from 1979 to 1991. He had a long list of activities as a consultant and advisor to national and international organizations, including the Prime Minister's Advisory Council; Thai National Research Council; WHO's Advisory Panel on Immunology, Global Advisory Committee for Medical Research, and Steering Committee for Dengue Vaccine Development. Honors included the Health for All Medal of WHO, D.Sc. (Hon) from Srinakharinvirot University, Plame Academicus from the government of France, and Fellowship of the Queensland Institute for
Medical Research. His research efforts, alone and with his students and collaborators, have been productive and meritorious. Early work concentrated on immunopathology, particularly in regard to infections diseases. Those efforts led to important observations about several parasitic and viral diseases. He has made notable contributions, for example, to the understanding of the causes and progress of cancer of the liver and of the biliary tract, relatively common malignancies in Thailand. Most significant, however, were a series of investigations of dengue, of dengue shock syndromes and of their immunopathology and immunoprophylaxis. The imaginative and high quality research has attracted attention throughout the world and brought the leading investigators throughout the world as collaborators. His work generated what currently seem to be the most promising agents for active immunization to prevent dengue infections.

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He is an educator who inspires students while he instructs. He attracted bright, able students to his departments and'laboratories, kept them at work and helped them to become productive clinicians and scholars. His 12 years as President of Mahidol University were additional testimony to his superb academic leadership. The Salaya Campus has continued to develop as a core part of the University. The creation of the University Library and Medical Information Center, the development of the Biomedical Instrumentation Center, the progress of the Nutrition and the Vaccine Development Institutes, and the research programs in neurobiology and reproductive biology were good examples. The University has broadened its scope significantly, including the enhancement of the Humanities, the development of a Faculty of Engineering, the creation of an international program, and the promotion of biotechnology.

With Professor Dr. Natth Bhamarapravati's great support, the ASEAN Institute for Health Development (AIHD) was originally established in 1982 as the ASEAN Training Centre for Primary Health Care Development. In 1988 the Training Centre became recognized as a separate institute within the Mahidol University. It was renamed as the ASEAN Institute for Health Development, and granted faculty status in the university. As an institute, the organization has continued to promote Primary Health Care through participatory community-based development. The ASEAN Institute for Health Development greatly acknowledges him as an expert from molecule to community.

Sawyer, W.D. "Natth Bhamarapravati, M.D., D.Sc.:

Mahidol University (2004), Memorial

to Lfe, The

A Tribute Upon His

Retirement" in

Biography and Academic

Achievements of Hon. Prof. Dr. Natth Bhamarapravati. Bangkok: Dansuta Press, 49-55.
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Professor Yasuhide

Nakamura
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Graduate School of Human Sciences, Osaka UniversitY

in.'..i.bration o,,n. ,r" In commemoration "i anniversary of the ASEAN Institute for Health Development, Mahidol University and the 120"' Anniversary of .Iapan-Thailand Diplomatic Relations, the institute will hold the 21't Annttal Natth Bhamarapravati Special Lecture on November 30, 2007. This will be the first international Natth Bhamarapravati Special Lecture held by ASEAN Institute for Health
Development. Dr. NAKAMIiRA Yasuhide is a Professor of International Collaboration, Rescarch Center of Civil Society. Graduate School of Human Sciences, Osaka University. After he worked at hospital as a pecliatrician irr Japan, he worked to encourage maternal and child health in hrdonesia (1986-88) and to promote refugee health program in TINHCR Pakistan Of1lce

(1990-91)

IIe was Takemi Fellow (1996-97) in Harvard School of Public Health for

irrternational health. His major publications include Qualitative asses.smcnl of comnttrnity participation in heulth promotion ctctivitics in World Health Forum (1996) and Child obttse ctnrl neglect in Jupun in Pediatrics International (2002). He is widely interested in promoting research through rnultidisciplinary approach in tl-re spirit of fieldworker; Maternal and Child Health (MCII) in developing countries, MCH handbook in the world, ancl child abuse in developing countries. Dr. Nakarnura is also a representative of Health and Development Service (HANDS). In 2002, he was a technical advisor of the Japan International Cooperation Agency (JICA) delegation to World Summit for Sustainable Development in Johannesburg.

Educational Career: 1993 Doctoral Degree (Ph.D.), Faculty of Medicine, The University of Tokyo 1977 Medical Doctor (M.D ), Faculty of Medicine, The University of Tokyo

Work Experiences:
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Professor, Faculty of Human Sciences, Osaka University Associate Professor, Graduate School of international Health, Faculty of Medicine, the University of Tokyo Takerni Fellow, International Health, Harvard School of Public Health Assistant Professor, Department of Pediatrics, The University of Tokyo Medical Advisor, Ministry of Foreign Affairs I lealth Officer, Pakistan Office of LINHCR in Islarnabad MCil experl of JICA in Medan, Indonesia Mitaka Public Health Center, Tokyo Metropolitan Government Department of Pediatrics, Tokyo Metropolitan Fnchu Hospital

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Editorial or Advisory Boards:

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Member, The New York Academy of Sciences Board, JapanAssociation for Intemational Health Board, The Intemational Society of Volunteer Studies in Japan Chief-in Editor, Journal of Intemational Health Board, Japanese Society of Travel and Health Representative, Health and Development Service (HANDS)

Publications:
Nakamura Y. Maternal and Child Health Handbook Program from a Global Perspective. 5th International Symposium on MCH handbook, Bentre Province, Vietnam, 2006

Nakamura Y. Public health impact of disaster on children. Japan Medical Association Journal. 2005; 4SQ): 377 -384 Bhuiyan S, Nakamura Y. GO'NGO partnership challenges and opportunities in the new Millennium: A case study of reproductive health initiative in Bangladesh. Bulletin of Graduate School of Human Sciences, Osaka University. 2004;30:209-220
Nakamura Y. Child abuse and neglect in Japan. Pediatrics Internation al.2002;44(5): 5S0581

Kiely M, Hirayama M, Wallace HM, Kessel W, Nakamura Y, Kiely JL, Nora AH: Infant mortality in Japan and the United States: pp375-397, In Health and welfare for families in the 2lst century, by Wallace HM, GreenG, Jaros KJ, paine L, Story M, Jones and Bartlett Pub.,
Massachusetts, 1999

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l. Global trends in international collaboration for health

The rnajority health and rnedical issues faced throughout the world cannot be solved within the core fields of medicine and public health alone. They are deeply rooted in contradictions on a global scale, spanning international economy, politics and wider society. It was in reflection of this that the concept of Primary Health Care (PHC) emerged in the late 1970s as a social reformist ideal.
(1) The prologue to Primary Health Care

Aid programs for reconstruction immediately following the end of World War II began with the Marshall Plan in Europe. Subsequently, many Asian nations gained independence in the 1950s, followed by African nations in the 1960s. Most of these new nations proclaimed equitable provision of health and medical care services as a core policy issue; however, owing to both an acute domestic shortage of personnel to deliver these seruices and to a paucity of basic infrastructure - such as electricity and communications - required for effective delivery, ultimately these nations had no choice but to depend on assistance from their advanced industrialized counterparts. Former suzerain states and other developed nations provided support in various forms including refurbishment of hospitals built in the colonial era as well as construction of new facilities and provision of fiee medical consultations tl"rrough religious organizations. Such effofts, however, yielded very little improvement in overall health standards in poverty-stricken developing countries.
In the period from the latter half of the 1960s through the 1970s, as the East-West tensions intensified with a focus on the U.S. and the Soviet bloc, a new North-South issue - that of disparity between advanced and developing nations - also came to light. It was in this period that a number of landmark initiatives emerged. One of these was the concept of interrnediate technology as proclaimed by Schumacher, whose volume Small is Bequtiful, first published in 1973, played a major role in theoretical development and promotion of a new focus on appropriate technologies. The 'barefoot doctor' movement of the late 60s, which emerged together with the cultural revolution in the People's Republic of China, also had a great impact on those engaged in the field of health and rnedical improvement worldwide (many criticisms later emerged as the realities of this movement became clear). David Werner's famous work Where There is No Doctor also emerged amidst this current of new tliinking. Published in 1977, Where There is No Doctor provided practical principles which were applied in health and medical care fields in developing countries for many years thereafter.
However, despite experimentation with a variety of new models including those described above, health problems in developing nations remained unsolved: if anything, discrepancies continued to grow. Sporadic efforts were made to correct inter-regional disparities, but

inequality

in provision of

health care

services

manifested

by

problems such

as

concentration of public health funding in large hospitals and absence of doctors in rural areas - only increased, with the majority of rural dwellers still unable to access basic health and medical services.

(2) The Declaration of Alma-Ata and Primary

llealth Care

It was not only developing nations which faced difficulties. Developed nations were finding
that advances in medical techniques had not led to improvement in health levels among their citizens. Rather, the result of progress had been a growing gap between rich and poor, heightened stress levels, increases in drug use and alcoholism, and intensification of other social conditions endangering good health. In response to this state of affairs, the Declaration of Ahna-Ata of September 1978 proposed a strategy for achievement of a common goal shared by the global community, encapsulated in the slogan 'Health for All by the Year 2000'. Article 6 of this Declaration expressed the following concept of primary health care:

Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of selfreliance and self--determination.

(WHO, 'Report of the Intemational Conference on Primary Health Care', Geneva: WHO, 1978)

PHC is an abstract ideal: inevitably, there are significant differences among countries and regions with regards to practical forms of expression of the ideal. Pursuit of PHC on the ground requires formulation of concrete objectives. The Alma-Ata Declaration lists the following eight basic components of PHC:

(l) Health Education;

(2) Safe Water Supply and Basic Sanitation;
(3) Food Supply and Nutrition; (4) Maternal and Child Health and Family Planning; (5) Expanded Program on Immunization (6) Prevention and Control of Locally Endemic Diseases; (7) Appropriate Treatment of Common Diseases and Injuries; (8) Provision of Essential Drugs.
These health service activities were already addressed in existing frameworks for health and medical service provision, and the fact of their inclusion in PHC was, in itself, far from novel. What was more important and rnore admirable about the PHC concept was that it spelt out

the ideals and principles for practical application of these health service initiatives at community level. PHC encompasses ideals such as equity and participation - groundbreaking concepts which had not been recognized in pre-existing approaches to health and
medicine. Ernphasis is placed on the fact that health and medical services should be delivered to all those who need them, overcoming gaps between rich and poor and disparities between different regions. There is also clear recognition of the need to move away from a one-way system whereby services are bestowed through health care professionals, and instead to promote active participation by the recipients of such services. Community participation,

effective use of local resources, appropriate technologies, integration and collaboration among different fields: these basic principles of PHC remaiu necessary conditions for the implementation of community health and medical initiatives even today.
(3) The Millennium Development Goals

The 1990s sawthe collapse of the former Soviet Union and disintegration of the structure of East-West antagonism founded thereon. Health and medicine came to be understood as issues of global significance, linked directly with other global problems such as population and the environment. It was in this period that the United Nations held a series of major international conferences: the World Summit for Children in 1990 (held in New York), the Earth Surnmit (UN Conference on Environment and Development) in 1992 (Rio de Janeiro), the International Conference on Population and Development in 1994 (Cairo), and the World Conference on Women in 1995 (Beijing). In 2000, the UN General Assembly integrated the principles on international development formulated in these and other major international conferences into a single framework titled the 'Millenniurn Development Goals', stated as follows.

(i)

Eradicate extreme poverty and hunger;

(2) Achieve universal primary education; (3) Promote gender equality and empower women; (4) Reduce child mortality; (5) Improve maternal health; (6) Combat HIV/AIDS, malaria and other diseases; (7) Ensure environmental sustainability; (8) Develop a global partnership for development.

All l9l UN member nations

must achieve these goals by 2015.

Health issues are given high priority, accounting for three of the eight pillars of the Millennium Development Goals. A variety of concrete objectives - including those of reducing by two thirds the rnortality rate among children under five, reducing by three quarters the maternal mortality ratio, and halting and beginning to reverse the spread of HIVAIDS and the incidence of malaria and other diseases - are included, and the responsibility of
each nation to

fulfill them by 2015 is clearly spelled out.

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2. Public health

initiatives: some examples

In every nation throughout the world, initiatives are being implemented to protect the health of citizens using methods most appropriate to national and regional circumstances. There is a great degree of variation from country to country in terms of social and economic conditions, sufficiency of health and medical resources such hospitals, health centers, doctors, nurses and other medical personnel, as well as the wider cultural climate in which health and medical services operate. This section introduces several practical examples of initiatives pursued with awareness of such variations.

(l) Posyandu in Indonesia

Posyandu (infant health examinations), a system which has been operating in Indonesia since 1985, involves PHC practices aimed to reduce the infant mortality rate through the involvement of local residents. Posyandu organizations established in villages around the country provide bodyweight checks for children under the age of five, implemented by local community members, as well as health services under the five pillars of maternal and child health, family planning, immunization, nutrition and measures against diarrhea. Posyandu

health examinations are conducted in a five-step process: (l) patient registration; (2) bodyweight check; (3) recording of bodyweight result; (4) guidance on nutrition and family planning and provision of vitamin supplements; (5) immunizations. The biggest difference between Posyandu and infant health examinations in Japan is that in the former, local community members participate in the examination process as health volunteers. Steps (l) through ( ) of the five-step process are handled by these volunteers, with health center staff becoming involved at step (5).
Anyone who can read and write can apply to become a health volunteer. After basic training at the health center, volunteers start work in Posyandu. In the North Sumatran village (population approx. 5,800) where this author worked in the 1980s, 59% of the 76 health volunteers had completed junior high school education - a higher proportion than the community as a whole. Agriculture was the prirnary occupation for most volunteers, who found time to participate in Posyandu in between their farrn-related tasks. Although motivations for becoming a health volunteer varied between each individual, tl-re following comment by the group leader reflects an aspiration of the community as a whole:

'Many small babies have died in this village up to now. Nobody wants to work as a volunteer - not even me, to tell the truth. But we must do our best if we want our children to be healthy and everyone to feel safe Iiving in this community.'
This expresses a basic spirit of independence and self-reliance among people who are by no means wealthy, but feel that tl'rey must do sornething themselves for the sake of their community.
(2) Maternal and child health handbooks

In Japan, maternal and child health record books were introduced in 1948, in the midst of the postwar reconstruction period. The first were notebooks of 20-odd pages printed on poor quality paper, containing mimeographed copies of handwritten text recording matters such as delivery of powdered milk rations. This systern of maternal and child health records is a

original: even in North America and Europe it is rare to find records of pregnancy, birth and child health all contained within one single volume.
Japanese

Today, these record books are in use in other countries including Thailand. South Korea and Tunisia. The books function in many distinct ways: as an aid for parents in rnanaging their own children's health records, as a common reference which can be used across different medical providers and in introductions to specialist clinics, as a tool for health education by facilitating better communication between health and medical service providers and users, and as a stimulus to transforming knowledge, attitudes and behavior among parents, to name just few. Patterns of use reflect the cultural, social and economic conditions of each country. In Thailand, where the record book system was developed in the 1980s, the books have a sense fun and include color comic strips; Mexico ernploys a reproductive health stance, replacing the conventional 'maternal and child' name with the title 'My l-Iealth Record' to ernphasis the child's perspective on health matters.

During a training visit to Japan in winter lggl,lndonesian medical practitioners encountered Japan's maternal and child health record system and were so impressed that work was initiated to develop a similar system in Indonesia. At the time the use of pregnanoy cards and infant cards (records of body weight and immunizations) was already widespread in Indonesia, and the government was just introducing a new system of infant growth cards. I-lowever, because each of these cards was issued separately, few parents would remember to bring all three of them along to health checkups. Japan's system inspired calls fbr Indonesia to introduce sirnilar concept of a single common handbook for use throughout pregnancy, birth and to record the child's growth and development.

An Indonesian version of the book, the cover of which featured a bold image of a mother holding a baby against a pink backdrop, was subsequently developed. The central Javanese city of Salatiga was designated a rnodel dislrict for initial distribution of the books, effected through a JICA (Japan International Cooperation Agency) project in 1994.It is notable that
the lndonesian version did not employ translations from the Japanese model but instead rnade use of existing Indonesian materials, with Indonesians themselves playing the principal roles in both production and dissernination of the handbook. In consideration of the multi-cultural nature of Indonesian society, the handbook's cover design was modified from state to state, emphasizing the character of each locality. As of 2004, not only JICA but also other international organizations such as the World Bank, the LIN Population Fund and UNICEF were lending their support to the system, enabling a total of around two rnillion handbooks to be distributed in 28 states across Indonesia.

3. Japan can also learn

from developing countries

needs to be emphasized that when seeking paradigms for regional society in the 21't century, Japan itself must use international cooperation in health and medical fields as an opportunity to learn from the activities of developing nations. Issues of community health in an aging society with declining birthrate, confronted by Japan in the post-WWII period of urban expansion and ageing population, are already a reality in many other Asian nations. Specialists from all over Asia, having studied concepts such as aged health care and hospice care in Europe and the U.S., are looking to Japan as Asia's most advanced example of these concepts in practice. Meanwhile, Asian nations are experiencing a high pace of reform in their health and medical sectors, and there is much for Japanese health and medical policymakers and practitioners to learn from these nations' capacity to respond swiftly to sudden changes in social and econornic conditions. South Korea was ahead of Japan in developing a legal framework to address the issue of domestic violence, while government bodies in Thailand took active steps to provide counseling services to prevent suicides in the wake of the financial crisis. In Tunisia, where 90Yo of the population is Muslirn, initiatives have been developed to educate young people about gender and reproductive health.

It

Turning our gaze to Japan, we see that this country is now home to many non-Japanese permanent residents including married couples of whom one or both parties are nonJapanese. Japan needs to enable such individuals to give birth and raise children in this society in a manner which respects the customs and community standards of theirhomelands. In other words, Japan is being required to develop community health and medical systems attuned to a multi-racial, multi-cultural society.

In Indonesia, I was struck by the manner in which children were raised, from babyhood, through contact with many different adults within and outside the family unit. A baby who won't stop crying is comforted not only by its mother, but also the father, elder sister, grandmother, and neighbors. It is taken for granted that a variety of adults will be involved in caring for the child. When the child learns to walk, it joins in group play with the other local children, tagging along behind the older children at first, but eventually learning to care for the younger ones too. Through contact with many different adults and children of varying ages, the child acquires important social skills. Indonesian society has managed to retain
something which Japan lost during the process of high-speed growth and development. We cannot turn back a time, but we can and must look back dispassionately at what we have gained and what we have lost in the few decades of the latter half of the 20th century, and think about setting new objectives. This will require enlisting cultural anthropologists, medical anthropologists, sociologists, economists and specialists from a variety of other disciplines to collaborate in bringing global perspectives to the process of revolutionizing Japan's health and medical systems.

Acknowledgement

would like to express my deepest and personal gratitude for the kind collaboration of ASEAN Institute for Health Development (AIHD), Mahidol University. When I was a young medical doctor working at a remote village in Indonesia, I learned the basic concept of PHC from Prof. Krasae Chanawongse. I learned how to educate the international health professionals under the supervision of Prof. Som-arch Wongkhomthong at Tokyo University. Dr. Sirikul Isaranurug and I have studied Maternal and Child Health Handbook and we have stimulated each other for a long time.

development by its able leadership and broad network in the world.

am sure that AIHD

will

continue

its growth and contribute the international

health

References Basch P.F. Textbook

of International Health 2nd ed. Oxford University Press. New York,

usA,

1999.

Sphere. the Sphere Humanitarian Charter and Minimum Standards Sphere, Geneva,2004

in Disaster

Response,

tlNFPA. State of World Population 2006. LINFPA. 2006

UNICEF. The State of the World's Children. LINICEF, 2006.
Werner, David. Where fhere is No Doctor, Hesperian Foundatron,1992'

WHO. World Health Report 2006. WHO, 2006

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great pleasure that I welcome you to this important International Symposium on of Global Health : Borderless Movement of Diseases to commemorate the 25'h Anniversary the ASEAN Institute for Health Development and the 120t1' Anniversary of Japan Thailand Diplomatic Relations."

It is with

The recent outbreaks of SARS, avian influenza, Nipah virus, dengue and chikungunya fever in the Asia Pacific Region have clearly demonstrated the vulnerability of countries to emerging and re-emerging infectious diseases. Dengue fever has expanded its geographical ,pr.ul. bountries in Souifr Asia and the Mekong basin have reported outbreaks in recent years. It is now endemic in most countries of the Asia Pacific Region. of the 2.5 billion people living in the tropics and sub-tropics at risk of dengue and dengue haemorrhagic fever, 1.3 billion - or 52Yo - live in the Asia Pacific Region.

Chikungunya fever can be classified as a re-emerging disease. Between 1960 and 1982, outbreaks were reported across Africa and Asia. In Asia at that time, chikungunya virus strains were isolated in Thailand, various parts of India an, Sri Lanka' Now, 20 years later, India and the Maldives are among countries reporting this disease, Maldives for the first time.
The Asia Pacific Region had the highest number of reported cases and deaths due to human avian influenzainZOO1 .Indonesia reported 56 cases with 46 deaths. Thailand reported three cases after a six-month gap, reminding us that we should not become complacent about avian influenza and that continued active surveillance remains a priority. Poultry outbreaks occurred again in the Republic of Korea, Thailand and Viet Nam where they were thought to be effectively controlled. This is another major challenge in preventing this disease'

Given the close animal-human interface in most countries in the Asia Pacific Region, a human influenza pandemic that originates in the animal kingdom continues to be a serious threat. In addition to having an impact on health and health-care systems, avian influenza outbreaks have huge socioeconomic implications.
We, therefore, need to plan and prepare to deal with outbreaks of all emerging diseases that may affect the Region. While some countries have a specific programme for this purpose, others have included ernerging diseases within their overall programme of communicable diseases. Whatever the structure within the country, it is important to ensure that effective and functioning systems are in place for early detection and response. The newly revised International Health Regulations, called the IHR (2005), have now been adopted by all WHO Mernber States. It was anticipated that they enter into force in June 200:7, at which point they become legally binding. IHR (2005) provides us with a legal framework for preventing, protecting and responding to the international spread of disease while avoiding unnecessary interference with international traffic and trade.

Member States are required to comply with the provisions of II-IR (2005) in order to effectively deal with all public health emergencies of international concern. They must, therefore, ensure that the necessary core capacities exist for implernenting IHR (2005). These core capacities cover surveillance and laboratory support, alert and response mechanisms, reporling mechanisms and communication flow, as well as border health issues. Compliance with these Regulations will no doubt require closer collaboration, effective coordination and timely information sharing among all relevant government sectors if we are to assure

international public health security. One sector alone cannot which government is rosponsible.

fulfil all the II-lIt obligations for

Infectious diseases do not respect international borders. Border health management is crucial for effective prevention and control of spread of epidemic-prone diseases across national boundaries. The continuing growth of tourisrn and commerce has increased risk of communicable diseases crossing international boundaries. The need for joint action plans has therefore become imperative. Border areas are parlicularly vulnerable to the spread of such diseases. So far, bilateral or multilateral plans of action have been developed for trans-border interventions for diseases such as AIDS, malaria, kala-azar and tuberculosis, but much more needs to be done to ensure effective implementation. A coordinated, transparent approach is required, parlicularly for surveillance and response to known priority communicable diseases as well as unknown emerging diseases, both within and between countries. Our efforts at reinforced cross-border collaboration will need to be in line with our new obligations under the IHR (2005).
As you may be aware, the WHO Regional Office for South-East Asia and the WHO Regional Office for the Western Pacific have jointly formulated the Asia Pacific Strategy on Ernerging Diseases. This bi-regional Strategy was endorsed by the two respective Regional Committees in September 2005 with a view to reducing the threat from emerging infectious diseases. The goal of the strategy is to ensure the early detection and control of such diseases, thereby minimizing their health, economic and social irnpact.

To ensure a consistent approach throughout Asia Pacific Region - which is home to more than 50%o of the world's population - the Strategy will be used as a framework to build the national capacities required for effective prevention, detection and control of emerging infectious diseases in our regions.
Partnerships are key to achieving these goals. Our experience with SARS and avian influenza has shown that effective prevention and control in the human population depends on multi-

sectoral collaboration and multi-dimensional approaches, playing a critical role.

with animal health

authorities

The Strategy builds upon and complements existing communicable disease programmes and frameworks, both regionally and globally. Implernentation of the strategy will help Member States meet the core capacity requirements for surveillance and response under the IHR
(2005).

The overall objective of this meeting is to discuss and agree on a framework for cross-border collaboration and propose a strategy to further strengthen this strategic tool in order to effectively tackle emerging infectious diseases and avert their potential impacts.

To achieve this, you will be reviewing the current cross-border movement of people, animals and livestock, and you will be sharing past experiences of border collaboration for disease control.

We also must formulate basic principles of IHR implementation related to cross-border collaboration for surveillance, prevention and control of emerging infectious diseases.

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Keynote speech

Chairman, Princess af Narathivas University Chairnran, Raks Thai Foundation (CARE Thailand)
Chairman, Asian Disaster Freparedness Centre {ADPC}

F*rnler Mirtister of Foreign Affairs F*under Member and Former Director of AII'lD, $ahidol University

In commemoration of the celebr*tion of the 25'h anniversary of the ASEAN Institute for Health Development and the 120th Anniversary of Japan-Thailand Diplomatic Relations

Perspective on East Asia: Asian Development Bank (ADB)

A recent arlicle in the Bangkok Post reports that the ADB consider that extreme poverty, for the most part, can be eliminated in East Asia (for the ADB East Asia includes the Mekong Sub-region countries, South Korea, Mongolia, the Philippines, Indonesia, Malaysia, Papua New Guinea, the Solomon Islands, and Timor Leste). Development in the region between 1990 and 2004 has seen most regional economies grow at an annual rate around the five percent mark, while the rate of absolute poverty (people living on less than 32 Baht per day) fell from 28 percent (whole of Asia 35 percent) to 8 percent (whole of Asia l9 percent); with that rate declining to I percentby 2020 (around 25 million people).
From its foundation 40 years ago, the ADB has facilitated channeling of investment funds from developed countries rnainly outside Asia to undeveloped Asia. This role will no longer be the main focal point in a region that has a growing capital surplus. With this rise in foreign exchange funds across Asia, the ADB foresees a new functionality developing for their bank. Or"re that is able to grow rnore rapidly in tandern with the region's f'ast evolving economic and political environments; with a focus shift from fighting poverly to facilitating faster growth, but at the same time continue working with countries to eradicate pcrsistent pockets of poverty.

overcolne its infrastructttre bottlenecks in transport, power, water, and sanitation. Over tl-re next decade Asia needs to invest at least $4.7 trillion in infrastructllre, a 50 percent higher investment rate
than at nresent.

To realize its new character, the ADB mr-rst help Asian countries to

World Dcvelopment Thinking

was invited by the Japan International Cooperation Agency (JICA) to participate United Nations Millennium Sumrnit Meetins held at Johannesburs in 2000.

the

The Johannesburg Summit tried to narrow down world development thinking to eradicate poverty and hunger by the promotion of Basic Health Care and Primary Education, when all 191 LIN Member States signed tlie 2000 Millennium Declaration, an agreement on the common values of peace and security, the protection of human rights, and the basic dignity of decent living standards for all people. Subsequently the Declaration's values were evident in a determined global developrnent agenda in the form of eight Millennium Development Goals (MDG), with a deadline of 2015, where countries would work together on definite targets to reduce poverty, and sever the roots of inequality and instability. The health, basic education, and economic expectations embedded in the MDG are in'fable l:

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Table 1: The Millennium Development Goals

Goal 1: Eradicate extreme poverty and hunger

Goal2: Achieve universal primary education

Goal3: Promote gender equality

Goal 4: Reduce child mortality

and empower women

Goal5: Improve maternal health

Goal 6: Combat HIV/AIDS, malaria and otlrer diseases Goal 7: Ensure environmental sustainabilitv

Goal8: Develop a

I partnership for development

Source: Thailand Millennium Development Goals Report 2004

The Sauri Experiment Jeffrey Sachs, in his "The End of Poverty" points out that rampant corruption in recipient countries should not be a valid reason for the more affluent international donor community for not investing in the eradication of extreme poverty in less fortunate countries or regions. What he envisages is a planned approach to empowering local communities to provide self help, and transparent use of donor investments in alleviating their cycle of extreme poverty with a relatively small investment by donors.
Tasked by Kofi Annan, the Secretary-General of the United Nations, in July 2004, Jeffrey Sachs, anti-poverty expert and U.N. adviser, along with colleagues from the UN Millennium Project and the Earth Institute at Columbia tJniversitv, traveled to a group of eight villages, known collectively as the Sauri sub-location, in the Siaya district of Nyanza Province of western Kenya. Their objective was to learn why extreme poverty continues to exist in rural areas and how it can be alleviated. What they found was a region overwhelmed by hunger, AIDS, and malaria; far beyond their expectations, but salvageable never-the-less.

Being appreciative that the best way to understand the local situation is through the voices of the people affected and through the collective experiences of international organizations and NGOs working in the area, the group visited farms, clinics, a sub-district and district hospital, and schools in the locale. In a meeting more than two hundred famished, weary and emaciated community members were addressed and given the purpose of the Millennium Project's assignment to understand the situation of communities like Sauri and to work with villagers to identify ways to help such communities achieve world-wide MDG of reducing extreme poverty, hunger, disease, and lack of access to safe water and sanitation. The community members were also told of donor aid available to put some of ideas to work in Sauri and help the international community learn from the experience in Sauri for their

benefit and for the benefit of villages elsewhere in Africa and afar. 'fhe rneetirlg was heartening for the visitors for the discussions lasted more than three hours in which the community members spoke with "dignity, eloquence, and clarity" about their dilemrna.
Sauri thus became the first beneficiary of the LIN Millenniurn Village Project, with the hope to show and prove to affluent governments, which have grown weary of providing assistance with hardly any encouraging outcomes, that indeed extreme poverty could be overcome, Sachs argues that aid, if managed properly, can make a difference. His hope is to prove that if well-off countries spend as little as US$70 a year on each person in a disadvantaged community, such comrnunities can move up out of poverty in just five years. The villagers and the UN Millennium Project tearn identified five development interventions that can make a difference in setting a course for development at little cost to the world, but a cost far too high for the villagers themselves and the Kenyan government on their own:

l.
2.

Agricultural inputs: Use of improved farming methods with proven technologies to increase crop yields (green manures, water harvesting and managernent, improved
seeds, storage facilities, use

ofnatural insecticides, etc).

Investments in basic health: A village clinic with one doctor and nurse for five thousand residents (providing free anti-malarial bed nets; effective anti-malarial medicines; treatments for HIV/AIDS related infections; antiretroviral therapy for latestage AIDS; and a range of other essential health care services).

J.

Investment in Education: Meals for all children at primary school; expanded vocational training could teach skills for modern farming, computer literacy, basic infrastructure maintenance, carpentry and the like; and basic hygiene. The villagers
are eager to be empowered by increased information and technical knowledge.

4.

transportation for those who need hospital care . One or more shared mobile phones could be useful in emergencies as well as for sharing information and communicating with the outside world.

Power, transport, and communications services: Electricity could be rnade available to the villages to power lights, a computer for the school, pLrmps for safe well water, power for rnilling grain and other food processing, refrigeration, carpentry, provide the ability for children to study after sunset, etc. A village truck could bring in farm inputs and take out farm harvests for the rnarket, and provide

5. Safe drinking water and sanitation. With enough water points

and latrines for

safety and convenience of the entire village would free up human resource hours used in the daily toil of fetching water. Basic technologies could be used for water collecting, storage, and distribution.

It was envisaged that in due course, when conditions improved and villagers become more self-supporting, services initially provided free to the villages could be put on a more commercial basis. 'Ihe villagers were very eager to join committees (schooling, clinics,
transport and electricity, farrning) to help prepare for actual investments and to ensure proper governance. What the donors and the Kenyan government needed to agree on was a suitable and bold strategy to govern the use of international help with transparency, efficiency, and equity.

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Private donors were encouraged and mobilized to fund the project. Corruption and underhanded local politics are an ever-present threat, but the donated money goes directly on Sauri's program, and also to funds for research that will help others replicate the program elsewhere. The Kenyan government supports the project by assigning civil servants where needed and local officials are involved in the planning. In this way the specter of corruption was lessened by taking away the opportunity for corruption and local ownership of the project was fostered through empowering the people.
Sauri was selected for this experiment because it was a forgotten place in a country that has witnessed corruption devastate its national economy; its remoteness has allowed poverty to get such a foothold; and it was typical of a village suffering from hunger in a maize-growing area and like rnost Kenyan farmers don't know the best farming practices and can't afford the right seeds. To adopt the populist approach and just feed them, would cost ten times as much per capita per annum as the approach the project had in mind and the problem would still be left unresolved; in the end they would still be hungry when the donor aid dried up.
There is an old Chinese saying that goes something like this " lf you give a man a fish to feed his /amily they will eat it all in one day. IJ you teach a man how to fish he can.feed his family

v,ith.fish every

Populist handout policies are akin to giving the man a fish and only create dependencies, while Sauri style programs leave the villagers self-suff-rcient in the end.

doy".

Just two years into the five year project the villagers were able to sell surplus food for the first time in decades. The project transcends better seeds and fertihzer and has taken an overall and long term approach, reopening the Sauri health clinic and rehabilitating contaminated water wells. The school lunch program for older students was expanded to all schoolchildren, and gets 10o/o of all surplus food grown by Sauri farmers. The local head master reports that the primary school's performance in standardized tests has gone from 198th out of 350 district schools to consistently scoring in the top 10.

With lessons learned from Sauri, the endeavor can now be expanded to 55,000 villagers in
the region. The idea is to have fewer experts per farmer as the project grows.

Actually during 1980-2000 one synchronized effort that was attempted in Thailand for Quality o1'Life improvements for the population was an integrated approach initially through the Ministry of Health (Disease llradication), Ministry of Education (Education Improvements), Ministry of Agriculture (Income Generation), and the Ministry of Interior (Overcoming Civic Inertia). Two more Ministries were subsequently added, The Ministry of Industry (Improvements in Industrial Productivity and Community Industries) and the Ministry of Commerce (Marketing Produce and Products).
the place of leadership, was highly centralized, top down, management style using authority in and with scant participation in planning and irnplementation by the major stakeholders; the under-franchised, under-privileged poor. Cooperation, networking, and liaison between bureaucratic entities were sporadic, uncoordinated, and often counter-productive; as tirne went on bureaucratic enthusiasm waned and funding dried up, the effort was unsustainable and eventually the effort was imaginary.

This effort was initiated by strong centralized independent bureaucracies and

For future Quality of Life Improvement endeavors, the Thai leadership could do well to follow closely the developments of the Sauri project to gain insight into why elirninating

extreme poverty in rural areas of Thailand has not already happened, despite the numerous projects over the years despite the objectives to do just that. It could also be very valuable to study the long-term usefulness of, and agenda behind, rlore recent populist policies that have been implemented top-down with little or no input from the grassroots level or other vital project stakeholders into the requirements, feasibility, planning, implementation, and review phases that are required to build value and sustainability for these projects.

The 30 Baht universal health scheme is one example of a popular and over-due step in the right direction for social justice in providing some form of relief for the Thai underprivileged; it was welcorned by the voters with open arms and at the polling booths. It was, however, not sustainable in its original form because of the lack of adequate consultation with the major stakeholders and beneficiaries before the planning and implementation phases; a good idea, but badly applied, especially when the Government were concurrently promoting Thailand as a regional hub for the export of health services and the strain that was putting on the capacity of the national health services systems. The two concurrent health services ventures vie for the same meager Thai health service human resources base without cocommitment to a program to train and produce the required quality and quantity of health services personnel to meet the timeframe that new human health services resources were
required.

Promoting and building a culture of transparency, self-reliance, and local control and responsibility seems to be the message from the Sauri experirnent, as opposed to the paternalistic, top down, handout, patronage style , favored by a great line-up of Thai governments and authorities, to rnaximize growth measured only by the groMh in GDP.

Urban poor: Mumbai, India

Mumbai, India, is a large city with a big urban poor population (a great proportion of them being newly arrived impoverished rural migrants seeking work and,/or escape from the extreme poverly of their rr-rral village environment).
Slums in Mumbai have existed for centuries and generally the conditions there are described as unspeakable. There was never any planned, infrastructure construction or implementation of facilities such as water, sewage, and drainage. Slum residents constantly have to deal with problems such as, regular migration, lack of water, no sewage or solid waste facilities, lack of public transport, flooding, pollution, housing shortages, and high infant rnortality. General Hospitals in the Greater Mumbai region are overcrowded and under resourced; most people depend on private doctors, rnany of whom do not have any qualifications or official training. The Worlci Bank has funded developrnent of 176 Primary Care Dispensaries, but they are finding that those ef'forts are underused and the water supplies to the area are problematic.

There has been a mixture of success and failure over the decades in efforts to successfully challenge the issues of providing these slums with basic amenities and services, and/or suitably and sustainably relocating the slum dwellers through forced evictions and voluntary removals. Efforls by the global, national, regional, and local communities to find the right blend of extemally implemented interventions to lift these unfortunate people out of the extreme poverty, which nearly all of tl-rem were born into, has seen a mixture of success and failure over decades.

Although comrption is often the cause- though more often blamed- for failures, comrption has not always been the root cause. It is more likely than not, the failures were also related to the dynamics of rapid urbanisation and human nature, and especially the lack of understanding of the impact of a globalising world on the developing economy by the leadership, government authorities, some NGOs, and many intemational aid donor countries (no matter how wellmeaning) - all too often being obsessed with measuring the success of development only in terms of the annual growth rate of the national the GDP.
Some of the more notable successes in Mumbai have grown out of the efforts of community based NGOs such as the Society for the Promotion of Area Resource Centres (SPARC), the Railways Slum Dwellers Federation (RSDF), and the Mahila Milan (Women Together). Through their joint initiatives and actions they have leamed of and clairned their legal rights within the city and the right to access public services, especially in cases where they have convinced the govemment and

authorities of the mutual benefits, such as in relocating slum dwellers away from the railway tracks. Any new venture could do worse than to build on these successes and experiences. The logistic and investment needed to extend infrastructure services delivery to the city's urban poor should be easier to accommodate than for the rural poor because of the close proximity to nearby existing city facilities, such as water pipelines and the power grid, however, efforts to date have often been seen as patchy and tardy.

An article by Anupama Katakam appeared in Frontline in January 2005 in which he wrote of the ambitious plan by the State and City Fathers to clean up and develop Mumbai into a modern metropolis. Dubbed tbe "Vision Mumbai plan", the vision being to turn Mumbai into a world class city by 201,3. ".., a slick city with wide roads, modern highways and more comfortable trains and buses, beautiful seaface promenades and gardens and playgrounds. There will be no shortage of public utilities such as water, electricity and sanitation either",' a livable and efficient city along the lines of Shanghai. The plan is also thought of as being "pro-rich, pro-privatisation and pro-builder ".
Anupama Katakam goes on to say that "... it is the poor and the voiceless, as always, who will have to pay a price ". To make land available for these projects, in December 2004 approximately 45,000 shanties encroaching on council and government land were demolished, to make way for construction envisaged in the plan. Many were rendered homeless by the demolitions. Countless more slum-dwellers will need to be relocated for the makeover of the city. An Assistant Municipal Commissioner who is overseein g a part of the clearing drive is quoted as saying "We don't have a target but our aim is to get rid of every illegal shanty in the city. The demolitions have been on the government's agenda hut because of the fu,o elections last year we could not carry them out. " A hefty underlaking considering that around 60 per cent of Mumbai's population of 12 million are classified as urban poor and live in slums. Most poor people live near their sources of employment. Wl-ren the government rehabilitates them, it is often in uninhabitable areas or at such great distance from their workplaces that they have to spend a fair amount of their earnings to get to work. Any transport re-development must surely take into account the transportation needs of the needy urban rnajority.

Although the intention to develop Murnbai into a habitable and proficient city is a very commendable mega project, let us hope that through good leadership the pace and direction of development eventually fulfills the vision to improve the city infrastructure, but not at the cost of exacerbating the woes of the marginalized majority of its inhabitants. In tandem with

the Mumbai make-over, there will also need to be action to solve the rural poverty situation in impoverished villages to reduce the increase in the migration from poor mral areas to Mumbai.

Although the circumstances and scope of Murnbai's urban poor does not mirror exactly the problems in Thailand, I arn quite sure that Thailand, and indeed other countries in Asia and elsewhere, could do well to learn from Mumbai's experience.

As the dynamics of relieving the hardships of the rural and urban poor world-wide become better understood, it is my hope that tl-re political will of the collective world leadership also keeps pace to craft and carryout the sometirnes hard decisions to work for the welfare of the majority. For Khon Kaen Municipality, my home town, and elsewhere in Thailand that experiences urban slum situations, valuable lessons could be learned from Mumbai.

Thailand as a Partner for Global Development

In Septernber 2000. the Govermrent ancl people of Thailand joinecl the international contmunity in pledging their support for the Millenniurn Declaration that sets out a global agenda for human clevelopment.
As a middle-iucome country with decades o1'' experience in advancing social and economic development, Thailand is a valuable pafiner in the global partnership for development. Thailand gives high priority to sharing this rich experience and accumulated knowledge rvith its neighbors and tlre world at large. as a contribution to global efforts to attain the MillenniLun Development Goals by 2015.
Since Thailand has already arrived at some of the goals, it proposed a series of MDG-plus targets on education, health, gender equality and the envirorunent. It has also produced a separate report on Goal 8, on global partnership.

Credit is given to the robust performance of Thailand's economy during the three decades leading up to the 1997 financial crisis, for already achieving, or is on its way to achieving, most of the MDG: The percentage of those living in poverty already halved; literacy rates at 96 percent for men and 9l percent for women; and almost universal primary education enrolment; the country is now engaged in restructuring for improvement of secondary education; overall health indicators for child and maternal mortality are progressing well; the menace of malaria is restricted to endemic regions and is manageable; and Thailand has also done very well in achieving near universal access to safe water and sanitation due to wellfi nanced govemment programs.

Table

Progress toward the Millennium Development Goals in Thailand: MDG Target Scorecard

1. Halve the proportion of people living in extreme poverty between 1990-2015: Alreatty achievcd.

2. 3.

Halve the proportion of people who sufTer from hunger between 1990-2015: Already achieved.
Ensure that by 2015, boys and girls alike

willbe able to complete a full course of primary

schooling: Highly likely

4. Elirninate gender disparity

in primary and secondary education. pref'erably by 2005, and in all levels ol'et'lucation no later tlran 2015: Already achievcd

5. Reducebytrvo-thirds,between l990and20l5,theunder-fivernortalityrate: Notappticable**l 6.

Reduce by three-quarters. between 1990 and 2015, the maternal mortalify

**2

ratio: Not applicable

Have halted by 201 5 and begun to reverse the spread of HIV/AIDS: Already achieved, but signs of possitrle reversal. Have halted by 2015 and begurr to reversethe incidence of malaria. tuberculosis, and othermajor diseases: Already achieved for malaria; Potentially for TB

8.

9.Integrate the principles of sustainable development into country policies and programs and reverse the losses of environmental resources Potentially

l0.Halve by 2015 the proportion of people without sustainable access to saf'e drinking water and basic sanitation. Already achieved
I I .By 2020 to have achieved a significant improvement in the lives of slum dwellers

Likely

Source: Thailand Millennium Development Goals Report 2004

Llnder-five mortality already approac:hing OECD levels, too lov, to redttce by tv,o-thirds

**2 Maternal ntortctlily already approaching OECD levels. too low to

red t rc e hv t hrc c -qu urt ers

The MDG 2004 report on Thailand, however, highlights that the people in the hills of the north and in the three Muslim majority provinces in the south bordering Malaysia, tend to be marginalized. Thailand also faces a formidable challenge in MDG 7 (sustainable development) because of the environmental damage caused through rapid economic growth over recent decades. What also is noticeable is that the wealth gap between rich and poor, and between rural and urban communities are widenins.

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The Measure of Thailand's Economic Growth Achievements

Through momentous econornic growth over the past 30 years or so, Thailand now claims the status as a rniddle-income country, albeit with a widening income gap between the haves and the have nots. What has been overlooked by successive Thai "Leadership", however, is that economic growth (growth in GDP terms) should not be accepted as an end in itself or as a means or opportunity to further enrich a minority of the people at the expense of the majority and the sustainability of the Thai resource base.

Economic developrnent needs to be more human development oriented and achievements measured in terms of job creation, poverly reduction, the creation of crucial resources for fundamental social services, and the protection and conservation of the environment; sustainable development. On the plus side for Thai style development to date is that Thailand has shown significant improvement in hurnan developrnent over the past generation. It is on track to accomplish the rnajority, if not all, of the United Nations'MDG well before the 2015 target date (Table 2). The nurnber living in extreme poverty has reduced from 38 percent in 1990 to ll percent in 2004. Other positives reporled by UN agencies are, for health, the proportion of malnourished children has dropped by nearly half. Malaria is no longer a problern in rnost of the country. Annual new HIV infections have been reduced by rnore than 80 percent since 1991, the peak of the epidemic. Also reported is that rnost children are in school, and the average years spent in education is increasing. Progress is being made toward gender equality, the lives of slum dwellers have improvecl, and some progress has been accornplished in dealing with urban pollution.
The minuses of Thai style development can be no better appreciated than people-centered view and assessments of development. Their approach:
use the

LNDP

"...follows a hurnan's lifecycle, starting with the first essential thing that everyone must have on the first day of life - health - followed by the next important step for every child - education. After scl"rooling, one gets a job to secure enough income, to lrave a decent housing and living environmenr. to enjoy a.fhntily ond community life, to establish conlocts ancl communicalions with others, and, last but not least, to
participate as a member of society."

Human Achievement Index

The UNDP Human Achievernent Index (HAI), developed by LINDP in 2003 as a tool to assess the state of human development, is a composite indcx using 40 indicators that cover

eight aspects of human Development:

. o .

health, education, employtnent,

1.',

.-1.

. . . o o

income, housing and living environment,

family and community life,

transport and communication, and

participation.

This summary appraisal of human development allows us to compare human development across the 76 provinces in Thailand; Phuket is placed at the highest human development level and Mae Hong Son, a remote, mountainous province in the North, as the most deprived.
The

HAI shows the persistence of the decades old pattern of inequality:

People in Bangkok, Bangkok Vicinity and other regional growth areas enjoy higher levels of human development than people in more isolated provinces. The North and the Northeast, as well as afew provinces in the deep South, are placed at much lower levels. "
"

Health
For the most part, Thais are relatively healthy with a life expectancy of 68 years for men and 75 for women. Most now have access to health care, through a government implemented scheme of low-cost universal health care services, which is now free.
Three major problems, however, persist:

l.

because of poverty or special conditions such as old age or

disability ,disadvantaged

groups remain vulnerable,

2. health threats come with social change and globalization

alcohol abuse and the continuing grip of HIV/AIDS, and

including bird flu, obesity,

3. inequalities

in health services delivery.

The HAI Health Index is constructed from data on underweight births, disability and/or chronic illness, physical illness, AIDS incidence, mental illness, unhealthy behavior, and physicians per population.

Bangkok, Bangkok Vicinity, the East, the South and the Centre have an advantage over the rest of the country. The health infrastructure is worst in the Northeast; however, signs of health problems are strongest in the North.

Table a

x lo 3 Health Index Top / Bottom Five Provinces

72. Kamphaene Phet (North) 73. Chaiyaphum (Northeast) 74. Khon Kaen (Northeast) 75. Lamphun (North)

L Yala (South)
2. Pathum Thani(Barrskok ViciniW) 3. Pattani (South) 4. Phans-nsa (South)
5. Satun (South)

76. Chians, Rai fNorrh)

Source: UNDP Thailand Human Development Report: Sufficiency Economy and Human
Developmet J. 2007

Distribution of the health infrastructure is highly inequitable. Health personnel continue to be concentrated in Bangkok and urban areas. In Bangkok the doctor to population ratio is 1: 879, compared to l:7,466 in the Northeast and 1 : 4,534 in the North. In Bangkok, the population per hospital bed ratio is l:224, compared to 1:747 in the Northeast, and 1: 503 in the North.

Education
With the advent of nine year compulsory education law, in 2005 Thais had an average of 8.5 years of schooling, compared with 7.6 years in 2002.
able

Education lndex

tsottom -Frve Provtnces

72. Sa Keo (East)
73. Nons Bua Lam Phu (North East)

l.

Banekok

2. Singburi (Central)
3. Pattani (South) 4. Nan (North) 5. Chon Buri (East)

74. Chaiyaphum (North East)

75. Narathiwat (South) 76. Phetchabun (North)

Source: UNDP Thailand Human Development Report: Sufficiency Economy and Human Development.2007

The HAI Education Index is constructed from data on mean years of schooling, upper secondary and vocational enrolment, lower secondary test scores, and lower secondary
students per classroom.

to education, and its equality, is still variable across the country. Bangkok outperforms the rest of the country, followed by Bangkok Vicinity, the Centre, the East and the South. Northeastern provinces lag behind.
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Issues of differential access, quality of education, education level of the workforce, and the mismatch between education and the labour market, however, remain unresolved. For one example, the top fifth of the population by income receives over half of all public spending on higher education. Higher education has expanded at the expense of vocational education, which is the type most needed by industry and agricultural pursuits.

Employment
Cunently in Thailand nearly everyone has work. The continuing economic recovery has seen the unemployment rate drop to 1.3 percent and the underemployment rate to 1.7 percent of the workforce in 2005. While the female participation rate in the workforce dropped slightly,

it

remains

high.

Unemployment was relatively higher

in

Bangkok and the Centre;

underemployment was high in some provinces in the South.

Provision for social security protection has grown with 8.5 million workers in the formal sector being covered for injuries and illness, maternity, disability, death, child support, oldage pension, and unemployment benefits. Questions remain about the 22-23 million workers in the informal sector who have no social security protection, apart from for the universal health scheme. Any scheme adopted to provide fbr social security protection for workers in the informal sector will need to be carefully planned and implemented to ensllre equity and sustainability of the system. Other important challenges and threats to be faced are occupational safety and agricultural pesticides. That215,543 workers in the formal sector were victims of industrial accidents in 2004 is discouraging. There is a bigger challenge for those in the informal sector (farm, construction, and home-based workers), who are in more severe circumstances due to the lack of knowledge, training, and legal protection. Agricultural workers face the threat of high levels of toxins from exposure to agricultural pesticides; 86, 905 rnillion tons of agricultural pesticides were imported in 2004, double the amount imported in 2003. In 2002, the Department of Disease Control reported illness from agricultural pesticide aI a "ate of 4.1 I per 1 00,00Opopulation.
The HAI Employment Index is constructed from data on unemployment, underemployment, social security coverage and occupational injuries.

The conditions of employment and social securities in Bangkok, Bangkok Vicinity and the East are better when compared with the rest of the country. Phang-nga is worst-off due to high underemployment and high occupational injuries related to the tsunami in late 2004. Samut Prakan and Samut Sakhon are ranked well because of extremely high employment,

low underemployment and high social security coverage, despite a poor record for

occupational inj uries.

t i.: ::ii:us,t

.i,i:.

,),. ,

T able 5 Employment Index l.

Samut Prakarn (Banekok

tsottom Five Provinces

72. Nakhon Si Tharnmarat (South)

Vicinitv)

2. Ayuttlraya (Centre) 3. Samut Sakon (Bangkok Vicinity) 4. Pathr-rrn Thani (Bangkok Vicinity)
5. Banskok

73. Sineburi (Centre)

74. Chainal (Centre)

75. Karnphaens Phet CNorth) 76. Phans-nsa (South)

Source: UNDP Thailand Human Development Report: Sufficierrcy Economy and Human Development. 2007

Income, Poverfy, and Debt In line with the economic recovery, 2004 household incomes reached Baht 14,963 per month. Despite this, a considerable number remained in absolute poverty (7 million people or ll.3 percent of the population- just under 90 percent of the poor are farmers and farm workers in the rural areas, having income less than 1,242 Baht per person per month); household debt has increased disturbingly; while the overall income distribution remains uneven. Table

Income Index: T e

Bottom lrve Provrnces

72. Buri Ram (Northeast)

L Banskok
2. Nontlraburi (Banekok

Vicinitv)

73. Nakhon Phanom (Northeast)

3. Samut Sakhon (Banskok Vicinitv) 4. Samut Prakan (Banekok Vicinitv)

5. Phuket (South)

74.Mae Hons Son (North)

75. None Bua Larn Plru (Northeast)

76. Surin (Northeast)

Source: UNDP Thailand Human Development

Report: Sufficiency Economy and

Human Development.2007

"lhe HAI Income Index is constntctecl from data on household income, porzefty incidence and household debt. The Income Index is one of the most skewecl. Bangkok and Bangkok Vicinity outpace the other regions followed by the East, the West, the Centre and the South. llhe Norlheast takes the bottom rank. slightly belorv the North. The proportion in poverty varies markedly by region: Bangkok 2 per cent; the Centre 5 per l6 percent; the Northeast more than l7 percent; and the Far South, Narathiwat and Pattani, two predominately Muslim provinces, l8 and 23 percent respectively.

cent; the North

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Personal savings dropped frorn 13.4 percent of income in 1999 to 6.3 percent in 2003. The proportion of indebted households increased frorn half to two-thirds frorn 1996 to 2004.The Northeast had the highest proportion of indebted households ;78.7 percent.
On top of this, the average amount of household debt has blown out from around 68,000 Baht in 2000 to 104,5718aht in 2004.In Bangkok, the Centre, and the East, the majority of debt is for housing, land mortgage or business loans, while in the Norlheast it is for consumption.

Income inequality remains high, with the top fifth of the population enjoying 55.2 percent of the total income, while the bottom fifth has just 4.3 percent.

Housing and living environment

75 percent of Thai households live in their own house on their own land. The percentage is higher in the rural than urban areas. Ninety-nine percent of households have access to safe sanitation, drinking water, and electricity. A large percentage also has basic household appliances such as refrigerators, and electric or gas stoves. However there are growing problems which are related to environmental deterioration. Natural disasters are on the increase with 70 provinces threatened by drought in2004, while 50 encountered floods; while more people were affected by pollution, water quality deterioration, and the lack of sufficient hazardous waste management measures and controls. The HAI Housing and Living Environment Index is constructed from data on housing security, possession of basic appliances, e.g. refrigerator and electric or gas stove, exposure to flood and/or drought, and pollution. The Centre is the top contender, pursued by the West, East and South. The North, the Northeast, while Bangkok Vicinity tail behind.

Table

7 Housing and Living Environment Index: Top/ Bottom Five Provinces

72. Sarnut Sakhon (Bangkok Vicinity)
73. Surin (Nortlreast) 74. Tak (North) 75. Ranong (South)

Ane Thone (Centre)

2. Sine Buri (Centre)

3. Larnpang (North) 4. Larnohun (North)

5.

Phetchaburi (West)

l6.Mae Hong

Son (North)

Source: UNDP Thailand Human Development Report: Sr-rfficiency Economy and IJuman Development. 2007

Family and communify life

The basic building blocks of Tl-rai society are family and community. Family relationships in general remain strong, and communities have strong traditions of cooperation. Today these institutions face increasing strains. Most elderly persons are still looked after within the family. In 2002, out of 6 million elderly, only 6.3 percent lived alone. This pattern will change, however, with the increase in the trend for a greying popr.rlation. The problems created by migration need more immediate resolution. Countless rural families are dispersed by the need to migrate in search of work. The number of single-headed households is on the rise. Communities also continue to be concerned over the rise in alcohol abuse, drug abuse and violent crime.

Table

8 Family

and Community

life Index: Top/ Bottom Five Provinces 72.

Ans. Thons (Cerrtre)

l. Nons Bua Lam Pliu (Northeast)

2.
Pathum Thani (Banskok

Vicinitv)

73. Phatthalung (South) 74. Chon Buri (East) 75. Chiane Rai (North) 76. Narathiwat (South)

3. Klron Kaerr (Northeast)

4. Loei (Northeast)

5.

Udon Thani (Norlheasl)

Source: UNDP Thailand Human Development Report: Sufficiency Ecorromy and Human
Developmer:l.. 2007

The HAI Family and Community Life Index is constructed from data on orphans/abandoned

children/children affected by AIDS, working children, single-headed households, elderly living alone, violent critnes, and drug-related arrests.
F-amily and community life is best in the Northeast, followed by Bangkok regions are approximately at the same level.

Vicinity. Other

Transport and Communication

The provision of transport and communication infrastructure is generally good in Tliailand. The road network is very extensive; however rnaintenance of rural roads and road safety signposting are often tardy. Road safety is a growing concern; traffic accidents are now in the top three causes of death. In 2003,56.9 per 100,000 population died in accidents, traffic accidents being the largest subcategory. Television is the most popular means to receive news and important information with over 93 percent of households owning television sets. Quality educational and entertainment programs, however, constitute only a minute portion of the program content. News programs are accllsed of being politically biased and rnind numbing senseless soap operas of perpetuatir-rg gender stereotypes and condoning violence against and by women.

The use of mobile phones, computers and the Internet has spread. In 2005, 36.7 percent of the population 6 years or older used a mobile phone, 24.5 percent used a computer and 12 percent used the Internet. But access to these new technologies is much skewed. More than 25 percent of people in Bangkok have access to the Internet, compared to l2 percent in the North, l0 percent in the South and 8 percent in the Northeast, mainly because of limitations in the rural telephone system.

Table

Transportation and Communication Index: Top/ Bottom Five Provinces

l.
2.

Banskok
Phuket (South)

72.

Chaiyaphr.rm (Northeast)

73. Tak fNorth) Vicinitv)

7

3. Nonthaburi (Banskok

4.

Surin (Northeast)

4.

Sine Buri (Centre) Ravons (East)

75.

Si Sa Ket (Northeast)

5.

76. Mae Hons. Son (North)

Source: UNDP Thailand Human Development Report: Sufficiency Economy and Human Development. 2007 The HAI Transportation and Communication Index is constructed from data on road access, TV, mobile phone and

road condition, vehicle registration, road length, land traffic accidents, Internet.

A vast inequality gap exists in the provision of transportation and communications. Bangkok is ahead of the rest of the country by a wide margin, followed by Bangkok Vicinity. The other regions are approximately at the same level, with the Northeast lagging a little behind.

Participation

Political participation has increased remarkably, especially with the decentralization of administration and the increase in the number of elective bodies. Voting at general elections
is technically compulsory but the penalties are not stringent, so the high and rising turnouts at the polls in 2001 (70 percent) and 2005 (72.5 percent) are a real measure of political interest.

There is no significant difference in the level of voter turnout across the country, though the Northeast turnout is slightly lower than other regions. In addition to voting, political awareness, political participation and the exercise of rights have taken several forms. People have explored new grounds and gained experience in political rallies, mass petitions, and constitutional debates. The move appears to be away from representative to participatory democracy. The foundation for active political participation is the strengthening of community organizations. The number of community groups per population was highest in the Northeast, the South and the North (89,84, 8l per 100,000 population respectively in 2005), and lowest in Bangkok (8 per 100,000 population). The same pattern is observed in the level of participation in local groups and community services. One major blernish in this picture concerns the representation of women. Women are also much un-represented as candidates at both national and local elections.
I i.,

Table 10 Participation Index: Top/ Bottom Five Provinces

l. 2. 3. 4. 5.

Amnat Clraroen (Northeast)

Maha Sarakham (Northeast) Lamphurr (North) Phans-nsa (South) Churnohon (South)

12. 73.

Chon Buri (East) Pathum Tlrani (Banekok Vicirrity)

74.
7

Banskok

5. Norrthaburi (Banekok

Vicinity)

76. Samut Sakhon (Banskok Vicinitv)

Source: UNDP Thailand Human Development Report: Sufficiency Economy and Human
DevelopmettJ.. 2007

data on voter turnout, community groups, participation in local groups, and participation in social services. The The Northeast is the participation leader, followed by the North, and the South. Participation

HAI Participation Index is constructed from

is lowest in Bangkok and Bangkok Vicinity. It is little wonder that over the years populist policies have been aimed securing the rural vote, especially in the Northeast.
We can see that from the LINDP view point and our own observations that, in general, the trend of progress in human development in Thailand is fine from a high level view. But in particular areas, there are serious issues about the equity, balance, and sustainability of this trend. The inequality in access to public commodities such as education, health, and social services is relatively high for a country at this level of development. In particular, the contrast between urban and rural areas and the formal and informal sectors is vast. Gender is also a factor. Women play a large role in the economy, but are still largely excluded from political roles, and as a result still lack important rights and their interests remain neglected. Geography matters. Certain regions are still slipping behind the overall trend.

Thai Concerns
What we Thais worry about or should be worried about today is: the bleak disparity between Thailand's irnposing overall economic and social improvement and the many inherent developrnent challenges that remain; the widening economic and quality of life gaps between the rninority rich and the rnajority poor where incomes are highly skewed, many people still live in poverty, and the provision of essential services differs greatly in quality and quantity in different areas of the country; the natural environment is under enormous pressure; and farnily and community life is strained by migration and urbanization. After decades of mainly reactionary, ad-hoc, corruption prone, poorly planned and implemented populist poverty eradication programs, rural poverty is still a major problem, especially in the Northeast Region. Urban poverty, to a lesser degree, is also persistent. It should be noted that as in Mumbai, the majority of Thailand's urban poor are in fact migrants from underprivileged rural areas. Thailand being a middle-income country with an adequate resource base does not have rural poverty anywhere close to the poverty levels that are experienced in Kenya, nor the urban

poverty levels experienced in Mumbai. Thailand, however, still has a persistently unacceptable level of rural and urban poverty through inequities in the opportunities in knowledge and wealth sharing in a land potential plenty.
Experiences in rural Kenya and urban Mumbai (lndia) are examples of discovering rural and urban poverty eradication interventions that need to take place and applying them to successfully achieve the MDG in those areas. Thailand could do well to draw on some the experiences in these programs. Sirnilar interventions may well translate to success in

Thailand in eradicating poverty.

Thai Urban Legends

One enduring Thaksinomics legend, repeatedly perpetuated by the conventional Western media, and widely believed by the rural population to this day, was the supposed importance it placed on the grassroots economy (helping the underprivileged). From a budgetary standpoint, Thaksin's populist policies, targeting mainly rural ethnic Thais, were very small put side by side with his government's gigantic state rescue of the primarily urban-based corporate sector "tycoons".
Despite widespread fears, perpetuated by academia and the local press, of a fiscal blowout, Thaksin's actual spending on his populist policies was always reserved, never amounting to more than 80 billion baht (US$2.1 billion) per year. In comparison, his government earmarked nearly 900 billion baht for the establishment of the Thailand Asset Management Corp, a state-run, taxpayer-financed corporate-rescue facility that generously bailed out selected indebted Thai businessmen.

Thailand's Sufliciency Economy

His Majesty King Bhumibol Adulyadej being cognizance of the extreme poverty suffered by his people formed an economic concept over many years as a way to alleviate poverty in Thailand, the Sufficiency-Econorny Concept. His Majesty formed this concept through his many faceted experiences: visiting and learning from the people; studying; experimenting; planning, developing and irnplementing development ventures to achieve his visions to help the people through many Royal Projects; observing the practices of locally funded and internationally funded rural and economic development projects; studying local and international business and financial practices and machinations: and scrutinizins and evaluating leadership and use of authority on the Thai political scene and in the" Thai Government administration apparatus. His Majesty's Sufficiency-Economy concept gained currency in the aftermath of the 1997-98 Asian financial crises. It has now been mooted as the basis for the future direction for Thailand's development activities. "Sufficiency Economy" means different things to different people. Its meaning and purpose

is poorly understood both locally and globally and is often used, abused, and generally

misrepresented by many to further their own agenda. A snccinct and more offlcial explanation closer to the true essence of Sufficiency Economy rnight be:

It is a philosophy rather lhan a theory. Bul the philosophy can be applied to every level of the economy. Ilouseholds should avoid overspending, businesses should avoid over-expansion and the government should
"A suf.ficiency economy is nol self-sfficiency. concentrate on protecting national resotuces."

Bank of Thailand Governo I'ridiyathorn Dcvakula, at a forum held bv the'Ihai Chamber of Commercc in Bangkok on 3 C)ctober 2006. A more detailed summary of the sufficiency economy is accredited to Prof. Medhi Krongkaew"

"Sfficiency Economy is a philosophy that guides the livelihood and behavior of people at all levels, .from the family to the community to the country, on mqtters concerning national development and administration. It calls.for a 'middle way' lo he observed, especially in pursuing economic development in keeping with the world of globulization. Sfficiency means moderation and rea.;onableness, including the need to build a reasonable intmune system against shocks from the outside or from the inside. Intelligence, attentiveness, and extreme care should be used to ensure that all plans and every step of their implementation are based on knowledge. At the same time we must build up the spiritual foundation of all people in the nation, especially state fficials, scholars, and business people at all levels, so they are conscious of moral integrity and honesty and they strive Jbr the appropriate u,isdom to live life with forbearance, diligence, self-awareness, intelligence, and attentiveness. In this way we can hope to maintain balance and be ready to cope with rapid physical, social, environmental, and cultural changes from the outside v,orld. "
Prof. Medhi Krongkacw is Professor of Economics at the School of Development Economics, National Institute of Development Administration (NIDA).
The sufficiency-economy concept can be seen as a guide for sustainable development, good and prudent governance, business and financial management, and farm management;just to mention a few of its applications. It can also be useful as a brochure to contented livins within your means.

Although the sufficiency-economy cor-rcept was incorporated into the 1997 Constitution, concepts, like the concepts of democracy, have often been selectively used and misused justify certain agenda.

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Conclusion

With my personal and humble experience in working with the under-privileged in health and education in North East Thailand, I have confidence that if heed is taken of the message in His Majesty's Sufficiency-Economy concept; that lessons are learned and suitably applied from experiments like those in rural Kenya and urban Mumbai (especially in the areas of local participation in requirements specifications, planning, implementation, and financial responsibilities); with strong Thai Government and Thai bureaucracy commitment; and with sensible applicable minimal help from international agencies and NGOs in the form of shared knowledge and technical know-how and guidance in the use of technological innovation and practices (especially in the areas sustainable rural development, health, energy, economics, and environmental management pursuits), we can achieve the eradication of extreme poverty in Thailand through this combined endeavor along with the efforts of the under-privileged (motivated by well-inforrned local leadership) to elevate themselves out of poverty in the MDG timeframe (by the year 2015). On the other hand, if the leadership is poor or self indulgent and the political will is not forthcoming, the situation will worsen.
Health, poverty alleviation, and sufficiency economy, including education, are written into Thailand's l0'n Economic and Social Security Development Plan, however, there will need to be and integrated approach under a strong determined leadership to get the planned results.

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References
Krongkaew, Medhi

"The Philosophy of Sufficiency Economy." Kyoto Review of Southeast Asia, Issue 4, Regional Economic Integration, October 2003. Kyoto: Kyoto University. Available at http //kyotoreview. cseas. kyotou. ac j p/issue/issue3/artic le-292. htm I
:

Sachs, Jeffrey D.

The End of Poverty; How We Can Make It Happen in Our Lifetime. London and New York: Penguin, 2005

UNDP 2006 UNDP

2OO7

Women's Right to a Political Voice in Thailand, 2006. Thailand Human Development Report: Sufficiency Economy and Human Development. 2007

UNDP Press Release

"sufficiency Economy: Thailand's Answer to Globalization". Bangkok: 9 January 2007.

Thailand Millennium Development Goals Report. 2004

United Nations Country Team in Thailand Associated Press Katakam, Anupama

"East Asia'Carr End Poverty"'. Bangkok Post,4 April2007

"For a new Mumbai, at a great cost", Frontline, Volume 22 - Issue 02. Ian. l5 - 28,2005
Understanding Primary Healthcare Management : From Theory to Practice. Bangkok: Burapliasilp Press, 1990 Rural Leadership and Change Managemenf. Paper prepared for Prepared for the Asian Institute of Technology (Bangkok) Training Course on Effective Leadership for Rural Development, l8-29 July 2005

Chanawongse, Krasae, Prof. Dr. Chanawongse, Krasae, Prof. Dr.

Sreshthaputra,

My Childhood : Krasae Chanawongse, From Smallto Tall",

(Bangkok Post Outlook, circa. 2001)
Magsaysay Award for Community Leadership Citation, to Dr. Krasae Chanawongse, 1973 Remarks by Ambassador Tokinoya on tlre occasion of the of a Japanese decoration to H.E. Dr. Krasae Chanawongse at the Ernbassy of Japan, Bangkok, 27 May

Wabogeb Ramon Magsaysay Foundation

Ernbassy of Japan in

Thailand

Preserrtatior-r Ceremony

2004. Crisoin. Shawn W

"ln Thailand,
2006

a return to 'sufficiency"'. Asia Times, 6 October

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INTRODUCTION
This is a story of OTCA, Overseas Technical Cooperation Agency, the precursor of JICA, brought a small tree from Japan in the late 1960s and planted in a poor province of ISAN. It was the collaboration of OTCA responded Ministry of Home Affairs in relation to Accelerate Rr-rral Development Project in ISAN. The project had two medical tcams from Japan despatched, one to Srisakhet and other to Buriram. Those days both provinces were known the poorest of the poor provinces in ISAN. The rural development scheme, therefore, gave high priority accelerating social and econornic developments in this part of the country. Health is one area in the hope bringing the better health care to the people. It happened that the Buriram team had the author who was eye surgeon'
The above is a story of OTCA tree planned in ISAN. However, we are please to see three decades later the tree grown up to a big tree of blindness prevention and community eye care' I therefore,, would like to present this story today. That helps review back how cotntnunity opl-rthahnology or eye care could emerge in Thailand. The author feels very much glad that he could make some contribution in it. He also on the behalf of OTCA and eye sector in Japan congratulates Thai counterparts for their great success in building up the Thai model of community eye care on the foundation of successful blindness control and provisicln of best possible eye care in home. This is his utmost pleasure that presentation would be one milestone in a long history of friendship between two countries, Thailand and .lapan. The situation in those days was that the whole ISAN lacked eye care even in the regional centres like Korat, Ubon Ratchathani and Khon Kaen regional hospitals . Population more than 20 million were left without quality eye care in those days. The author was the first specialist, who trained in Siriraj and Japan later in ophthalmology. He spent cxtrcrnely busy days and nights there in Buriram provincial hospital from 1966 to 1969. Flowever, it was his first time that clinical specialist in eye care was exposed to reality, the people's need of eye care. To him it was rather simple to restore vision of the cataract blind. However, it gave him to realise that there must be something more than surgery. However, it was beyond for a poor clinician, who was not yet enlightened with public health and community approach. Those days no one told hirn of Primary Flealth Care and many grip on the idea like mobile services. He was told that politicians in Bangkok had the idea from Central Arnerica using medical team for very political purposes.

Buriram experiences in the late

1960s

It was a fortunate that the author had rural services in his early period of professional life. It gave him invaluable opportunity shifting from clinical professional to a new type of professional. He became much aware to the real needs of people in the rural Thailand. The country itself was in struggle in social and economic developments including health care system as well. The author thanks to his ISAN experience and tries to look fbr the different
kind of eye care, which could serve better to people and society.

Those days

all were much excited with mobile services without knowing exact cost-

effectiveness and sustainability as well true benefit. Instead, there must be an alternative to replace such a vertical approach. He did not hear yet any new action already emerging. To the author in Buriram eye clinic no one told him on Sarapee project, Lampang projects and Primary Health Care was not in the horizon of health care. However, it was great chance

benefited hirn with many advantages of eye care in the rural services. His surgery was often one man show and not many expensive equiprnent are needed. Flowever, the result, like cataract was so very drastic. Visual acuity returned with very high sr"rccess rate. This is the reason why later he stress in Primary Eye Care that cataract surgery serves as an entry point that bring Primary Health Care to the heart of con-rmunity.

Ramathibodi experiences
The second project of OTCA in health care in Thailand was cooperation with Ramathibodi hospital. OTCA helped two departments, ophthalmology and pathology in term of despatch experts and provision of equipment. The author was invited to Ramathibodi after Buriram in 1969. There he was assigned to develop refraction, orthoptic and electro-physiology units. I-le went back to university lifb of teaching, research and services. However, he was only the staff who ever worked in the rural province before Ramathibodi. His Buriram experiences always rerninded him that this is a Tliai medical school, neither New York nor Tokyo. Our students would go to serye Thai people, not New York and Tokyo. The Buriram experiences urged me that Ramathibodi eye department should develop new categories of professional. They must stand between ophthalmologist and people. They must work with more authority and expertise. They might need more training and authorities transferred frorn ophthahnologist. Training give them new knowledge and skill transferred. Where new staffs are coming frorn? They could be staff nurses in the department with additional training. They are encouraged to carry on new assignment like screening, managing sirnple eye conditions including minor surgery. More irnportantly, special and new assignments must be community works related to prirnary prevention. The author therefore, began a course for staff nurses and arranged to open a screening clinic in eye department run by them. Having taught in some manipulation, such the retrobulbar injection and some stcps of actual eye surgery as well made them more than scrub nurses in surgical theatre. I'hey could speak to people better with their language and proved to be good health educator. This was that he had been thinking since his Burirarn days. His thor,rght was eye care team concept and the creation of Mid-level Personnel in Eye Care (MLP/EC). 1'hey proved later in the national blindness prevention prograrnmes that they are most important profcssional in the success of the programmes.

Eye deparlment

in

general has less advantage

in

central system

in the hospital.

Ophthalmology department has to carry out various examinations by own. Refraction, muscle balance, f'reld vision, ocular electro-physiology and so on are all carried out by own personnel in the department. Service quality therefore, much relied on trained personnel in the department. This idea, in turn, led to introducing new personnel who are ophthalmologist assistants in eye care team. The idea, eventually, went to the plan of the Mid-level Eye Care Personnel (MLP/EC). Their presence could help assure wider coverage as well as better quality of eye care. Ramathibodi was the first site where such various trainings took place. Not only Ramathibodi, however, trainees came from many places. It went to Ministry of Public llealth. Finally, Ministry of Public I-lealth took the same programrles when the blindness prevention programmes began early 1980s. As a result, Mid-level Eye Care Personnel proved highly useful and made great contribution to the success of the national programmes. Korat Institute of Public Health Ophthahnology was the place to where such trainings brought down. In the national programmes for the blindness prevention MLP/EC training in Korat was a very important human resource development. Not only Thailand, however, it helped the neighbouring countries in Indochina sub-region ask Korat train for them..

Bang Pa-in Communify Ophthalmology teaching programm

Ramathibodi also initiated teaching community eye care for both medical and nurse students. The teaching was part in Community Medicine programmes in Bang Pa-in exercise. The author began it as a set of two 90-minute classroom lectures. The last class of medical and nurse students sit together in the class of 90 minute. Teaching of Community Eye Care, was named "Field Ophthalmology". This was long before eye sector in general, starts to speak Community Eye Care. Teaching began in the early 1970s. The above illustiate many innovations in Ramathibodi eye department ready to community services. It went prornptly when blindness prevention started in the ministry and the author was invited to be a senior adviser. Moreover, these activities impressed WHOA{Q inviting the author later to join the WHO blindness prevention programmes. Targeted territories were two WHO regions of the Southeast Asia and the Western Pacific. In Thailand the home programmes began in 1983 where the author had to work with his colleagues in the ministry.

Generalisation of Ramathibodi experiences

The author spent years in the rural services and teaching ophthalmology in a brand-new medical school in Bangkok in the late 1960s to the end of 1970s. All experiences in those days, helped him go to the next stage of blindness prevention in the Thai Ministry of Public Health. He was also invited to WHO headquarters to manage blindness prevention at the

global level.

His experiences could be summarised as follows:

l.
2.

3. 4. 5.
6.

Eye care services must be targeted to the all population subgroups. Therefore, community is the place where to go and work. Eye care should be delivered in eye care team. It comprises of: a. Ophthalmologist b.Mid-level Eye Care Personnel - centrally trained ophthalmologist assistant or substitute c. Junior assistants, locally trained. Eye care network consists of facilities of different levels delivering different quality of care. Developments of eye care teams and facilities are necessary for eye care regionalisation and all eye problems must be solved within own territory. Training of eye care personnel requires a new set of curriculum suited into the country situation and reflection of needs of people. New training should begin at under-graduate level. This does mean Community Ophthalmology should be made part in Community Medicine teaching. Moreover, residency programme should include Community Eye Care training based on Community Eye Care.

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Eye care in the past

The country situation in the 1960s and the 1970s with regard to eye care in Thailand was a typical pattern comlnon to all developing coutries in the Regions. The status in those days could be summarized as follows:

o . o o . o o

Ophthalmology had been a minor specialty among rnedical disciplines Eye professionals were mostly found in large cities like Bangkok and taking care

of
the well-being of a small fraction of population. Unawareness, if not totally neglected, on the public's need for eye care even at the level of policy makers. Curative-oriented services prevailed and the professionals'benefits were well protected.

In conclusion, eye care had been only available to the minority in urban society. On the other hand, that in the rural was, in general, has been merely a rudimentary existence. Let alone general health status, eye health remained to such a level that trachoma control was of high priority in large parls of the country. In the rnajority of rural provinces the trachoma programme was at a stage still premature to be integrated into the local health scheme. The same was applied to malnutrition. It was prevailing arnong the preschool age group in many provinces suffering frorn vitamin A deficiency. Poor hygiene, inadequate sanitation, neglected health education, and so forth were profounding. In addition, poverty and ignorance worsened the situation. No blindness data was known. However, the average blidnness rate higher than 1.0% .
The urban comrnunity, however, was also manifesting serious problems. Eye facilities available in Bangkok always flooded with visitors. Eye clinics were only found in a limited number of large general hospitals. The urban cases with every sort of aihnents outnumbered the rr,rral who were seriously suffering hardly to access to proper eye care. The solution therefroe, was to be MLP/EP

and decentralisation
ophthalmologist.

of eye care to

non-specialist. However,

this is stritly opposed by

The national programmes for the prevention of blindness, Thailand The special features that the Thai programmes display can be listed as follows:

1. 2. 3. 4. 5. 6. 7. 8.

Activities are initiated by

a peer group

of ophthahnologists of the Ministry of Public

Health. Their voluntary moves did not get any attention and recognition of the authorities at the beginning. The strong solidarity generated a spirit of self-determination and involvement. The concept of teamwork has been palced at the core of eye care service provision. All problems were solved through the process of group learning. The "Primary Eys Care" approach was endorsed as the key strategy. The programmes were inexpensive. Eventr-rally the programmes were bror-rght to the neighbouring countries as a regional model.

The beginning of the national programmes

The national programmes started with a sequence of crash programmes initiated by a few ophthalmologists in the Ministry of Public Health. Most of them then had been in eye seruices for years in the rural provinces. Adrnittedly, they all lacked public health backgrounds, yet they got together and fought their way to bring their programmes to the attention of authorities.

Having been faced with any problem they tackled and solved it. They learnt much through action. However, eventually, their efforts had been rewarded. The programmes were recognized and the Ministry of Public Health finally, granted an official supports. It decided to integrate blindness prevention into the national scheme of health development. Systematic activities of eye sector, all eye circle in and out of the rninistry then followed on the track built by them. Because of thier sweat and tear and enthuciasm for years the eye sector of the ministry are now considered as the rnost public health minded clinicians in the ministry. The Thai Ophthalmolgists Association rewarded the pioneer group in 1990 with a golden rnedal for their distinguished contribution to people of Thailand.

The Ophthalmic Cell, central coordinating group

The situation, however, began to change in 1978. WHO recommendations came for the first time to the Ministry of Public Health from the Regional Office for the Southeast Asia. It urged that the ministry should take an urgent action against blindness. It coincided when WHO itself had just begun the regional action in relation to promoting blindness prevention. There was a swift response in the Division of Provincial Hospital.Having heard the news, a tiny group of ophthalmologists frorn rural hospitals presented themselves and urged a prompt action. Calling themselves "Ophthalmic Cell, led by the director of the Division of Provincial I{ospitals in those days, who was himself a qualified surgeon but a self-trained eye surgeon, a diminutive peer group began preparatory steps. It was the creation of a task force for prevention of blindness in the

ministry.

During that time, the ophthalmic cell's status was not in any sense official. However, it laid down concrete foundation in the ministry on which the national programme was gradaually built up later. It was therefore, natural that at the begiruring no clear mission was designated officially. Yet, it played a significant role as an action grolrp tmder the above diector. Taking only the privilege of WHO's recommendations it worked out various preparations by its own which it rnight considered appropriate. Its first achievement was a nationwide gathering of health sectors. All eye units were sommoned to Bangkok late 1978. The first national seminar on "Restoration of Eyesights for the Curable Blind" was convened. It was the first tirne in Thailand that ophthahnologists met under the topic in non-clinical ophthahnology. Invitations were also extended to mcdical schools as wcll as private sector.

PIan of action at the initiative stage

The above seminar also succeeded in adopting a tentative plan Ophthalmic Cell. It cornprised of the following action components :

of

action prepared by the

l.
2.
3. 4.

Manower development for tertiary and secondary eye facilities with surgeon and nurse in a ration 1, to 2. Strengthening eye care services at the intermermediary level as the first priority. This is to mean that provincial hospital should have own eye unit taking care of people 500,000 to 1,000,000 at tl're beginning. Action progralnlnes against cataract and glaucoma (PACG and seconcady glaucome) are put at the core of action. To link eye care elements with "Primary Health Care" programmes at all levels.

With respect to the first action of ophthalmology training, foftunately, the rector of Mahidol University was a strong supporter of blindness prevention. As a result, the two deparlments of
ophthalmology, Siriraj and Ramathibodi, cooperated very well.
However, the operational level. especially the physician's course, sometimes met negative reaction from conservative professionals. Yet the outcome was very satisfactory. Within a two years time, 19 new eye units were opened in succession. Each had one surgeon and two ophthalmic nurse practitioners. On the contrary, the nurse course met wann support all the time at Ramathibodi Nr-rrsing School. Their excellent performances made great contributions later."Primary Eys Care" development, blindness surveys and mass cataract interventions in the later period well proved their technical competency as well as their strong determination. We highly appreciate their contributions for the success of the national programmes.

"Primary Eeye Care" in Thailand

The concept of "Primary Eys Care" in a consolidated form was first introduced into Thailand just short after the national programmes began. The Ophthalmic Cell again gave a quick response. The fact was that it has always been aware of it and placed it a basis of the national action, "Primary Health Care" had justified their activities. Their swift moves reflected on the workshop conducted in early l98l . It was totally devoted to technical discussions on "Primary Eys Care" topics. In the workshop many reports were presented in relation to assessing ongoing activities from the "Primary Eys Care" point of view. This was the beginning of the Thai programmes with a banner of "Primary Health Care/ Prirnary Eye Care,/Prevention of Blindness" stage. Prior to this was a transient stage with crashed programmes.

The workshop helped identif! all the preparations necessary in shifting the mainstream of the national programmes. Later that year a new workshop was repeated again specifically for developing the detailed programmes of action that put "Primary Eys Care" into operation. Once again all eye units got together and worked side by side for a whole week. A great deal of tasks were shared among the participants. The achievements covered not only the action programmes but also the teaching packages. Together with the guidelines for day-by-day managernent, the list of supplies and equipment as well as a monitoring/supervision mechanism were all prepared. All were completed in the one-week workshop.

"Primary }lys Care" was just about to be introduced, one should acknowledge the Thai situation with respect to the country's " Primary Health Care". It had already been there with remarked progress. That fulfilled certain conditions which are necessary and suffrcient to facilitate such an easy turn.

In addition, the existence of ophthalmic nurses encouraged the new shift to the great extent. They are great power in organizing courses which health workers and volunteers were trained locally in "Primary Eys Care". They proved themselves excellent teachers in this regrad.

"Primary Eys Care" development

The aforementioned workshop was followed by new activities; 10 model provinces were identified and took intiatives. The rest soon followed. Thus, in effect, blindness prevention hereafter had become totally a part of "Primary Health Care" which was, perhaps, the new
beginning of the national programmes.

It was a new challenge to the Ophtalmic Cell to manage "Primary Eys Care". In fact, so far, no country could provide useful information regarding the know-how of "Primary Eys Care" development. Again, it had been muddling through all the way for the management.
The following are, however, the technical steps taken in the "Primary Eys Care"development:

1. Defining common eye problems at the community level In the Thai programmes the following conditions were identified to be covered under

the

o . o . o o o . o

"Primary Eys Care" scheme and set in the order of priority.

Cataract

Glaucoma

Eye trauma Corneal ulcer Trachoma and its complications Eye infections Nutritional blindness Pterygium Conditions with visual acuity less than 3/60

2. Preparations of "Primary Eys Care" courses

"Primary Eys Care" training in a simplified form was regarded as not another ophthalmology course for non-medical people. It should be "Eye Care" training which "action-oriented" for "problem solution" approach. These above conditions must be taught in the first place. All teaching materials were prepared on that line. Along with it action rnodels as well were made lor various levels.

The courses were arranged to consist of three different levels:

l) Primary Eys Care" course: Phase I (Trainer's course) -one to two-week course for all staff nurses frorn district hospitals (primary level, the first level of referral) held at the provincial eve unit.

2)

"Primary Eys Care" course: Phase II (District course) - one-week course for district staff from health stations; to be held at district hospitals by the trainees of the previous

course.

3) "Primary Eys Care" course: Phase III (Community couse)

- a short course for

as

community health volunteers (village health volunteers and communicators) as well community leaders held at the primary level.

In parallel, provincial eye units were instructed to hold a short refresher course for medical officers from district hospitals trained in selected eye topics. This was thought essential to give them leaderships in relation to the local plan of "Primary Eys Care".

Eye referral networks (regionalisation of eye care) Regarding referral system, the Thai model defined the different levels of eye care and quality sets of supplies and. equipment for each. A monitoring/supervision mechanism was another requirement. Effective referral networks would work effectively on the presumption that all levels would cooperate with each other and supported by sufficient logistic measures.

of care differs among them. Accordingly, it specified the different

The local geography was highly advantageous in the Thai case. Usuallly provincial eye units are located not beyond 50 km from most peripheries in the average provinces. It therefore, facilitated easy accessibility to eye care in most cases. So far, "Primary Eys Care" was proved to work in this country. When the strategic shift took place in 1982, the rural eye units had already increased from22to 44. It was a remarkable achievement that such a rapid progress was made in "Primary Eys Care" development. This made to avoid expensive altemative like mobile service. The point was that this could have drawn attention of authorities. Eye care integration proved less costly but highly effective.

In 1988 "Primary Eys Care" already has come to existence in 50 out of 72 provinces. The rest followed gradually. By now all provinces have it. Even without eye unit, ophthalmic nurses take care and link it with eye care networks. The figure available now, irnplies that how that all provinces with eye units, the new challenge will be how to bring it from one district to another. It seems "technical cooperation between districts" will be the answer. Actually it runs in this way.

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Cataract intervention
The national survey took place in 1983 revealed that the country has a cataract blind of 240,000. Hence, mass intervention was urged to start ealier in the country. However, the Thai programmes had a diffent strategy. Let Priamry Eye Care network covered first the whole country. Instead eye camp approach like Indian subcontinental in this ocuntry PEC helps cases finding and refenal. Cataract surgery could be part of routine services in eye units of provincial hospital. Accelerated production ofeye surgeons soon every provinces could open own eye units.

The above was proved the Thai programmes had mass cataract intervention after compeltion of PEC development in 1990. Surgery took place in sterile theatres in provincial hospital and post perative care in eye ward. This satisfied both sides, surgeons and general public.

Korat Institute of Public Health Ophthalmology

The institute was first established in 1986 in Maharat Nakhon Ratchasima Regional Hospital with the following mission.

2. 3.

Headquarters to the national programmes for the blindness prevention Promoting eye health system and clinical research. Training centre for eye care personnel ofdifferent categories

Later a special mission was added to be the base for regional TCDC in the two WHO regions of the Southeast Asia and the Western Pacific. In this relation the institute continues to organise

WHO prevention of blindness intercountry workshop for Indochina countries (Cambodia, Lao PDR, Myanmar, Thailand and Viet Nam), every two years 2. Mid-level Eye Care Personnel courses for Thai nurse students and lrom Indochina countries. The course comprise of 6 rnoth basic course and 4 month additional course like refraction, orthoptic training in joint projects with two medical schools, Chiangrnai and Siriraj. Record shows that the institute produced MLP,EC from 1979 to 2006 in total 687. of which 46 are from three Indochina countries. J. Korat eye care management course is widely reputed as a public health training course for ophthahnologists in the Western Pacific region. The courses were held every two years with around 30 participants from more than l0 countries in the region of the Western Pacific. Faculty are invited in the region as well globally. Reputation went widely over the world.
Recently member countries in the region, especially Indochina countries came much closer in collaboration. Couple with geographical privilege and the progress in eye care system more opportunities are brought to Korat to plays very important role in TCDC in the region. It is also a sister centre of Juntendo University, WHO collaborating centre in Tokyo. Hence it works very closely with Tokyo. IAPB business as well it has Korat as the country office.

The reputation of the institute went very far. However, the institute itself in reality is functional existence. However, many ophthalmologists and MLP/EC in home and the regional member come get together help for special programmes like WHO intercountry workshops. Its most irnportant projects are training of MLP for horne students and the neighbouring countries. WHO collaborating centre, Tokyo opens it Thailand office here for the regional programmes. Korat always works together with Tokyo centre. Moreover, Korat is Thai Office of International Agency for Prevention of Blindness. In addition, rnany international NGOs ask Korat to help their programmes in the region because of Korat position and credit in the region. Success of the national programmes

Two decades had passes since the beginning of blindness prevention. Eye sector in the country worked very hard for a common goal, eye care for all and no longer people suffer frorn avoidable
blindness

The third national blindness suruey conducted in 1996 revealed that the blindness rate in Thailand had reduced to 0.34Yo. The figure was well below the national goal that average prevalence must be less than0.5o/o. Nowhere within the country it remain higher than 1 .0o/o.The level of eye health now in Thailand could reach almost the developed country. As a result the rninistry cerebrated this success on l6 May 1997.It was the day that the country made to declare no longer avoidable blindness remains in the country. That was the resr-rlt after two decades of eye sector had fought against avoidable blindness. Thailand was the first country in the region of Southeast Asia succeeded in elirninalion of avoidable blir-rdness.

The past two decades was long joumey for eye sector in home.The Thai society had travelled through three different stages of blindness situation as follows. Preplaming stage Primary Health Care/Primary Eye CarelPrevention of Blindncss stage Eye Health Care System development stage Finall it goes to the last stage: Stage IV Non-communicable diseases control scheme
Stage
Stage

I II Stage III

However, it also was reminding eye sector that the country has now stepped into the Stage IV, Non-communicable Disease Control stage. It is the last stage where major blindness changed to unavoidable type. The new challenge is hard to handle by the known kr-rowledge nowadays.

Eye Care model in T'hailand based on Community Ophthalmology Wlry communily oplttltolmologlt approach now?

As f-ar as blindness prevention is in the Stage I, Preplanning stage, ma.jority of blindness lirnd are such the un-operated cataract, blinding mah-rutrition, trachoma and so on. 'fheir colnrlon characters are rather sirnple in detection by the non-professional. Even the non-medical as wcll can detect thern easily. Management as well is also easy. Moreover, mass law is available in technical guidelines and manuals. A good sample is that community members can detect blinding cataract and refer for surgery.

The above is applied for almost all blindness of type I and type II in PEC (Type I - comeal blindness and Type II - lenticular blindness). Managements for type I and II are well established. The non-medical or non-ophthahnic persorurel could handle after a shoft training in PEC. However, difficulty is encountered in Type III - blindness from the posterior segment of the eye is not easy. Special knowledge and skills are required in management. This is the reason why management goes to the high level facilities. There must be eye care team able to diagnose before proper management, Management must be individual basis according to ophthalmology. In conclusion, in the stage like Non-communicable Diseases Control stage facilities of all levels should be linked from community up to the last level have to be in a well-coordinated joint work for common goals, successful "secondary prevention". Moreover, primary prevention becomes equally important. This is the reason why community eye care requires comprehensive care. Different categories of eye personnel working at the different levels according to their given roles set in a continuum, lrom primary. secondary up to terliary prevcntion. To clarify the distinction between Community Ophthalmology and Community Eye Care might should aware to the teaching system in medical institutions. Community Ophthalmology might be part in ophthalmic sciences being taught to medical personnel. However, when it was brought to real use at community it might require many other branches of border sciences added by collections of knowledge and skills. Ophthalmology and eye care as well differs in this way. To us Community Ophthalmology could be said that it belongs to Community Medicine. Whereas Prirnary Eye Care belongs to Primary Health Care. Two important concepts of community ophthalmology From ltospital to communily
Saying in this way we should start understanding that community eye care is not specialist services that brought down to community. Frorn their clinic to where people are living and working is not community eye care. This is often misinterpreted among specialist. It could be called comrnunity medical eye care, of which curative services placed at centre. It should be understood that some services should start at community like primary prevention in large part has to be planned taking place not at eye clinic, however, community.
There are two important concepts to begin with community ophthahnology l. Eye care team concept 2.Eye care network concept

Eye care in community ophthahnology must be comprehensive because of composition of the seruice targets in cornmunity.

At any point of tirne community people are suffering from some sort of eye problems. The figures are known around 10Yo, of which majority are simple and not much significant clinically and
public health. However, if refractive errors and reading problems are included the figure goes up 30 to 40 o/o. In developing countries around 0.5 to 1.0 % of.population are blind (according to the definition and categories of visual impairment, ICD 10tl' Ed.) These people require iertiary prevention (often in a fonn of community-based rehabilitation inthe developing cor.rntries). There also must be a group of people with eye problems around l0%. They need some sor1 of help.

: "::2"

However, reality is that the majority are healthy because either they are fortunate or their good life
style.

2) People with eye disease established, - secondary prevention, early detection 3) People had visually impairment (blind or low vision) - tertiary prevention

1) Healthy people - prirnary prevention, to prevent from eye diseases.

and management

It is clear that eye care needed under the above circumstances must be cornprehensive and whole community members are service targets. This is the distinction between commlmity services of
specialist group and community eye care services.

Now we came up to what action we need in the new era of stage III and step up into the beginning of stage IV, non-communicable diseases control.
However, our new joumey starts with the following social and professional justice are strictly kept

with us.
There is only one standard ofeye care. Best possible eye care of the days. Equity, equal and fair to all.

Concept of eye care team

In this article Mid-Level Eye Care Personnel or nurse practitioner in eye care in the Thai system

was already mentioned. Since great contribution

Health different Ophthalmology continues in eye care system in Thailand. However, we distinguish two categories of MLP/EC.

of

Korat Institute

of

Public

2.

l.

Ophthahnologist assistant - work in the eye care tem where ophthalmologist is the leader. Ophthalmologist substation - work in the facilities without ophthahnologist, providing eye care under supervision of non-ophthalmic medical.

It requires for MLP/EC require a standard quality. Therefore, training is taking place centrally under standard curriculum approved by Thai Nursing Council. The need in home is so great because of the possible extension of eye care down to community hospitals. One ophthalmologist needs two MLP/EC also at this level. Many community hospitals as well request this category of health personnel in staff members.
Concept of eye care network
The Thai system is developed under a well-prepared plan of network covering almost the whole country since very success PHC developments. Eye care is integrated in this system and the table below show its framework.

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Level
First level ofcontact

Population served
r0.000

Facility Third level of referral Third level of referral

Quality of care
Auxiliary eye care

Manpower
Public health nurse

First level of refenal

100,000

Medical eye care

MedicalOfficer, MI-/EC (ophthal. substitute)

Eye care team

Second level of referral

500.000

r. 000.000

Third level ofreferral Third level ofreferral

Specialised eye care

Third level of refenal

Sub specialised/
care

eye

Eye care team

Note: "Specialised eye care"

retina cases

management of cataract, glaucom4 eye injury and simple surgical

"Sub-specialised eye care"

- a complete line ofdifferent

sub-specialties is available

Comprehensive eye care at the different levels of facilities

Table: The eye care network facilities and quality of care

Level

Facility

Major roles
Non-medical/auxiliary eye care:

First level ofcontacl

Health centre

L 2. 3. 4. l.

More primary prevention, like health education (PEC) Supervision of community workers. Management of simple clinical cases Collection of basic eve information.)

Medical eye care Consult the cases referred fiom community and health

cantre.

First level of referral

Community hospital

Provision of eye care by medical oflicers orland MLP/EC ophthalmologist substitute. 3. Direct supervision ofhealth centres and indirect over

2.

4. 5.
Second level of referral

health workers in community. Surgery of simple extemal eye conditions. Training of health staff in the district.

Provincial hospital eye unit;

At this level less primary prevention. To the contrary curative (secondary prevention becomes more and serves as the headquarters of eye care planning, training ad well as eye
health system research.

of community eye care services and followed by resources development and mobilisation.
Planning capacity
Third level ofreferral Regional hospital

All activities

are sub.iect to regular assessment based on health

system assessment.

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IIow we develop community eye care model

Usually we choose an administration tenitory lived by manageable size of'populations. 500,000 and not more than I million. This approach was wellproved to work in Thailand.

Different features of community in tenns of social and economic developrnent, geography and climate as well as ethnic composition and so on are all taken into the planning of community eye care development. However, all these are characterised by the different eye care needs and care system should based on that in the way to relieve the eye health issues of people.
Action, usually begins with identifying eye problems in the targeted community, and followed by list up in the order of priority. To each condition the best possible solution is then sought and relevant and necessary actions are identified for service provision. All these steps are nothing very new, however, be taught in health planning. However, the most important step is to estimate the workload of eye care teams. [./sually, cataract services are the starting point from where the whole workload could be estimated. Workload implicates requirement of hurnan resources of all
categories.

Usually among 1,000,000 populations at least 1,000 cataract operations are required annually in order to keep the community free from the cataract blind. Sophistication of need for eye care along with better-off socio-economic status may bring the figure to increase. I-lowever, the r-reeds approach could tell the minimum requirement. The 1,000 cases cataract operations in the cornmunity is needed for to be blinding cataract.

In Thai experiences, the above figures proved to work in the planning. However, they are not
based exactly on scientific grounds. Assumption from the Thai experiences is that one surgeon can operate around 500 cataract cases one year. This number could be used as a base line in estimating

the total number of surgeons required for a given community. Then one slrrgeon needs two MLP/EC and 4 junior assistants, who trained locally (see eye care personnel pyrarnid). This is a practical way to estimate the number of eye care teams in the Thai model. Decentralisation of eye care
We have seen the Thai systern of eye care in general has been in continuons evolution. Starting from preplanning stage in the beginning of 1980s, when society was poor. The whole health system was very behind. However, we are huppy to see that in time it always moved lbrwards by efforts bringing the better eye health to people. This is very true in ISAN where once health services were left very much behind. The author, however, see the situation changed drastically now compared to the old days. He believes strongly that the change rnust be the result from 'l'hai eye sector and helps from different groups supporting the works of eye sector in the last three decades. Also it is the author's proud that he could have opportunity join this change at his very early days. He thanks to OTCA and JICA for this mission was given to hirn. The progress includes the success of Thai programmes fbr the blindness prevention. fhe great honour rewarded Thai eye sector that Thailand is the first member in the WHO region of tl-re Southeast Asia succeeded in elirnination of avoidable blindness. .

Now community eye care is adopted to be a new strategy in the furthering the eye care in Tl-railand. We therefore, foresee the future of eye care and to where eye sector is heading? In this
regard we are aware of decentralisation of eye care just about taking place. Shifting eye care down

to district from provincial capitol is a new trend. Since upgraded community hospitals welcome the young ophthalmologists to work there. Universal accessibility policy with 30 Baht policy as well is applied to cataract surgery. It helps people for easier accessibility. This is a radical change in ISAN as well. It is also a remarkable progress accelerating eye care network development in terms of community eye care system.

Community eye care from concept to action

Having now a new strategy of community eye care clarified in the blindness prevention and eye health promotion all activities are therefore, realigned on the foundation providing comprehensive eye care to all groups of populations. We have seen that original concepts of community eye care are two folds;

2.

l.

Eye care team Eye care network, and

General goals of cornmunity eye care are to provide comprehensive eye care to the whole community members. Now let us outline relevant actions necessary for the developing community eye care. It could be summarised as follows:

1. Identification of

2.

community characteristics like geography, people and their characteristics concerning historical, cultural as well as econorlic status. Determination of specific eye problems particular to each population subgroup. . Small children - ongenital anomalies and developmental, infections, nutritional, injury, o Schoolchildren - eye injury, refractive errors, strabismus, and amblyopia o Working group - occupational eye health, environmental eye health, injury prevention o Elderly group urgical and non-surgical cataract, reading problem, the

3. Determinatio' or r.uriurJortotrtliiff:tffiffii3ttT 4.

ophthalnology a'd individual and comrnunity management. Actual actions rnust be defined in each level of prevention activitics o Primary (health education, behaviour change, etc.) o Secondary and comntunity (basedor/ar-rd institution-based screening and ctc.) o Tertiary (community-based/institution-based rehabilitation)

system must be based on inter-institr.rtion linked registration of visual impairrnent and diseases. Community-based blindness study is no longer give reliable information because of the cornplexity of the disorders.

It is also important that eye health information

In parallel to enforcing clinical capacity at all levels of facilities, the welfare and security schemes should be strengthened in health financing and compensation for those with visual
impairment. There must be a nation-wise health insurance system is introcluccd to cover the whole population. Sufficient budges as well prepared in social and industrial sectors. Besides, health care in private sector would be stronger now. This provides alternative for public as well as to be competing with the state system.

Population subgroup approach

Cornmunity members could be sub-grouped as below:
No
2
J
A

Population subgroup
Small children
School children

Labour force

Adult
Elderly

Subgroup specific eye problems and feasible solutions must be worked out. Thus, ophthalmologist will be busy again as thcy were once when initiating PEC.

"Healthy Eye Community" concept

Having eye care brought down to community hospital; the following changes conseqllently, might be occurred. Specialised eye care is made available at where people are living and working. Almost all eye problems could be solved in individual community. Eye care there must be continuously improved and upgraded for satisfy community people. T'his help community is selfsupportive concemed with eye health. Accepted this must be the case for any community, then what would happen in that cornrnunity with 100,000 populations? This leads to a concept of "Healthy Eye Community".
The above populations will have annual new cases of cataract surgery approxirnately 100 in order to keep that community free from blinding cataract. At the same time there must be another 100 cases of intra-ocular surgery at least. Refraction, low vision care are the services areas which handled by MLP/EC. It is now easy to be free frorn needless blindness. Moreover, communily could enjoy now better visual life. Refractive errors and reading problems, squint and low vision as well solutions are available within community because the comrnunity is now "l-lealthy Eye Community".

"Healthy Eye Community" concept has been haunting with the author for long time since two decades ago we had cerebrated the success of elimination of avoidable blindness. Moreover its prototype had already been brought to Yala. It is known as "Yala Health Eye City development project. To us the concept gives us a new action direction in relation to community eye care development. Thus, Thai community will shift to the period to build own "l-lealthy Eye Community".
The above specifu a set of new action of eye sector together with community. The community will be becoming a territory where all members enjoy the best possible level of visual life. Moreover,

working with health and environmental sectors the community changes to looks beautiful and cornfortable. Healthy Eye Community gives better quality of life.

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Population subgroup

Subsroun snecific eve nroblems

Congenital anomal ies, refractive errors, strabismus, arnblyopia, injury, infection

Feasible solutions
Comprehensive eye care

Srnall children

with specific clinical ophthalmological

approaclres

Eye care in MCH Vision screenins Comprehensive eye care

with specific clinical ophtlralmological

2

School clrildren

Refractive errors, strabismus, amblyopia, injury, i rrfection

approaches.

Vision screenirrg Eye care in school health, injLrry prevention, and low vision care
Comprehensive eye care

with specific clinical

Refractive errors, occupational and
a

ophtlralrnological
approaches.

Labour force

environrnental eye diseases, injury, Posterior segment disorders of the

eye

Eye care in workplace Law enforcement in

prevention ofeye iniurv.

Comprehensive eye care
A

Adult

Refractive errors, occupational and environmental eye d iseases, inj ury,

Posterior segment disorders of the
eye

with specific clinical ophthalmological

approaches

Conrmunity care and institutiorr eve care.

Comprehensive eye care

Elderly

Occupational and environrnerrtal eye diseases, injury, Posterior segment disorders of the eye
Cataract, surgical and non-surgical cases, readirrg problems

with specific clinical ophthalrnological

approaches

Community care and

institLrtion eye care.

Note: Common posterior segments disorders in community eye care programmes are listed below: . Glaucoma

oDM r ARMD r Hereditary disorders o Surgical and non-surgical cataract o Reading problerr . Low vision . Childhood blindness

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'Possible, national and regional models "Healthy Eye Community" approach is applied to the different countries gives a variety of different action models as shown in the followine table
No.

Country

Indonesia

Model "Healthy District Proj ect" Producing cataract free district (500,000 -1,000,000 population and reading glasses for non-surgical cataract elderly populations. School eye health strengthened with refraction care is compulsory.. Note: District in Indonesia is equivalent to Thai
nrovince. "Healthy eye city project" (Yala) for urban communities. Eye Health Prevention and Promotion of all populations in rnunicipality of Yala with respect to the all populations subgroup. "Health Eye District Project" (Dankhuntod/Korat), Korat. First, specialised eye care is made available by eye care team at community hospital. Community screening for the posterior segment disorders are made regular activities. The presence of MLP/EC school and community screening could take place in the middle of community by local team worked together with community volunteers. Vientiane Health Eye City Project Comprehensive eye care in provided at Ambulatory Eye Care Centre of Vientiane. This is the headquarters of healthy eye city projects. The different eye health promotion programmes serve different population subgroups. Tang Hoa Healthy Eye City Project Hai Phong Flealthy Eye City Project In both cities, eye hospitals are responsible for the projects. Both serve community with comprehensive eye care to the whole city populations including school eye health and community/institution based screening of the posterior disorders of the eye..

Thai model

Lao PDR

Viet Nam

In completing this presentation the author would like to show one old picture taken in 1999 when Ministry of Public Health cerebrated the success of elimination of avoidable blindness. In the picture there are ophthalmologists from Japan in the group won the award. One is author, however, the rest are from Juntendo University School of Medicine, eye dcpartment staffs were honoured with this award. To the author this is convincing cooperation of Japan eye sector to the Thai programmes for blindness prevention.

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APPRECIATION
The author wishes to express his deep appreciation to Prof. Pornchai Matangkasombat, president of Mahidol University, and Dr. Wirat Kamsrichan, the organiser of the meeting for providing great honour of presenting article today. Also his appreciation is to Mr. Katsuji Onoda, the JICA resident representative for inviting the author presenting this article of the old OTCA projects in the area of eye care system development.
Taking this opportunity the author should express his gratitude to all his colleagues in Japan and Thailand. His gratitude is also extended to. WHO Collaborating Centre, Juntendo University. Prof. A. Nakajima and Prof. A. Kanai, two ex-directors and Prof. A. Murakami, the present director, have always been in support of the author in his works in Thailand.

REFERENCES K. Konyama: The experiences in the services at Buriram Hospital, Thailand, Ganka, vol. 9, No.10, 1967,p151-757.
K. Konyama, V. Srisuphan, S. Chammuang; Eye diseases in rural community, Siriraj Hospital. Goz.vol 24, no.l0, 157 4-1592,1972 K. Konyama, Role of paramedical personnel in (screening Clinic) in Ramathibodi Hospital: Acta Soc.Oph.Jap, vol. 82, No.8, p546-554,1978 K. Konyama, V. Tansirikongkol, S. Chindanonta: Strabismus among Thai Race: 6'l' Congress APAO, Ball7976. K. Konyama, T. Akamatsu: Ophthalmic Rehabilitation Clinic, Except Med. International, Series No. 450, p1919-1923,1978 K. Konyama, P. Boonsawat: Students in the School for the Blind, Bangkok: J. of Medical Assoc. of Thailand. Vol.54, No.4, p253-255,1973

K. Konyama, V. Tansirikongkol: Survey of visual function among school children, Trans. The 8"'APAO, p800-810, l9g1
K. Konyama, Prevention of blindness in Thailand: Trans. The 8tl' APAO, Bangkok, p827848, l98l WHO, Strategies for the Prevention of Blindness in National Programmes, A primary Health Care Approach: WHO/Geneva, 1984 K. Konyama: The past, present.and future of blindness prevention in the region of AsiaPacific: Trans. The 17t" APAO, Manila, in printing K. Konyama: Indian national plan for prevention of blindness and control of visual impairment Part 2, Ganka, vol.2l, Vol.9, p963-969,1979 K. Konyarna: Indian national plan for prevention of blindness and control of visual impairment Part l, Ganka, vol.22,No.5, p57l-578,1980, K. Konyama: The national programmes for Prevention of Blindness in Bangladesh, Ganak, vol.22, No.l2, p1459-1466, 1980.

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K. Konyama: Eye care services and blindness prevention in Viet Nam, Ganka, vol.28, No.2, pl79-181, 1986
K. Konyama: Eye care system development in Lao People's Democratic Republic, Trans. The lTtn APAO, Manila, in printing

K. Konyama, V. Visonavong: Mass cataract intervention prograrnmes in Lao PDR, the Japan-Korea joint meeting in Ophthalmology, Tottori, 2000, in printing.

lOth

K. Konyama. Korat Institute of Public Health Ophthalmology: p-288 -289,Leading Lights in the Asia-Pacific, 2006,
K. Konyama: Prevention of Blindness in Thailand, What we have learnt from the National programmes? Institute of Publci Hhealth Ophthalmology, Maharat Nakhon Ratchasima Hospital publication, I 998. K. Konyama: Korat Institute of Public Health Ophthalmology, p-288 -289,Leading Lights in the Asia-Pacific, XXI Congress Asia-Pacific Academy of Ophthalmology, Singapore,2006

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The ASEAN Institute for Health Development, formerly known as the Training Center for Primary Health Care Development (ATC/PHC), was found in October 1982 as part o1' the ASEAN Human Resource Development Project supported by the government of Japan. The ATC/PHC project was jointly proposed by Mahidol University and the Ministry of Public Health. Along with four other regional centers the ATCiPHC was set up at the Salaya Carnpr-rs of Khorr Mahidol University in Nakhon Pathom province, other regional center are located in Kaen, Chon Buri, Nakhon Sawan, and Nakhon Srithammarat under the care of the Ministry of
public health

HRH Princess Maha Chakri Sirindhorn came to preside over the ceremony for the laying of the foundation stone forthe AIHD building on 23 July 1983. This auspicious day was taken by the AII{D people as the birthday of the institute.

In 1986, the ATC/PHC became AIHD following a decision by the Mahidol University Council. The prornotion in status came as a result of proven success of the center in fulfilling its rnissions in a short period after its inception. This made AIHD become on a par with otlrer Faculties and institutes of the university.
In 1982, AIHD was financially supported by the Japanese government. The technical cooperation was in the form of bi-lateral cooperation between the institute and the Japanese Intcrnational Cooperation Agency (JICA) with rnajor emphasis on activities related to primary health care in Thailand and in ASEAN countries. In 1988, AIHD began technical cooperation with other international agencies to expand its scepe of activities to cover other areas of health and quality of life developrnent including AIDS, environmental problern, and participatory development. Administration of the institute
Until present, the institute has been underthe administration of five directors, respectively: Dr. Krasae Chanawongse
Assoc. Prof.

Dr. Yaowarat Poropakkhant

Prof. Dr. Som-arch Vongkhomthong

Assoc. Prof. Boonyong Kiewkankha Assoc. Prof. Sirikul Issaranurag

AIHD Facility Aihd has a fully equipped auditoriurn with sound and projection systems. There are
meeting rooms available.
several

The library offers the usual services through its link with the Mahidol University Central Library on the Salaya Campus.lt offers extensive collection of books on PHC, health development, AIDS
and theses.

The ASEAN House is located in a quiet corner of the Salaya Campus and is an ideal place to study or rest. There are 51 airconditioned roorns,TV refrigerator and telephone. The ASEAN House has a comfortable dining roorn, and for relaxation there is a common room, computers with the internet access. securitv service.

International Collaboration
Canada Asia Partnership Project (CAP) CAP was a quality of life developrnent project to coordinate in participatory development based in communities and carried out by the people living there. CAP involved a three-way partnership between the Institute of Primary Health Care in the Phillipines, The Division of International Development of Canada and AIHD. Funds came from the Canada International Development Agency (CIDA).

EC.AIDS Program

The EC.AIDS Prograrn slrpported by the European Commission was developed for Model Development and Capacity Building for HIV/AIDS Intervention in Thailand. the goal was slow down the rate of new HIV/AIDS infections in Thailand through the development of intervention models that promote safe sexual behavior among all population groups. WHO Collaborating Center for PHC Development

lst of October 2004, The World Health Organization confirmed the extemsion of the designation period of ASEAN Institute for Health Development as the WHO Collaborating Centre for Primary Health Care (PHC) Development until 30th Septernber 2008.
Since the

WHO-CC's main function is to provide information on primary health care in the region, offbr international training programs for organizational development. under The slogan "Health for

All"

HMAIDS Regional Coordination Center (RCC)

A joint project between AIHD, the Japan International Cooperation Agency and the Thailand International Development Cooperation Agency has resulted in a HIV/AIDS Regional Coordination Center (RCC) located at AIHD with the aim to develop hurnan capacity building in the 4 targets countries namely CLMV: Cambodia, The Lao PDR, Myanmar and Vietnam. The first phase of RCC was approved on April l, 2005 as a three-year project aiming to establish coordinatiorr for regional HIV/AIDS infonnation and training.
Human Resource Development
The Master of Primary Health Care Management
Since 1986, The MPHM program is a master's degree program taLrght in English and requires an intensive 10 to l2 months to complete. The students are doctors, dentists and health officials who upon cornpletion of this course will dernonstrate irnproved skills in health management and in national leadership.

Mini Master of Management in Health

AIHD along with Preventive Medicine Association of Thailand offer a Mini Master of
Management in Health certification program for personnel in health-related fields. Participants in the Mini Master of Managernent in Health upon completion of the course are able to understand the principles and practice of management of public health organizations, Tliis is largely a selfstudy program that can be done in 6 months.

International Training Programs

Since 1982, AIHD has offered 199 international training programs more than 3,103 participants from 59 countries have come for academic training, seminars and workshops to increase knowledge and skills in public health. The topics are as follows

l. Primary Health Care Management 2. Safe Motherhood and Child Care: community-based

approach

3. Primary Health Care Management Advancement Program 4. PHC at the District Level 5. Integration of Health and Social Development: Thailand's Experience 6. Management of Communti-bases Preventiion and care of HIV/AIDS and more
National Training Programs

AIHD has assisted in human resource development of the Thai health system through
participatory learning, towards professional workshop leadership and more.
Research and Development

198

programs involving 8,872 participants. These national training programs included topics such as participatory action research, effective management of professional training programs,

AIHD supported the work of its professors and researchers in producing research both in the production of knowledge, resources and processes, as well as in the publication and application of the results of that research through academic service to the society, transformative research and commun ity development.

AIHD engages in qualitative research towards a global standard in health excellence and serving as a center of information and application of health research to development needs in
ASEAN countries.

Our Honor Award

presenting the former director

recognized the important role of AIHD by of the institute with the World Health Organization Award in recognition of its contribution to Primary Health Care Development. The Japan International Cooperation Agency (JfCA) has also recognized the contributions made by the AIHD by giving

on the occasion

of its 50th Anniversary, WHO

the institute a special award for its Human Resource Development on Primary Health Care.

Our Future A: Academic Excellence with Sociul Responsibility

I : I nternatio nalizat ion

II: Harmony with Culture und Environment

D: Dynamic Management

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ASEAN Institute for Health Development (AIHD), Mahidol University was requested by the American Refugee Cornmittee International to participate in a very irnportant collaborative project called "strengthening the Control of Infectious diseases among Burmes Migrants and local Thai Population along the Thai-Burmese Borders." Commented on July 2005, this 3year project encolnpassing 4 districts of 3 provinces namely Karnchanaburi, Chumphorn and
Ranong.

The key collaborative partners of this community-based action project were the Provincial Health Offices of Karnchanaburi, Chumphon and Ranong Provinces; Vector-Borne Diseases Control Centers of the Disease Control Department, MOPH.; AIHD of Mahidol University, Right to Play (an international NGO), the College of Public Health of Chulalongkorn University, and the American Refugee Committee International which was executing agency. The Project was funded by USAID.

The responsibility

of AIHD is human capacity building support for the province/district

health system based on PHC, encompassing government health workers within the areas of responsibility of both the Provincial Health Offices and the Vector-born Diseases Control Centers in the Project areas.

Thailand has a wealth of valuable lessons learned in trying to resolve the country's health problems, utilizing limited resources and technology, which has evolved into primary health care (PHC) approach even before the.Alma-Ata Declaration in 1978. The national health systems development in Thailand has conformed closely with WHO's global strategy for health for all through PHC approach. The integration of vertical disease control programs into the PHC has been appropriately accomplished.
appears that in the last 2 decades, rapid globalization, industrialization and urbanizations compounded by unusual population migration in some border provinces created new threats of new, emerging and re-emerging infectious diseases. As such, the challenge of strengthening integration of health services for the control of infectious diseases through PHC approach is highly needed, especially in border provinces next to Myanmar.

However,

it

AIHD had decided to take this opportunity to implement a small project for training modules field testing, aiming to review and revise the whole set of Prirnary Health Care Management Advancement Program (PAC.MAP) Modules which firstly published in 1992. A set of modules, appears to be too voluminous for a short course training such as needed in this Project. It was deemed to maintain appropriate contents with rninor rnodification for better user-friendly modules in its new version.
The Project training process carried out by AIHD has been carefully and systematically processed to serve planning and management purpose of the Project as well as update the former PHC/MAP Modules with additional vision to serye other newly developed community-based sustainable development programs in the long run. The PHC.MAP Modules Set has been donated by Agakhan Foundation to the public domain to be freely improved and updated. It was renamed as the "Sustainable Development Advancement Program HSD.MAP Modules for wider usefulness in the public domain.

ii,

main reasons of why the PHC.MAP Modules need review and revision. T'hey are There has been rapid movement in recent years toward decentralization which means decentralizing PHC management to local managers and communities within the Provincial/District Health System Based on PHC. (2) The rapid globahzation. dramatic increases in international travel, changes in life style, urbanization including over-crowding in cities . This includes the continual evolution of pathogenic microorganisms as their mechanism for survival resulting in the growing importance of new, emerging, and reThere are 3

(l)

emerging infectious diseases (3) The worldwide threat of the most dreadful infectious disease in the history of mankind, the HIV/AIDS,

It is therefore indispensable to review and revise the PHC.MAP Module in cornbination with field testing in the training process of managers, supervisors and service providers within the Provincial/District Health System Based on PFIC in the Provinces of Karnchanaburi, Chumphon and Ranong according to the ARC International's Project Planning. F-or the effectiveness of field test and evaluation of the HSD MAP Modules, the integrated program will be focusing on HIV/AIDS, TB and Malaria.
Of great concern is the fact that health workers are often trained separately by specialists of vertical programs in respective areas such as Malaria, TB, IllV/STi with little emphasis on primary health care principles. This has resulted in the confinement of health worker's knowledge and skills only in each particular areas in which they are trained.
Thus, the horizontal integration of TB, Malaria, and HIV/STI is critical in strengthening capacity of health workers in all 3 areas of diseases, enabling the manager to maximize health workers' efficiency and effectiveness in simultaneously handling all the 3 disease areas.
One of the integral mechanisms to transfbrm this idea into reality lies in the utilization of the principle in HSD.MAP Module 3, entilled " Planning and assessing health workers". It assists

health workers in developing their realistic work plan that will lead to early identification of health problems, planning for various types of care, identification of high risk gror"rps and risk factors/behaviors, as well as the job description establishment and monitoring of health workers' activities. This mechanism will ultimately contribute to tl-re irnprovement o1'the integrated health program effectiveness and efficiency of health worker's performance.

The process of pretest, post-test and evaluation in terms of the Project's inputs-outputs process are to be analysed and synthesized as well as documented and will be presenting in the International Syrnposium on Globol llealtlt : Borderless Movement of Diseases.

..

are considered to be at high-risk

of HIV/AIDS to

assess the

risk behaviors, and awareness

both

level on the prevention

of HIV/AIDS. Following the WHO RSA Guide (2003),

qualitative and quantitative study methods were used in this RSA. The sample of tea garden workers consisted of 108 males and 150 females. The mean age of the respondents was 24 years ranging frorn 12to 47 year. Approxirnately half of them were found to be illiterate and the average income of respondents taka 8762per month.

I'IIV/AIDS Awsreness and Perception: Fifty-seven percent of all respondents (42% of females and 79o/o of males) were found to be aware of FIIV/AIDS. Seventy two percent of
the respondents stated that they did not realize the chance or possibility of being affected by AIDS. Only 2 percent of thern believing that they were extremely vulnerable as they had "regular sexual intercourse" and "sex with multiple partners". Se-uusl Beltavior: About 42 percent (n:45) of the male respondents while l5 percent (n:23) of the female respondents had sex with a partner other then their spouse or lover. A very high porlion of married (83%) and the unmarried (86%) respondents who had had "paid sex" stated that none of their acts were protected by condom use. 71 percent of all married with lovers and 43 percent of all

urunarried with lovers reported that all sexual acts were not protected by condom use. Among the unmarried,2T percent of the urunaried had sex with one lover and 6 percent had sexual encounters with more than one lover during these occasior-rs. About 23 percent of female respondents claimed to have had sexual encounters with one or more lovers during

INTRODUCTION AND RATIONALE

More than half a million tea garden population havc been working in four districts of Bangladesh. The disease burdens of the tea garden workers are loaded with tropical diseases like malaria, helmenthesiasis, diarrheal diseases, tuberculosis, RTI / STIs etc. The tea garden management is responsible for providing the workers with medical care but the quality of the care is not satisfactory. The health and social problems are provoked by poverty, overcrowding, ignorance and illiteracy, and high child and matemal morbidity (Majumder, 2001). The HIV epidemic is evolving rapidly in Bangladesh particularly among high risk populations like drug users, sex workers, transport workers, transgender and tribal populations (BSS, 2005) The underlying causes of the epidemic include poverty, gender inequality and high rnobility of the population, all of which are present in Bangladesh, a densely populated country with about 140 rnillion inhabitants. Most people live in rural areas (76.6 per cent), but there is continuous migration to urban areas. hnigration to other countries for employment is also very common, particularly amongst yollnger
i.

people, laruely to the Middle East, lbllorved by Singapore ancl Malaysia. 'fhe two neighboring countries- India and Myanmar- are already experiencing a serious and rapidly rvorsening epiclemic

of FIIV/AIDS. In addition, behavior pattems and extensive risk lactors that lacilitate the rapici spread of the infection, along with other foms of sexually transmilted diseases (STDs) like syphilis and gononhea, are also widely prevalent in the country. The RSA in Sreemangal district
of Sylhet was conducted under sirnilar guidelines- to study the lifestyles of tea garclcn workers and tribal population in the region and assess the extent of their vulnerability to I-llV/AIDS. The relatively lorv level of HIV prevalence in Bangladesh today does not guarantee the low prevalence tomorrow. Experience teaches Lls that early epiclerrics clo not show their magnitude at first and place few demands. All risk factors which gives birth to explosivc IIIV epidernics are present in Bangladesh today particularly among the high risk popr"rlations o1Bangladesh (BSS, 2005). But there is paucity of valid information on the nature. extent and patterns of behaviors of vulnerable groups for FIIV in the study area like Noakhali-Laxmipr,rr which would be significantly usefr-rl to develop appropriate intervention measllres to address the said problem.

LITERATUITE REVIEW
Recent Behavioral Surveillance Snrvey (BSS, 2005) data indicates an increased in thc risk behavior and declining in consistent condorn use in sexual encounlers. The IISS data also indicates that the vulnerable population is well integrated into the surrounding urban community both socially and sexually, thus raising the grave concern about the spread of HIV infection. Once HIV prevalence crosses the 10% level, epidemics become very difficult to control. Policy makers and programmers within the Government of Banglaclesh, bi-lateral agencies" national and international NGOs have a key role to play in recognizing the urgency of tlie situation and taking immediate action (Choudhury, M.R.& Mathan,2000).

It is estimated that more than half a rnillion workers are working in the tca
garden worker in four districts of

gardens as tea

llangladesh. Among them more then 50 "/o are women. As the tea garden workers who are women remains confined within the bor-rndary of the tea estate, they do not know anything about what is happening or"rtside their bor-rndary and arc isolated from the rest of the country. As a result, their aspirations are very low (llSS. 2005).
A relatively young sample was pllrposively selected by the RSA, as a prirnary goal of the research was to study the behavior of young and adolescent workers in tea gardens. 'fhe rationale behind including a sizeable porlion of yor-rng workers in the sample was to study a grolrp that is potentially more vulnerable to sexually transmitted diseases, as their extent of knowledge abor"rt such cliseascs and access to health care rnight be limited. Consequently, almost 44 pcrcent of the workers
covered by study are under the age of 20 years (Habib,. 2004).

The survey also sl-rowed that rnajorily of the tea garden workers are illiterate, and no worker had an educalion background higher than a secondary level. This was also uncovered dr"rring the FGDs, where representatives of various tribal/religious groups conferred that education lcvels among tea garden wotters are poor. Very minirnal levels of education have also been detccted among tribal mentbers, with almost 70 percent of the respondents being illiterate (Amanr-rllah.2002).

The low levels of education among both tea garden workers and Khasia people have major irnplications, as far as health studies are concemed. First and foremost, it acts as a constraint for the target groups for having proper access to information and knowledge about I{IV/AIDS
The RSA has detected that reported incomes of tea garden workers are very low, calculated to be around Tk. 970 per month (it should be noted here that income related to personal, instead of family income, was gathered). The median personal income is even lower for the group, at

Tk. 720 per month, while the maxirnum-minimum range is Tk. 3000 to Tk. 300. For both groups of tea garden workers and Khasia tribal rnernbers, the data shows that sexual behavior of respondents is strictly heterosexual, as all sex acts have been reported witl-r members of the
opposite sex (Arnanullah,2002)..

While the target groups may not be displaying unsafe sexual bel-ravior from the perspective of being involved in same-sex relationships, the RSA has detected that other elements of indiscrimate sexual practices are widely prevalent among the target groups. Iror example, almost all sexual acts performed by manied respondents (both tea garden workers and Khasia tribal rnernbers) with their spouses are unprotected. A few married respondents have also claimed to have sex with lovers in the last seven days, and in most cases, these acts were unprotccted. Condom Llsage among unmarried respondents with lovers is also not universal,as 46 percent of unmaried respondents have reported that they do not use condoms (Mathan, 2000). Incidence of "paid sex" has also been reported by respondents, both from married and unmarried groups. Interestingly, a portion of females has also reported that they have engaged in "paid sex", possibly as "recipients" rather than "makers" of payments. Again, even in cases of paid sex, a considerable portion of both tea garden workcrs and Khasia tribal members have reported to have not used condoms.Thus, the practice of having multiple partners (both of the paid and unpaid variety) places a portion of the target group at risk of STDs, as usage of protection is very low. Moreover, a portion of respondents who engage in such behavior are currently married, which means that their spouses are also subsequently being placed under risk.
The high likelihood that unsafe sexual practices are prevalent target grollps is fr,rrther verified when we taken into account their low levels of awareness about condom Llsage. Condom Llsage among both married and unmarried groups occLrr very indiscriminately- even in cases for target group members who engage in sex with multiple partners. A substantial minority of respondents from both the tea garden workers and Khasia grollps has also bcen found who are outright unaware from where they might obtain condoms. Also, it has been reported by many that they are not using protection on hedonistic grounds, as it diminishes their pleasure during sexual acts. All in all, these factors suggest that are significant barriers to condom usage among both the tea garden workers and the tribal communities (Choudhury, 2003) .

The incidence of unsafe, promiscuous sex is also apparent when we take note of the high prevalence o1' S'fD/RTI symptoms among the target grolrps. A sizeable porlion of respondents (44% of tea garden workers and 52o/o of the Khasia tribal members) has reported of having STD/RTI symptoms at present, indicating that a sizeable portion of the population members indulge in unprotected sex, possibly with rnultiple partners. In addition to serving as an indicator of the unsafe sexual behavioral practices of this group, the high incidence of STDs also increases their vulnerability to become infected by the AIDS virus (Amanullah,2002)..

RESEARCH METTIODOLOGY Following the WHO Rapid Assessment and Response Guide (2003), both qualitative and quantitative study methods were used in this RSA to assess tl-re risk behaviors, treatmentseeking behavior and awareness level on the prevention of I{IV/AIDS members of the general population in Sylhet. Multiple qualitative techniques, such as observation (participant/ non-participant), in-depth interviews, and focus group discussions (FGD) were used for assessing the existing status of risk behaviors of HIV/AIDS vulnerable groups. In quantitative methods, structured and pre-tested questionnaire were used fbr one to one interviews with rnembers selected from different tea garden worker and tribal groups. Interviews were only taken after obtaining verbal informed consent from the respondents. Secondary data was collected from respective record and reports, statistical handbooks, local newspapers news on different aspects of drug use and sexual behaviors of sex workers. Finally, the qr-ralitative and quar-rtitative findings were triangulated to ensure validity and reliability of this RSA finding.
Sampling A convenient sample was drawn by the research by using purposive sampling techniques. Respondents from tribal groups ancl among tea garden workers were purposively selected for the FGDs and one-on-one interviews. In addition, key stakeholders were located and interviewed for their in-depth insights into the behavior of tribal population and tea garden workers. A rnulti-site sarnpling technique was used to make the study as representative of the whole area as possible. Study Sample The target populations of the RSA were different tea garden workers. The table portion of sample in each grolrp that was realized tluough purposive techniques:
Table A: Sample realized according to Target Group Tca gardcn Workcrs
Mr"rslim male

shows the

FGDs
z
2 2
I

Sample size lbr structured interviews

27 44
81

Muslirn female Hindu male Hindu Female

Adolescents

106

2 9

Total

258

Data collection The first set of data was obtained frorn face-to face interviews with primary respondent. The second set of data included qualitative data from in-depth interviews, focus group discussions, and observations. The third set of data was the secondary data obtained from various relevant sources.

Ethical Considerations The ethical principles followed were in line with the National (BMRC) and WF{O Guidelines for Ethical Review of Epidemiological Studies. Considerations regarding confidentiality and the protection of research participants from harm, invasion of privacy, and the provision of emotional and practical support were given priority.

Qualify Control and Monitoring

Field investigators rnet the research supervisor on a daily basis to submit observation sheets on which the former would identify gaps in data collection and give necessary guidance. To ensure quality of information, all collected data were checked and verified at the field level. The research supervisors adopted the strategy of checking each other's dataat the field level. This was done with an idea of rnaking a cross check to examine the accuracy of data collection during the fieldwork. The answers in the questionnaire were duly coded and entered into the SPSS program-version 11.5. The Data Entry Operator entered all the data collected by the held investigators. Apart from using this SPSS program, some qualitative information were also analvzed manualv Data analysis Data checking was done twice- once by the field investigators prior to leaving the place of interview for cornpleteness and correctness of filled questionnaire, and secondly by the supervisors. A1ler complete assurance of obtaining correct data set, data entry was done into the computer using the SPSS software and final checking and cleaning was done before analysis. All statistical analysis was performed by SPSS for window.

RESULTS
The sarnple of tea garden workers consisted of 108 males and 150 females (Table 1). The mean age of the respondents was 24 years ranging from 12 to 47 year. Approximately half of thern were found to be illiterate and the average income of respondents taka 8762 per month. About 57 percent of the respondents were married

HIV/AIDS Awareness and Perception: Fifty-seven percent of all respondents (42o/o of females and 79Yo of males) were found to be aware of HIV/AIDS (Table 2). The awareness levels about HIV/AIDS among the non-muslims were lower (54%) than the Muslims (66%).
The key transmission routes identified by the aware respondents were "sex between male and females"(20%o),"sex with sex workers"(23Yo), and "needle sharing" (28%), "Ltnsafe blood transfusiot-rs" (11oh) and "sex without using condorrs" (16%). Forty seven percent of the respondents did not know the means of protect from contracting AIDS. Seventy two percent of the respondents perceived the risk of or possibility of being affected by AIDS, while another 20 percent stated they believed they had no chance of contracting the virus. The remaining 7 percent believed that they had low to high risk of contracting the disease, with 2 percent believing that they were extremely vulnerable as they had "regnlar sexual inlercourse" and "sex with multiple partners".

Sexusl Behavior: More than three forth quarter (77%) of rnarried respondents mentioned having sex with their spouses in the last Tdays (Table 2). About 90 percent of tliem engaged in only vaginal sex only, while 9 percent reported of having both vaginal and anal sex and I percent (n:l) had only anal sex. Incidence of anal sex was reported among both Muslims (5%) and non-muslims (12%).90 percent of the acts were not protected (95% of Muslirns and 88% of Non Muslims). About 5 percent of rnarried respondents reported that they had sex with lovers during last 7 days. Among the unmarried,2T percent of the unmarried had sex with one lover and 6 percent had sexual encounters with more than one lover during these occasions. About 23 percent of female respondents claimed to have had sexual encounters with one or more lovers during last seven days, compared to 9 percent for the males.7l percent of all rnarried with lovers and 43 percent of all unmarried with lovers reported that all sexual acts were not protected by condom use. Only 4 percent of rnarried respondents and l0 percent of the unmarried clairned to have had sex with paid partners in the last sever.r days. Interestingly, it was noted that both male and fernales had had "paid sex". The rate of having "paid sex" was noticeably higher among Muslirn respondents (l l%) than non-muslim respondents (5%). All the males who engaged in paid sex had female sex partners, while all females had male partners. A very high portion of married (83%) and the unmarried (86%) respondents who had had "paid sex" stated that none of their acts were protected by condom
use.

percent, ), "pain during intercourse" (gyo), pain /pus during menstruation(20Yo), and "pain in the lower abdomen" (19%). About 56 percent respondents (57% married and 55Yo urnmarried) stated they had no symptoms at present. . Drug habits: There was no incidence of IDU or heroin addiction among respondents.

STD/RTI: When the respondents were asked about STD/RTI, they mentioned such symptoms as "itches or burns while urinating" (17%), "itchiness while menstruating 02

DISCUSSION AND CONCLUSION The RSA in the Sreemangal district of Bangladesh was conducted between two popr.rlation groups- tea garclen workers that were considered to be at high-risk of I IIV/AIDS, due to their risky sexual behavior and overall vulnerability caused by low education backgrounds and insufhcient incomes. An investigation into the lifestyles of the target groups revealed that there were considerable gaps in the knowledge, attitudes and practices of such members that serve to increase their vulnerability to the disease. Awareness levels about HIV/AIDS and knowledge about transmission routes and preventive measures was found to be low among rlany, which was consequently reflected in their behavior. Condom usage was very scattered among respondents, even in cases of members who engaged in sex with multiple partners. A triangulation of findings frorn the in-depth interuiews, observations and FGDs also suggested tliat promiscllous behavior
was prevalent among tea garden workers, and was noted that a large chunk of this workirig class is made up of tribal members. Moreover, a high incidence of STD,,{{TI symptoms among the hrget

groups also suggested that, not only were there target groups engaging in sex witli rnultiple partners, but in most cases, these acts were possibly unprotected. The lack of awareness about condoms as a protection device was also detected when it was noticed that a noticeable portion of the sample cor-rld not recall the sources from where condoms can be obtained.

All in all, these findings

gap

have made the RSA team conclude that, a) there is a considerable need-

awareness and knowledge levels about HIV/AIDS among target groups, b) there is incidence of unsafe sexual practices, caused by the prevalence of promiscuous behavior and the low levels of condom usage, and c) the vulnerability of the target groups is increased on account of their low levels of education and incomes.

in

RECOMMENDATIONS
In view of the sexual risk behaviors identified among the groups of subjects in this study, the following multi-faceted strategies are recommended in order to reduce the spread of STD/HIV infection among them and the rest of the community.

i.
ii.

Tea garden owners could be made more aware about the dangers of HIV/AIDS, and their advocacy capacity could be built on so that they disseminate information and knowledge about the disease to the workers.

There appears to be widespread gaps in the awareness and knowledge levels about HIV/AIDS, as a large portion of the target groups has been found to be unaware about how the disease spreads and how it might be prevented. Both mass media and personal communication strategies should be utilized to develop awareness levels among target
groups.

iii.

There also appears to a need-gap in the practices of population groups as related to safe sex and condom usage, which suggests that there is a need for behavioral change communication that promotes safe practices.

ACKNOWLEDGBMENTS
Authors would like to express sincere thanks to the officials and field staff for conducting the field work of the study, and research team for their hard work and effort that went behind in producing this report.

'll'',t':

..i.":i:"

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':

'

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r1 ,-.:',,,r;"

Annexure Tables
Table 1. Socio-demographic profile
Muslim Non-Muslim
Male
Female
o/o

Atl
N=
258

N:71
Age (in completed year) Upto 20 yrs

"h

N:
187 88

"h

N:
108

N=
150

Vo

Vt

25

35

Az+t

38

35

75

50

l ta I.tJ

44

2l-25 vrs
26-30 vrs 3 | + years

t7
20
9

24 28

28
38
JJ

l5
20

t4
25

l3
ZJ

3l
JJ

2l
22
7 1t LI

45 58
A1 AL

I7
22

l3
25

l8
22

3l

Median Ase
Range

28 26

1l

t6

z)
t2-47
25

t4-45
28

12-47

t4-47
35

12-45
25

Mode Mean Age Standard deviation

Jf
23.6

24.6 6.87

26.2 7.9

22.2 6.72

23.9 7.48

Education Illiterate NFE & Formal - Upto

6-10
5

Jf
25

49
35

86

46
38

30
A1

28 44 27
2

9l
49

6l
JJ

t2l
96 39 2 167

47

7l
29

)t

l0

t4

t6

29 z

t0
0

l5

ll+
Monthly income
uDto Tk 1000
46
4
J

87
8

121 22

82

67

70
7

r00
4 I

95
4

83

Tk l00l-2000
Tk 2001 -3000 Avs income in Tk Marital status Currentlv Married
Unmarried
Separated/W idowed/ Abandoned No. of wives for married men

l5
J

22

26
8

l3
4

6 878 68

)
98
83 6

875
52 44
4

t072
66 40
2

696
80 62
8

876
146
57

48
19
A

6l
)t z
97
4
100
1-3

53

27
5

4l
5

t02

40
J

l0
64 2 66

l8
More than I Base (married men)
Range
I

95
5

46
I A1

98
2

64
2

97
100

l9

100

100

66

l-3
70 98
185 2

It
99

l-3 t46
J

Present Living status Spouse/Fami lylParents Alone

108 0

100 0

98

2s5
3

99

t*x* 2%t* &:ru'eiw*rsmrlv

*t *k*

&SX&$!d Sc'rsti*a***

f*r

*4*e{t$'c Sewei*lpsyr***

ADrc I. HI V/AIIJb AWATENESS Table 2. HIV/AIDS Awareness and perceptiron rce

Muslim

Non-Muslim

M le

N:71
Aware of HIV/AIDS
Yes
A1
1A

o/ /o

N:
187

"/,

N:
108
85

Femalc

Atl

N:
150

o/ /1,

N:
258

Vo

66 34

l0l
86 22 28

54

?o

tli
87

A')

148

57

No
Source of HIV/AIDS Awareness Radio
Friends/Farn i lv/ Cornmun ity

46
22 28

z)
c)

2l

58

il0
JJ

+J 22 26

1I

ZJ 24

ll
35

\2
2

30

24 o
5

38

t4
8

39
2

Book/newsoaoer

4
2

t5
72
5

l5
7l
5

t2
2

l5
2

tl
7

II
IJ
5

Bill board/ooster
TV
Government health worker NGO worker Mothers club worker/Health worker From doctor/from s irlteacher Govt. hospital/ health complex Labor House
Base (aware) 36
2

77
A

58
2 o

68
2 7
8

50
5

79
8

r08
30
LJ

ll
t-) 2 2

LJ

28
A

l9 l0
7 I 8

19

24

38

20

t0
1

7
()

t6
0

25
0 0 2

l6
f)

tt
3
r)

o
3

J
8

47
9
I 8

r00

l0l
)o
0

100 20
0

85

100

63

r00

148

r00
20
I

Major HIV/AIDS transmission routes idcntified

Sex between male and female

l9
2

7
0

22
ta IL

i5
2

29

Male to male sex Sex with sex worker Mother-child (By birth) Mother-child (Through breast feeding) Sharing food/clothing
Unsafe blood transfusion
Sex without using condom

t7
A

zo
4 9
7

26
4

22
A

z6
5
A

to
J

J1+

LJ

z
o

4
8

J
I

6
2

J
7

t4
2

t2
8

7
IJ
13

8
5 IJ

l3
t3
29
6 2
J
3

t2
12

10

2l
28
4

ll
l6
6
2 4
A

Needle Sharing Being untidy

t3
2

29
6

l9
7

26
2 0

l9 l9 4l
J

l6
L)

ll
l6
28
5
I

A1
8

Mosquito bite

0 2
I

0
.+

2
J
J

z
5
A

0 2

2
J
A

Mixing with AIDS patient/sharing food Have sex with multiple individuals/ sex
work Do not know
Base (aware)

4 2

24

5l
100

33

JJ

35
85

4l
100

22

35 100

51 148

39
100

47

l0t
43

100
A1 +J

bi
27

Correctness of response Only correct answer Partially Correct answers Only incorrect answer Do not know
Base (aware)

l5
8

32

3l
12
1

36

4i
z+
0 35 100

58

39

t1
0

l9
7

t9
7 )J

l+
8

l5
0

27
7

l8
5

24 47
9
7 7

5l
r00
19

JJ

35 85

4l
100

22
OJ

57

39

l0l
25 22
IJ

100 25 22
t-) 100 2

r48
34 29

100
ZJ

No. of correct answers : Ways of HIViAID S tran mtsst0 n

I correct

answer

L)

27

ll
t5
IA tt

t7
24

2 correct answer

l5

t4
6 85

l6
8

20

3+ correct answer Base (aware) Median

Range

l5
r00 z

22
100 2

20
148

l4
100 2

41

l0l

100

63

t-4
2

l-4
1.9

t-4
1.7

l-4
2.2

t-4
1.9

Avs. correct answers

.f.

t:

t,i

:. r:r illr L.|,:i,

ilx

l:;

rf i : t ti.j:tll

:!

Table

2.

HIV/AIDS Awareness and perception (continued)

Muslim N= 7l oh Non-Muslim

N:
187

oh

Male o/o N= r08

Fcmale

Atl
N=
258
oh

N:
r50
Z)
20
lC)

o/o

Major Preventive Measures Identifi

Havine sex with condom

ed

l3
12
3

28 26
6
IJ

26

26
21

t6
1a IJ

t9

JI

j.) JJ 6

26

Not sharing needles

Taking doctors advice Blood test before transfusions

2l
16

l5
7

)z
8

zz
A

6
3

t6

6 12
14

L)
0

22

Not have sex with multiple partners Not Have sex with sex workers
Do not know To keep away from AIDS patient Wash sex organ after sex

z
25
I I

4
53 2 0 0

t2 t2
44
J 4 I

t')
t2
44
4
I

l4 l6
52

t5

l5 l0
9

l4
69
A

44

25

40
3

47
J

z
A

z
5

z
0
I

0 0

0
2

Using medicine
Base (aware)

0 85

0 100

47

t00
38
6

l0l

100

63

100

t48

100
A1 +J

Correctness of response Only correct answer Partially Correct answers

l8
J I

4)
7

29
8

34 9
5

)q 2 2

54
3

7
5

oi l0
6

7
4

Only incorrect answer

Do not know
Base (aware)

z
53 44

4 44
85

25

44

52
100

25
63

40

69
148

41
100

47

100

t0l

t00
24
14 9 100 I

r00

No. of correct answers: Ways of protecting oneself from AIDS ')^ I correct answer ll 2 correct answer 3+ correct answer
Base (aware)
7

lo

l9
1a IJ 5

li

2l
r6

29

20

l5
l3
100 2

t4
9
101

lt
I

l0

ll
63

l8
100
2

2l l5
148

t4
10

41

85

100

100
2

Median
Range

t-4
2.1

t-4
t.7
J

l-4
1.6 0 6 2 0 6 2

t-4
2

I-4
1.8

Avs. correct answers Self Perception: Chance of contracting H V/AIDS

Very High
Moderate
0
0

z
5

t+

J J

2
4

0
0

l0
2

4
0

l0
2

Low No Chance Do not know Total (all respondents)

Reasons for reporting Regular sexual intercourse

20
50
71

28 70 100

35

l9
IJ

25
75

t)t t87
J

23 6g

30

20
75 100

55 187

2l
72

112
150

r00
100 0 0

108
0 0 0 0

r00
0 0 0 0

2s8
J

r00
75 25 25

"Very high" chance of contracting AIDS

0 0 100 100 100 J
I

75

Having sex with multiple partners

Partner is not faithful Base (respondents who reported a "very hieh" chance)

0 0
J

25 25 100
4

l
A

100

100

Table 2. HIV/AIDS Awareness a and perception (continued)

Muslim Non-Muslim Male
Female
o/ /11

Atl
N=
258

N:7t
Reasons Regular sexual intercourse
0
0

ol,

N:
187
2 2 J
I

al/

/(,

N:
108

N:
ls0

v,

for reporting "moderate chance" ofcontracting AIDS

0 0

20
20 30
z
2

tl
JJ 33 t1 lt 6 100 0 4 0

25
0

2
2
J

20 20
30

Having sex with multiple partners Do not use condom while havinc sex

0 0

0 0

25
0 100

with oartner Visitins the barber

l0
100

l0 l0
100

Base (respondents who reported a 0 0 l0 "moderate" chance) Reasons for reporting "low" chance of contracting AIDS

Occasional condom use during sex Have sex with one partner
Base (respondents who reported a

0 0 0

0 0
0

I
I

50 50

I
I

50 50 100

0
0

50 50 100

0 0

r00

"low" chance) Reasons for reporting no possibilities of contracting AIDS

No STDs at oresent Go to doctor for regular check-up
Use condom with husband loartner Use condorn regularly while having sex Use condom occasionally while having
SCX

0
0

0
I

0
4

J 0
2

l0
0
7

J
I

0
5

)
J

2
4

0 4 2

25
0

l0
2
A

29
6

t6
8

ll
U

3l
0

l5
2

27
4

Have sex with only partner Abstinence Keep myself clean Do not have sex with sex worker
0 6

25
0

il
6

')A

l0
J

9
2

l6
4

4
4

30
5

l0
6

29
3

t6
4 28

12
I I

40
3 J

l6
2
8

29
+

Faithful Do not have sex (unrnarried) Do not know

Base (respondents who reported a

l0 l5 l5
r00

17
J

7
4

t5
7

l6
0

0
5

2 35

t7
100
55

20

100

25

"no" chance)
Treatment Seeking behavior if worried about ST DS
Government hospital Private doctors/c linics Relatives Friends Pharmacy
t

r00

30

t00

20
48

28 68 20
7

4l
107 27

25 57

ll
8l
5

l0
75
5

56

37

o/
r55

26

74
36
5

49
ai

60

t4

l4
6
2
n

z+
J J

4l
t7
5
7

l6
7 2 J
J

t2
4
7 7
A

t2
I

ll
6
7

I 0 0
J
I

Kaviraj/Ayurved iclTea garden doctor

Aware/knowledgeab le persons Health workers Health center

0 0
2 I

l
7

0
0

4
2
I

0
0 0
8

7 6
2

6
2 2
I

0 0

2
I

2
2
I

Spouse/familv rnembers NGO/BCSU workers/ Mothers Club

workers Labor House

2 0

z
5

12

t2

t4

1 0

4 0

l0
0
5

il
I

I
I

I I

0
J

Will not go anywhere

Do not know/cannot say
Base (all respondents)
0
71

2 z

o 2

0 100

r87

t00

108

r00

150

t00

258

100

Table 2. HIV/AIDS Awareness and perception (continued)

Muslim Non-Muslim

N:71
Awareness of source of obtaining condoms Family planning worker Grocery stores/small shops Health workers/NGO Medicine store Hospital/ Doctors chamber/pharmacy
Doctors chamber/pharmacy

th

N:
187
8

o/o

Male V" N=
108

Female

Atl
N=
258
o/o

N:
150

Vt

2 88 6

44
9

62

105

56

8l
6

l0 6l
26
JJ 0

'1

t2
149 32
70 J

41
T7

58

t2
27
0 0 JI 100

z)
51

l2
27 z
I

t2
27 l I 29
100

l9
0 0

)t
3

).r
J

22 0 0 45 100

J 2

z
7 108 6

0 68
150

z
75

Do not know
Base (all respondents)

22

)J
187

28
100

7l mptoms to

100

258

T a ble 3

STD/RTI

Muslim

Non-Muslim

Male

Female

Arl N=
2s8
"/o

N:71
Incidence of sexual health problems Itches/ burns while urinatins
Pus from urinary cyst

N:
187
ai J+

"

N:
108
12

N=
1s0

o/o

t4
0 1 6 9
7
A

20
0 6
8

l8
J

ll
0
J
8

36

aA J

48
5

t9
2 6
5

Ulcer in the sexual organ/anus Itchiness in sexual orsan

Itchiness with menstruation (only for female) Excessive menstruation (onlv for female) Bad srnell with menstruation
Pain while having sexual intercourse

t2
8

6
4

l3
5

9 J

l6
t4
30

9 0 0 0
7

l3

2l
9

l1
5

0
0

30

20

t2
6
8

l0
6

l6 )o l5 5l
A'' 74

ll
IJ
10
).1

t6
20
22
51

l6
t5
35 36 107

9
8

0
6 0 7

l0

9 20

Pain/pus during menstruation (only for fernale) Pain in lower abdomen

16
14

z)
20

l9 t9
57
LIJ

0
8

28

)U

t9
56

No symptoms

38

7l

66

49 240

t45

Duration of the main symptoms Avg no ofdays Measures taken for main symptoms
No care taken
Government hospital

256

104

t97
66
7
4

l8
J 0 4

56 9 0

48
4

62
5

22
0
2

63
0 6

44
7
L

59
9 J

60
6
A T

Clinic
Traditional healers (kab irai i/Airved/Heki mi) Private doctor
Pharmacy

l3
22
6 0
J

l6
4
2

22
5

o
5

l8
ti la

t6
6

2l
8

22

tn
l0
4

l
2

ll
4 2

J J J

0 0 0

0
0 0 100

Marie Stopes
Others
Base

z
2

z
J

J
A

z
J

)z

100

78

100

i)

75

100

ll0

r00

Duration of days after which treatment

was sousht Avg in days
39.3 6.4 28 21.1

''.'

,a..,"::

ABSTRACT
case study design was used to analyze how malaria messages were conveyed and communicated in mangrove delta of Laputta, Myanmar, highlighting barriers and locally appropriate solutions. The study focused on 8 villages (4 remote and 4 non-rernote) stratified by major economic activity (fisliing and farming). The study period covered l2 months, in the year 2000. An initial review of malaria component of the self-care manual was followed by 8 focus group discussions, 24 in-depth interviews and structured interviews of 405 married couples. No representatives of 45.4% (184/405) study households attended the self-care training. Almost all men (95.6%) but a much lower proportion of women (66.7%) thought that men should attend the training programme (P < 0.0005). Only 66.4% of 405 households had a manual at the tirne of . survey. Although a recently introduced self-care manual that dealt with malaria and some other important disease problems was perceived to be useful by 96% of men and 78o/o of women, it was used by only 24o/o of men and 47%o of women. Malaria information in the manual was accurate but many people found it difficult to understand selected parts. Difficulty in reading, lack of free time to read or preferring other forms of rnedia rather than the manual hampered its use. Poor training attendance with strong female orientation and low rates of keeping the manual at home resulted in low rate of use or not using the manual at all. For those with low literacy to adopt the correct practices, new ideas must reach their homes through effective mass media channels either by modifying the present manual or by using other means of communication. Men need to be trained together with women to achieve their full support in promoting the use of the manual and undertakins the advocated behavior.

KEY WORDS
malaria, self-care, information, barriers, Myanmar

l.INTRODUCTION
Malaria is a global concem and is a developrnent and poverty issue (Olliaro et a\.,2001 Remme e/ al., 2001). The disease is ranked as the top priority public health problem in Myanmar with 80% of the population being at risk of contracting malaria. Moreover, malaria is a complex disease characterized by wide variations in epidemiology and clinical manifestation in different parts of the world as a result of species of malaria parasites that occur in a given area, their susceptibility to commonly used or available antimalarial drugs, the distribution and efficiency of rnosquito vectors, climate and other environmental conditions and the behaviour and level of acquired immunity of the exposed human populations. Population movement has introduced resistant parasites to areas previously free of drug resistance (Bloland, 200I; Cowman and Duraisingh, 2001). In that case, up-dated messages are essential through variety of communication channels. The adoption and maintenance of new behaviours depend on how messages are conveyed and communicated (WHO, 2001). The effectiveness of health education melhods was explored in two selected health centres of Myarunar and found limited use of information provided (Le-Le-Win er al . 1996\.

The approach of self-care training and delivering self-care manuals to mral households in Laputta was one of the components of Human Development Initiative (HDI), being supported by the United Nations Development Programme (IINDP). The project was introduced for information empowerTnent by favouring the spread of health messages for specific conditions leading to more appropriate health behaviour including prevention and treatment of simple malaria. The magnitude of the problem of malaria in Laputta revealed among in-patients around 114.6 males per 100 females in 1998. The case fatality rates between 1991 and 1998 ranged from 1.3 to 5 per 100 cases at township hospital (Township Health Department,1999). Even among people with poor literacy, carefully designed print media can promote the diffusion of information through existing sociocultural networks and health workers. The major objective of the present study is to identiff how malaria messages are conveyed and communicated in the selected rural area of Laputta, highlighting specific preferences, barriers and locally appropriate solutions.
2.

METHODS

kilometers south-west of Yangon City. This rural area has 432 villages (2.1 million population). The main socioeconomic activities were subsistence farming and fishing. Malaria is markedly seasonal, with most transmission and disease occurring at the end of the rainy season. Self-care intervention was introduced in 1997 operationally perceived to cover prevention, self-treatment and self-referral focusing major health problems inclusive of malaria. The training of trainers programme for self-care (as operationally perceived by the project covered prevention, self-treatment and self-referral) was initiated in late 1998. Community sessions focusing on women in Laputta started between March-April, 2000. Selfcare manuals had been available in villases since March 2000.
Study design and sampling The case study design was used with multiple evidences obtained through qualitative and quantitative approaches (Yin, 1994; Creswell, 2003). The study focused on eight villages (4 remote and 4 non-remote) stratified by major economic activity (fishing and farming). A full list of eligible households was identified as a sampling frame. Of these, 50 eligible households per village (400 manied couples) were selected randomly. Next, if there was more than one eligible couple in the selected household, random selection was done by drawing lots.

Study orea The study was conducted in eight villages of Laputta, a mangrove delta situated about 380

Data co llection metltods The language, style, illustrations, sequence and contents of the malaria component of the manual were reviewed initially. The malaria component discussed the importance and severity of the disease, the importance of correct treatment, and provided information on transmission and prevention. Altogether 80 discussants (36 men, 44 women) joined 8 focus group discussions (FGDs) following the self-care intervention. Subsequently, a structured interview questionnaire (SIQ) was administered to 405 eligible couples (currently married with at least one child under l0 years of age) followed by 24 in-depth interviews (elders, religious leaders, school teachers, administrative authorities, health workers including volunteers, d-g sellers). Part of the questionnaire focused on socio-demographic characteristics, self-care training and the self-care manual. Field observations supplemented the survey findings.

Datu processing and antlysis Qualitative data were first transcribed and translated and were then processed and analyzed with ETHNOGRAPH version 5.0 while the quantitative data were analyzed with the Statistical Package for Social Sciences (SPSS) version I1.0. McNemar's test for categorical variables with a binary outcome and the 'Marginal Homogeneity' test for categorical variables with more than two outcomes were used for naired data. Ethics The study as part of the WHO/TDR funded research project (ID 991091) received ethical clearance from the Institutional Ethical Review Committee of Department of Medical Research (Lower Myanmar).
3. RESULTS

The study population (405 manied couples) was within the age range, 19-64 years (mean of 36.6 + 8.6 for male and 32.8 + 7 .9 for females), 12% (981810) were illiterates and 56Yo (450/810) had completed prirnary school. The majority of men (75%) worked all year round while half of the women were dependents. No representatives of 45.4% (1841405) of study households attended the training. Reasons for not sending anyone to the training were: members were busy (68/184; 37yo), or travelling (551184;29.9yo), or the rest were unaware of the programme. Inegular attendance due to economic activities, caring for a sick person (both children and adult) and difficulty in understanding the contents of the manual were reported during FGDs. Some felt dissatisfied, as the information provided was not new to them, some did not like the teaching method or did not accept people from their own village as their trainers. Of 221 respondents joining the training, nearly half (l0ll22l; a5.7%) did not attend regularly. As explained by one LINDP/I-IDI program personnel, baniers were more or less related to poor sensitization of villagers before the training started and insufficient knowledge of trainers with difficulty in explaining back to those who attended the training leading to lack of confidence in them.

During FGDs, men had neither commented on nor prohibited their wives from attending the training program. Reasons ascertained from men's FGDs for women not attending the training, attending inegularly or discontinuing attendance included, too busy with household chores, inconvenient for those with an economic activity, lack of interest in health matters, and financial worries. Ahnost all men (3871405, 95.6%) but a much lower proportion of women (2741405, 66.7%) thought that men should attend the training programme (P < 0.0005). Nearly 34% (1361405) of households had never received or had lost their manual while 66.4% (2691405) of households had a manual at the time of survey. Although the rate of using the manual at any time in the past was not high, the majority perceived the manual as 'very useful' with females less likely than males to find it useful (31414A5;78Yo vs. 3901405;96%;P < 0.0005, Table l). Ahnost 63% (2541405) of women and 70o/o (2821405) of men acknowledged that the manual was useful for "gaining knowledge about health". More women (80/a05; 19.8%) than men (241405:' 5.9%) found the manual useful for providing information about treatment (P < 0.0005,
Table 2).

Men's and women's FGDs agreed that women read more than men during their leisure time. However, in fishing villages, men have some free tirne during non-fishing weeks. Reading the self-care manual was assessed for any time in the past and within last two weeks before the survey. Significantly fewer wolnen than men never used the manual Qlal405;52.8% vs. 309/405 76.30/r; P < 0.0005). Most respondents had not read or asked others to read the self-care manual to thern

within the past two weeks (3621a05;89.4% of women, 3541405;87.4% of men, P :0.729, Table 3). In the study area, although development activities are underway, because of poor literacy skills, villagers even they were literates (40% of men, 620/o of women) avoided print materials with health messages and their misperceptions were barriers to correct actions. Other reasons cited for women not reading the manual included; reading is boring, do not have regular reading habit and poor eyesight. These findings were supported by results from the household survey in which the majority (51.7yo, 1871362 of women vs.69.2Yo,2451354 of men) were too busy to read the manual. The second most common reason for not reading the manual was it was not available (l5oA, 551362 of women vs. I3Yo, 471354 of men) whereas poor reading skills was the third most common reason, more commonly stated by women than men (Table 4). Similar reasons were highlighted during an IDI. Information on malaria in the manual was accurate but many people found it difficult to understand selected parts indicating the need for improvement. Although the manual was perceived as useful by 96% (3901405) of men and 78o/o (3141405) of women, it was only used by 24% (961405) of men and 47Yo (1911405) of women, respectively. The gap between use and perceived usefulness indicates difficulty in reading, lack of free tirne to read or prefening other forms of media rather than the manual.

Availability of malaria information througlt channels otlter than tlte manuul The choice of communication modalities should be based on evidence of people's preference (Egbule and Njoku, 2001). In study households,44.6o (361/810) of respondents stated that the self-care manual was the most appropriate way for them to leam about health matters whereas health education journals/posters/pamphlets were their second choice (208/810; 25.7%). The preference for the manual was highest in two fishing non-remote villages. Differences were statistically significant (P : 0.04) indicating a strong preference for the manual over other forms of print materials. However, almost a third of respondents preferred either discussions with health
workers or health talks. Gender speciJic predictors of preferences of media clrannels Face toface discussion and health talks vs. self-care mqnual

Women living in fishing/non-remote and farming/remote villages had a significantly lower preference for face-to-face discussion and health talks than for the manual after controlling for other variables. This relationship was not observed for men. Men preferred less of face-to-face discussions and health talks over the self-care manual in households with ) one male and female literate. Women who worked all seasons had significantly higher preference for face-to-face discussions and health talks than those who were dependents or worked only seasonally (Table 5). let vs, s elf-c a re man ua I Major economic activity and accessibility significantly contributes towards greater preference by women for joumal/posters/pamphlets over the self-care manual, in farming/remote villages and in farming/non-remote villages compared to those in fishing/remote villages. As noted earlier, the rate of availability of the self-care manual in these villages was over 70olo. Men's lower preference for journal/poster/pamphlets over the self-care manual was influenced by female literacy in the household and media-ownership after controlling other variables. If the partner was literate, there was a higher preference for the manual by men and also among those who were able to read and write, compared to those who could not and those with > one contact with public or private health services within past one year. For women, increased preference for print media other than the manual was found among those who worked all seasons compared to dependents and those who
Jo u r n a Up o ste r/pa mp h

worked seasonally (Table 6).

4. DISCUSSIONS AND CONCLUSIONS For increasing compliance to instructions of self-care manual, positive reinforcement by
interpersonal communication with health workers, volunteers and community leaders required fuither strengthening. According to the theory of social action, the role of the health worker is distinguished as the mediator on behalf of disadvantaged groups (l.{utbeam & Harris, 1998). Thus, more interpersonal contact with health workers and exposure to media other than the self-care manual is desirable. Results also indicated that the malaria component of the self-care manual focuses on providing information to encourage individuals to change behaviour but just knowing the facts is not enough. People need opportunities to build on their knowledge, skills and beliefs in their economic and cultural situations (Arber & Khlat, 2002). Enhancing functional or skill-based literacy could improve both men and women's ability to realize their own and their family needs in self-care against malaria. During the period of study, there were no libraries and community based

leaming centres in study villages. This scenario dernands changes for a favourable leaming environment especially in remote villages where there is little chance of people meeting health workers from whom they could obtain health information. Disease control programmes alone cannot solve this social issue which may also be replicable to other area development settings globally.
Poor training attendance with strong female orientation and low rates of keeping the manual at home resulted in low rate of use or not using the manual at all. Findings are not surprising as household literacy rates and reading skills in the study area are not high with low acceptance of print media including the manual. For those with low literacy to adopt the conect practices, new ideas must reach their homes through effective mass media channels either by modifying the present manual or by using other means of communication. Men's views are imporlant as they can help increase women's involvement in health decisions and community based intervention programs. Training men together with women is of major importance in this aspect to promote gender equity (Moss, 2002) in malaria knowledge and practices. This is desirable especially as men are leaders and rnajor decision-makers in study households and in the broader context of Myanmar society. Health and literacy skills could develop simultaneously by enhancing the use of the self-care manuals and other forms of print media.

Programmatic implications are as follows. Initiatives for developing community based learning centres and village libraries to stimulate reading habits, as in other parts of the country, are to be encouraged. As posters are popular and are preferred over the manual, increasing their availability in study villages will enhance the spread of information. To increase the use of the self-care manual, regular reading sessions in line with local acceptability might be the solution. Tirning of these meetings could be decided by the villagers. Other media and interpersonal communication with health workers should complement the manual. Men need to be trained together with women to achieve their full support in prornoting the use of the manual and undertaking the advocated behaviour. This action is desirable as men they often make decisions about treating suspected malaria in their households. Audience research for logical sequence and appropriate design to improve acoess of malaria component of the manual is required. As the information flow has no boundaries similar to spread of the disease, best practices through efficient and available resources in local to global settings could enable to fill up the knowledge gaps in malaria.

j.i:-:l-:,I 'j

inI

ACKNOWLEDGEMENTS
This study is part of the research project entitled: "Gender dimensions in malaria self-care in rr"rral Myanmar" funded by WHO/TDR, Project ID 991091. Profound gratitude goes to Ministry of Health Myanmar; Directors General from Departments of Medical Research (Lower Myanmar) and Health; Director (Socio Medical Research), Director @ublic Health), Head of the Divisional Health Department, Ayeyarwaddy Division, Head of the Township Health Department and his basic health staff and voluntary health workers; and all community members and authorities concemed in the study area and data collectors for the smooth conduct of the research project.

REFERENCES

Arber S and Khlat M. (2002). Introduction to 'social and economic patterning of women's health in a changing world'. Social Science and Medicine,54,643-647.
Bloland PB (2001). Drug resistance in malaria. WHO/CDS/CSR/DRS 12001.4
Cowman AF and Duraisingh MT (2001). An old enemy, a new battle plan: Perspectives on combating drug-resistant malaria . EMBO reports 2, 2, 77-79; doi: 10. I 093/emboreports/kve032.

Creswell JW. (2003). Research design: qualitative, quantitative, and mixed methods
approaches. Thousand Oaks: Sage. Egbule PE and Njoku EM. (2001). Mass rnedia support for adult education in agriculture in southern Nigeria. Adult Education and Development, 56, 779-187.

FAO (2000). Information as a means of empowerment. In: FAO editorial group [Eds]. Gender and food security: the role of information, Rome: Food and Agriculture
Organization, 15-19.

Le-Le-Win, Aung-Kyaw-Kyaw, Setkya-Soe, Nyo-Aung, Khin-Sandar-Oo et al. (1996). Effectiveness of health education methods displayed at the selected health centres, Yangon Division. Myanmar Health Research Congress. Yangon: Department of
Medical Research.
Moss N. (2002). Gender equity and socioeconomic inequality: a framework for the patterning of women's health. Social Science qnd Medicine, 54, 649-661. Nutbeam D and Harris W. (1998). Theory in a nutshel/. Sydney: University of Sydney.

Olliaro P, Taylor WRJ and Rigal J., (2001). Controlling malaria: challenges and solutions. Tropical Medicine and International Health. 6,922-927 .

Remme JFIF, Binka

F and Nabarro D., (2001). Toward a framework and indicators for monitoring roll back malaria. The American Journal of Tropical Medicine and Hygiene. 64,76-84.

Township Health Department (1999). Township Health Profile of Laputta.

WHO (2001). Information, education and communication. Lessons from the past: perspectives for the future. Geneva: World Health Organization.
Yin RK. (1994). Case study research: design and methods. Thousand Oaks, CA: Sage.

TABLES Table

1.

Perceived usefulness of the self-care manual by gender, Laputta, 2000

Usefulness of the manual

Male (n = 405)
390
10

Female (n = 405)
314 77
77.5
19.0

Very much To a certain extent Not useful Don't know

96.3
2.5

t.2 l2 Marginal homogeneity test Z:

0 5

0.0

0.5 3.0 6.86, P < 0.0005

Table 2. The reason cited for perceived usefulness of the self-care manual by gender, Laputta,2000
Characteristics Not useful & useful partially
To gain knowledge about health

Male (n
5

:405)
1.2

Female (n = 405)

t4
254 20 27

J.)
62.7 4.9 6.7
19.8 2.5 P < 0.0005

282
38

69.6 9.4
13.1

Useful for family as well as for others

Can prevent the disease
Can provide treatment by looking at instruction

)J

Others & not answer

24 3

5.9 0.7

80
l0

Marginal homogeneity

Z:3.5,

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Table 3. Use of the manual (malaria component) by gender, Laputta, 2000

Characteristics
Yes Never

Male (n = 405)

,h

Female (n = 405) t

Read or asked others to read the manual to them any time in past

96 309 27 24

McNemar Chi-square : 57.0, P < 0.0005

87.4

23.7 76.3

191 2r4

47.2
52.8

Read or asked others to read the manual to them in the last 2 weeks

No
Once

354

More than once

6.7 5.9 Marginal homogeneity Z :1.52,P

362 30 13

89.4

: 0.129

7.4 3.2

Table 4. The major reason for not reading the manual during the past two weeks by gender Laputta,2000 .

Characteristics
No interest Poor reading skills Busy Not necessary Do not know who can read Reluctant to ask those who can read Don't know Loss/ borrow the manual No response

Male (1 = 354)
No.

Female (n = 362) ,/, No.

4.0
7.1

25 245 5 4 9 47 5

t4

69.2
1.4
1.1

2.5

Note:

34.2, df :7, P < 0.0005 Chi square is computed by combining cells with sparse numbers. Total does not add up to 405 in males and females due to skip question.

Chi square

13.3 1.4

32 44 187 13 I 18 7 55 5

8.8 12.2 51.7

3.6 0.3 5.0

1.9 15.2
1.4

*n "Slobal fi*althr Esrderle*s &lcvemsnt cf P***ase"

Table

Multinomial logistic regression analysis of media preferences (face to face discussions and health talks vs manual) and selected characteristics by
gender, Laputta, 2000 Face to face discussion and health

talk

vs self-care

manual

Adjusted 95' Cl OR Major economic activity & accessibilify

Fish/non-remote Farm/remote Farm/non-remote Fish/ remote @ Male literacy in the household > One literate 1.00 All illiterate @ Female literacy in the household ) One literate 1.00 All illiterate @ Owned TV, radio/cassette

Characteristics

Male (n = 405)

Female (n = 405)

#P Adjusted values OR
0.52
0.53

g5',

ct

#P values

0.28 0.28 0.38

- 0.95

0.034*

0.70 1.00 0.01-1.17

0.081
1.03

- l.0l 0.053x - 1.31 0.26s

- 3.10
0.961

0.29

0.34

1.00

0.27

0.11-0.65

0.004*

1.03

0.42

-2.50

0.957

1.00

Owned either Owned both None @

one write

1.63 0.51 1.00 0.51

0.86-3.07 0.tt- 2.33

0.16

0.133 0.385

Literacy skills Able to read &

L00 Unable @ Seasonal variations in employment Work all season Depend/ work some season @ Contact with health services
> One contact No contact @
## Pearson Chisquare

-1.58

0.242

0.79 1.00

0.41

-1.50 0.481
- 2.80
0.013*

r.79
1.00

.13

r.28
1.00

0.73

-2.25
P

0.395

y2 = 38.3, df

:34,

: 0.28
at P < 0.05;

y2:72.9, df :72,

: 0.45

Note: @: Reference category; * : significant

P < 0.10.

t:

marginal significance 0,05 <

# P values for predictor variables are the result of the Wald Test for chi-square (z statistic). ## Pearson Chi-square is the test statistic used to decide the good

fit of the final model. It

differs from Wald Test for predictors. In model testing, the goal is to find non-significance, to find a model that is not reliably different from a full model (Tabachnik BG & Fidell, LS 2001. Using multivariate statistics, Boston: Allyn and Bacon, pp 578).

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Table

Multinomial logistic regression analysis of media preferences (Journal / poster / pamphlet vs self-care manual) and selected characteristics by gender, Laputta, 2000
Journal / poster/ pamphlet ys self-care manual

Characteristics Adjusted OR

Male (n :405)
95o/o

Female (n = 405)
#P

Cl

values

Adjusted OR

95o/o

Cl

#P values

Major economic activity & accessibility

Fish/non-remote Farm/remote Farm/non-remote Fish/ remote @

l.l9
2.84 3.02
1.00

.41-3 .00

0.710

I . r 9-6.80

0.019*
0.013 "

1.26-7.26

Male literacy in the household

> One Iiterate 0.68
1.00

0.18-2.67

0.585

0.66

0.22-1

.98

0.459

All illiterate

L00
0.16-0.82

Female literacy in the household > One literate 0.36

1.00

0.015*

0.74
1.00

0.28-2.00

0.554

All illiterate

Owned TV, radio/cassette

Owned either one Owned both None
@

0.54 0.38
1.00

0.27-r.05
0.1 I -l .36

0.07r

0.137

Literacy skills
Able to read & write
Unable @ 0.30
1.00

0.t l-0.81

0.017*

0.50
1.00
2.7 5

0.23-1.07

0.0741

Seasonal variations in employment

Work all season

Depend/ work some season @

.57-4.83

0.000*

1.00

Contact with health services

> One contact No contact
@

0.3 8

0.21-0.69

0.001*

1.00

: 38.3, df : 34, P : 0.28 y2:72.9,df:72,P=0.45 *: significant at P < 0.05;t: marginal significance 0.05 < P < 0.10. Note: @: Reference category; # P values for predictor variables are the result of the Wald Test for chi-square (z statistic).
##Pearson Chi-square
^tr2

##

Pearson Chi-square is the test statistic used to decide the good

fit of the final model. It differs from Wald Test for predictors. In model testing, the goal is to find non-significance, to find a model that is not refiably different from a full model (Tabachnik BG & Fidell, LS 2001 . Using multivariate statistics,
Boston: Allyn and Bacon, pp 578).

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ABSTRACT

In July 1999, a single dose of live-attenuated SA 14-14-2 Japanese encephalitis (JE) vaccine was administered to children living in the Bardiya, Banke and Kailali districts of Nepal. In 2004, the original vaccinated population experienced a fifth seasonal exposure to JE. In order to measure efficacy of the vaccine we performed a case-control study comparing the prevalence of the adrninistration of vaccine in patients with JE hospitalized in the Bardiya and Bheri Zonal hospitals and in age-sex matched controls resident in the Bardiya district. Among the 219 village controls, 114 had been vaccinated (52.1%) while only one of 20 JE cases had received live-attenuated JE
vaccine. Five years after administration of a single dose, SA 14-14-2 provided a protective efficacy of 96.2oh (CI 73.1-99.9%).The study was conducted during the period of May 2004 to November 2005 with a financial support of Glovax Company Ltd. Korea KEYWORDS
Japanese encephalitis
;

Flavivirus;

Vaccine

1.

INTRODUCTION

administering JE vaccines, budgetary constraints made it irnpossible to irnplement an immunization program. The donation in 1999 of a large quantity of SA14-14-2 liveattenuated JE vaccine (live JE vaccine) offered an opportunity to provide for some of those needs and to evaluate efficacy [3].

Between 1978 and 2003,26,661 cases and 5,381 deaths due to acute encephalitis have been reported in Nepal [1]. Mortality and long-term sequellae rates are high in the age group below l5 years [2]. Although Nepal health authorities favored protecting the population by

ll-24 July 1999, nearly 160,000 doses of live JE vaccine were administered to children, ages l-15 years, resident in 3 districts of Nepal[2,3].In Bardiya district 79.9o/o of children in this age group were vaccinated, 34oh in Banke and lSYo in Kailai districts. When measured during the year of administration, the efficacy of a single dose of JE vaccine was 99.26% (Cl 94.9-100%) while 1 year later it was 98.5% (CI 90.1-99.2%) [3,4]. Here we report vaccine efficacy observed after 5 years ofseasonal exposure.
During

2. MATERIALS AND METHODS

2.1. Study locations und subjects

Using methods described previously [3,4], a case-control study was performed in Nepalese children, adolescents and young adults, ages 6-20 years, residents in Bardiya district. Controls were selected from individuals of the same sex and ages living in the same village as JE cases. Study protocols were submitted to Nepal Health Research Council in November 2004 for approval of this case-control study. Because of the Maoist insurgency in Nepal, interview of controls was initiated in OctoberA.{ovember 2005 almost i year after the end of 2004 epidemic. Written informed consent forms were completed by parents or guardians of cases enrolled in hospitals and age-sex matched village control cases.

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2.2. Selection of cases

The case-control study was restricted to residents of the Bardiya district who were admitted to the Bheri Zonal or Bardiya district hospitals in July/October 2004 as the only JE vaccine administered in this district was the live vaccine given in July 1999.

In May 2004, JBT visited the Bhen Zonal hospital and Bardiya district hospital to select study physicians, lab technologists and nurses and conduct a 2-day training program in specimen collection/storage, interview methods and clinical record-keeping. The inclusion criteria and the standard procedures for selecting and reporting cases were defined and discussed with study staff.
Cases of JE complied with three criteria-(l) acute onset of fever of up to 7 days duration; (2) one ormore of the following: change in consciousness, stiff neck, limb weakness, or long track neurological signs; and (3) IgM positive JE ELISA in a serum obtained at least 5 days after onset of fever. History of JE vaccination was elicited at the time of hospitalization and noted on a specially designed protocol in the hospital chart. After serological results were available on hospitalized cases, investigation team members (JBT HCO, YMS and SY) met in Bangkok on Septernber 2005 to review the clinical records for conformance with the JE case definition and to obtain records of name, age, sex, home address, admission history, physical examination and data on hospital course.

Inclusion criteria Jor JE cases in the case-control study were es .fbllows: year of birth between June 1984 and 1998; continuously resident in Bardiya district since June 1999; admitted to Bheri Zonal or Bardiya district hospitals with a primary diagnosis of JE from July to October 2004; clinical JE (see case definition); laboratory confirmation (paired or single sera positive in a IgM capture ELISA and/or plaque reduction neutralization test).
Exclusion criteria: Bacterial encephalitis or meningitis based r-rpon CSF culture or smear; immigrants to Bardiya district after 1999 vaccine campaign.

2.

3. Serologica I determinations

serological tests were performed on coded samples Development, Mahidol University, Bangkok, Thailand.
2.3.1. Plaque reduction neutralization tests (PRNf)

All

at the Center for

Vaccine

Separated sera were kept under -20 .C before testing. Neutralizing antibody was determined in LLC-MK2 cells by PRNT using the 50% plaque reduction endpoint method described by Russell et al. [5]. Serial four-fold dilutions of serum were made (l:10, 1:40 and I :160). An equal volume of diluted Beijing strain JE virus (genotype III) to contain about 4050 pfu/well were added to each serum dilution tube. Following incubation at 37 .C for 60 min, 0.2 ml was removed from each tube and inoculated onto triplicate six-well plates of confluentllc-MK2. Each platewas incubated at 37 .Cfor 90 min and the monolayers were then overlaid with 4ml of 3.5Yo carboxy methyl cellulose/rninimum essential medium, Earles. Plates were incubated for 7 days at37 .C with 5% CO2. Plaques were counted and PRNT 50s were determined using SPSS. An antibody titer of 1:10 or above was considered positive. JE viruses isolated from Nepal and India also belong to genotype III [6].
2.3.2. IgM/lgG ELISA

IgG or IgM assays as described by Innis et al.l7l were modified by performing tests in microtiter plates coated with goat antihuman IgG or IgM. Diluted serum samples (l:100)

were added to 96 well plates coated with antihulnan-_ or -_ chain antibody. JE viral antigen prepared in Vero cells (lrlakayama strain) or control Vero cell culture supernatant was added, followed by enzyme-labeled antiflaviviral monoclonal antibody and substrate. Absorbance values of viral and control wells were measured. Results were expressed as a ratio of adjusted optical density divided by 0.5. A positive value was equal to or greater than 1.00.

2.4. Selection of controls

Age-sex matched village controls were selected as described previously [3].We recruited all available matches, or between 6 and 20 controls/case to avoid potential sarnpling bias. Inclusion criteria for controls: individuals resident in the same village as a serologically confirmed JE case;the same sex and age as index case (born between June 1984 and 1998).

In October 2005, we organizedaZ-day training course to prepare field staff in the procedure of selecting controls. From OctoberA.,lovember 2005, JBT and field staff visited villages of confirmed JE cases and identified/confirrned the JE case by his/her name, age, sex and father's name as recorded in hospital during the time of hospitalization. Vaccination status of JE cases was again checked by re-interviewing parents. Controls were identified by starting at the home of the index case and visiting sequential houses in a clockwise direction.
2.4.

I. Ascertainment

of' vaccination history

vaccination registry or the family JE vaccination card. The child was classified as unvaccinated if there was no written evidence of vaccination, the parents or guardians reported no JE vaccination in 1999 and there was no record of the child's name on the vaccination registry.
2.

At least two fieldworkers interviewed parents or guardians using a structured questionnaire and in depth interview to elicit recall of vaccination status. It should be noted that the campaign-style adrninistration of live JE vaccine in 1999 was a unique event. Based on the information obtained by interview, a cl-rild was considered as vaccinated if the parents reported JE vaccination during 1999 or there was a record of the child's name in the

5. Statistical methods

Vaccine efficacy is calculated as 1-relative risk (RR) which can be replaced with the odds ratio of vaccination among the cases to controls [8-10].We used exact logistic regression to calculate ORs and the exact confidence interval, conditioned on various numbers of a matched set for one dose of liveattenuated vaccine compared with zero doses [ 1]. LogXact 7 for Windows was used to analyze the data set.

3. RESULTS

3.1. JE situation and vaccitrcrtion status

[n2004, from all of Nepal, 1543 cases and 131 deaths (9.8% CFR) of acutc encephalitis were reported to the Epidemiology and Disease Control Division (EDCD) of the Ministry of I-lealth, Nepal. One hundred and eleven cases were residents of Bardiya district where the administration of live JE vaccine in 1999 was reporled to be 80% U.12,131. No other JE vaccine had been adrninistered in this district by means of an organized campaign.

3.2. Case-control study

During the 2004 ciutbreak, 20 cases admitted to Bardiya and Bheri Zonal hospitals met the criteria for entry as JE cases and were confirmed serologically with a positive IgM antibody and/or PRNT antibody in acute or convalescent sera (Table 1). Among 20 long-term residents with serologically confirmed JE (mean age 7.8+1.96 years) enrolled into this study, only one child had a history of having received JE vaccine in 1999. As evidence of etiology, all cases were con-firmed by JE IgM ELISA and also each of 19 tested sera circulated significant levels of JE PRNT antibodies (Table l). Of 219 age-sex matched village controls, 114 (52.05%) had evidence of JE vaccination in 1999.
We calculated a median unbiased estimated of the odds ratio of 0.03818 with lower and upper confidence bounds of 0.0008 and 0.2692 and a protective efficacy of a single dose of 962% (CI73.I-999%) (1'able 2).

No significant difference was observed in protective efficacy in this compared with the two previous case-control observation periods measured in 1 999,2000 and 2004 (p > 0.05).

4. DISCUSSION

Fortuitously, the high immunization rate in Bardiya district in 1999 led to a decision by Nepalese health authorities to omit this district from participation in the killed JE vaccine campaign of 2000. Teams visiting villages to enroll control subjects found that most householders vividly remembered the 1999 imrnunization campaign, parlicularly because it was followed almost immediately by an unusually large JE epidemic and the effectiveness of SAl4-14-2 vaccine was immediately apparent to a very large number of people. The disproportionate vaccine coverage rate reported for the entire Bardiya population (80%) in 1999 campaign and that of the villages where JE cases and control lived (52.05%) was probably due to differences in vaccination coverage among some villages. The further the village was from the site where vaccines were administered the lower the vaccination coverage during 1999 vaccination campaign. JE cases tended to occur in villages with relatively low vaccination coverage. The vaccination rate of the control group was about 50%, which is similar to rates reported in our previous studies [3,4].

In China, with 17 years experience administering this vaccine, more than 200 million children have been vaccinated and more than 50 million doses of vaccine are produced
annually [4]. Numerous large-scale field trials in China have shown an efficacy of at least 95% following administration of a single dose of vaccine followed by a booster given at an interval of 1 year [14]. Studies in China have demonstrated protection 11 years after a single dose was administered campaign style to children l-10 years old while two doses were given to birth cohorts. Because of the requirement in China for the administration of two doses of SA14-14-2 vaccine there has been little opportunity to measure the efficacy following administration of a single dose. In our previous reports, the efficacy of a single dose JE vaccine at the first year was 99.25Yo (CI94.9*100%) and I year after vaccination as 98.5% (CI 90.1-99.2%) [3,4]. Here we show that protective efficacy was essentially sustained unchanged (96.2% CI:73.1-999%) for 5 years.

It is important to note that no authentic severe events were found to be related to the vaccine following the administration of 9.38 million doses of SA 14-14-2 vaccine to children in India in 2006 [15]. Given this recent affirmation of its safety and in view of additional evidence of

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of a single dose of SA 14-14-2 vaccine we recommend immunization with this vaccine be extended to all populations at risk to Japanese
sustained long-term protection encephalitis.

ACKNOWLEDGEMENTS
We wish to thank Dr. Durga Pradhan, pediatrician, and Ms. Bhunu Shah, Project Nurse at the Bheri Zonal hospital, Nepalgunj and Dr. Arjun Shrestha, physician and Ms. Devi Thapa, Project Nurse at Bardiya hospital for care and identification of JE cases. Thanks also for the laboratory technical assistance of Mr. Govinda Paudel and Mr. Gyanendra, laboratory technicians, respectively at the Bheri Zonal and Bardiya hospitals. Our appreciation for the support of Dr. Yam Bahaur Basnet, Medical Superviser, Bardiya hospital and Mr. Nanda Lal Shrestha and Mr. Arjun Gautam, Medical Recorders, Bheri Zonal hospital. Assistance with hospital and village visits to identify cases and controls was provided by Mr. Pushpa Khaniya and Mr. Mitra Bhattarai, Health Assistants, School of Health Sciences, Chitwan, Mr. Jeevan Rajauria, lab assistant and Mr. Sita Ram Chaudhary,

Community Medical Assistant at the Bardiya hospital. Ms. Laxmi Malla, Program Officer provided secretarial assistance and Mr. Prithbi Raj Baidya, Yeti Chem Distributor, helped to maintain sera in the cold chain and forwarded sera abroad for laboratory testing.
Japanese Encephalitis Support Group Nepal

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REFERENCES

Ministry of Health, Epidemiology and Disease Control Division, Nepal, JE Cases; 2004.
Bista MB, Shrestha JM. Epidemiological situation of Japanese encephalitis in Nepal. J Nep Med Assoc 2005;44:51*6.
Bista MB, Banerjee MK, Shin SH, Tandan JB, Kim MH, Sohn YM, et al. Efficacy of single dose SA 14-14-2 vaccine against Japanese encephalitis: a case-control study. Lancet 2001 :358:79 I -5.

Ohrr H, Tandan JB, Sohn YM, Shin SH, Pradhan DP, Halstead SB. Effect of single dose of SA l4-14-2 vaccine I year after immunization in Nepalese children with Japanese encephalitis: a case-control study. Lancet 2005.366:1 375-8.
Russell PK, Nisalak A, Sukhavachana P, Vivona S. A plaque reduction test for dengue virus neutralizing antibodies. J Immunol 1967 ;99:285-90. Chen WR, Tesh RB, Rico-Hesse R. Genetic variation of Japanese encephalitis in nature. Gen Virol 1990'.1 | :291 5-22.
.I

Innis BL, Nisalak A, Nimmannitya S,Kusalerdehariya S, Chongswasdi V, Suntayakorn S, et al. An enzyme-linked immunosorbent assay to characlerize dengue infections where dengue and Japanese encephalitis co-circulate. Am J Trop Med Hyg 1989;40:127418.
Orenstein WA, Bernier RH, Dondero TJ, Hinman AF, Marks JS, Bart KJ. Field evaluation of vaccine efficacy. Bull World Health Organ 1985;63:1055-68. Rodrigues LC, Smith PG. Use of the case*control approaches in vaccine evaluation: efficacy and adverse effects. Epidemiol Rev 1999;21:56- 72. Rothman KJ, Greenland S, editors. Modern epidemiology.2nd ed. Philadelphia: LippincottRaven;1998.

Hirji KF, Mehta CR, Patel NR. Exact inference for matched case-control studies. Biometrics
1988;44:803-14.

Ministry of Health, Epidemiology and Disease Control Division, Nepal. Annual Report 2002 and2003.
Bheri Zonal Hospital and Bardiya Hospital JE Case Record Section Report 2004.

WHO position paper. Japanese encephalitis vaccine. Wkly Epidemiol Rec 2006;81 :331-40.

[15] State investigation reports of Adverse Events following Immunization (AEFI) after Japanese encephalitis (JE) vaccination in high risk districts covering 4 States of

the country. Reported in JE flash: http://www.path.org/vaccineresources

/files/JEflash l4Nov06.

Table

Laboratory confirrned JE cases from Bheri Zonal hospital and Bardiya district hospital in2004
ELISA First sample
Second sample

Serial
no

Age/sex

PRNT 50

nterval

First
sample

Second

sample

between first and second sera

JE vaccination
h

isto

ry

collection 22 days
I
I

IeM
N3

IeG
0.34 0.79 0.52 0.44 0.79 0.56 0.68 4.03

IeM

Iec
I .61

NT Ab
JL I

NT Ab
923

No
No

6tM
6tM

0.1'7

l.l5
L87
2.79 0.26

days

N4 N6 N7 N8 N9
N12 N24
B5

2.02 0.83 0.53 2.04

1.40

0.74
1.27

057 272

NA
>1000
96

3 davs

No
No
No

l2tM
6/M
8/M

7 days
I

t.76

z)

0 davs

NA NA NA
r.08
1.45

NA

l5l
NA
215 >1000
441 617

NA NA NA NA
>1000

Unknorvn Unknorvn
3 davs

No No No
Yes

6lMa
I

NA NA
4.24
2.83

tra

2.05 0.94 0.39

1.69

9tM
6/F

6 days 6 davs
I

NA
t.6'1
1.81

No No No No

B8

9tM
I

r.83
2.09 2.46

|.94

3t3
75

0 days

Br0 Br2

l/M
t/M

0.43 2.27 0.33 2.28 0.34

|.6',7

NA
r.98
1.56 1.48

<10

7 davs
I

0.89 0.60
0.7'7

ll
22

78
563

0 days

Bt5

7tp 7tM
7/F

r.38
2.19
1.32 1.66

Unknolvn

No
No No

Bl6
Br7

3470

2666
I

oavs

0.48 2.39

t.34 t.52
1.46 1.50 1.67 1.25

l5
>1000

340

7 davs 8 days

Bt8
820

7lM

>1000 >1000 >1000 >1000 >1000

No No
No No

t/r
6lM
6tF

0.57

0.5l

l.l5
1.57 1.95

>t000
NA
1934 1452

9 davs Unknown Unknown

82l
823

NA
0.01

NA
0.77 0.57

824
u

9/M

0.43

t.12

Expired

Tabfe

Effrcacy of a single dose live-attenuated SAl4-14-2 JE vaccine (result by LogXact)

Doses of vaccine

Cases

Controls (N= 219)

105

Received
0

(N= 20)
19

Efficacy ("h) lexact 95oh (confidcnce interval)l

96.2% rcr73.1-99.9%)

tt4

.**u* *i.rir' l&tlmiu*r$*r'$ i:lf l|Nl: ,l.!$il.&${ $n*$,iflm{*

f*r

${,*tx$t$r il}*v*l*psmrmtx[

ABSTRACT
The Gender Sensitive fuberculosis (TB) Control Intervention study was implemented to compare the effectiveness of gender sensitive TB control intervention with non intervention community in terms of case detection, social problems in accessing TB Care and treatment outcolnes particularly among the fernale TB patients of rural community. A total of 350 new TB patients (age > l5 years), cornprising of 175 frorn intervention and 175 patients from non intervention community were sarnpled following systematic sampling technique, during April 0l ,2004 to April 30, 2005 and followed-up till completion of treatment. The findings revealed that the majority of the females (65.5%) were within the age group of 15-34 years. The median age of female TB patients was 25 year and rnale TB patient was 40 years. The fernale patients of control community confronted more social problems and stigrna than the intervention community. The female TB patients of the intervention community had confronted less strong type social problems and stigma (20%) than the control community (25.8%) which is statistically significant (P< 0.05). The female patients of intervention comrnunity had better knowledge (83.6%) than the control community (68.2%). The fernale patient detection rate was remarkably increased in the intervention community after using Gender Sensitive Package Services during the year 2004 (34.37Yo vs 26.69%) to 2005 (35.05%vs28.57Yo). The treatment outcome of the female patients in regard to the cure rate was much better among the females (86.7%) than male TB patients (77.1%). The cure rate of the fernale patients of the intervention community (91.8%) was even better than the cure of the female TB patients of the control community (8I.9%). The findings suggest that the Gender Sensitive TB Control Interventions could be effective in similar situations.

INTRODUCTION
Tuberculosis (TB) remains tl-re prirnary killer of adult women and men in developing countries despite the existence of highly effective tools that can completely cure the disease (Jacobson,200l). Bangladesh ranked 5t'' arnong the top 22high TB burden countries of the world where 300,000 new tuberculosis cases occur every year, half of them are infectious and therefore spreading the infections in the community (WHO, 2005). Tuberculosis is associated with taboos, fear and stigrna, together with poor facilities and unfriendly health care provider's behavior which discourage the patient's smooth access to the health center, -fhe although highly effective TB drugs are available free of cost. report of National TB Control Programme (2005) revealed the present case detection (50%) in rural communities where only 30 and 70 percent of the registered TB cases of rural hospital were adult women and men respectively. The other study indicates the socio-cultural barriers and unfriendly TB care, prevailed in the rural community, discouraged females in seeking treatment from the health center. More than three forth quarter of females (82.7%) wanted to diagnose TB secretly and 85.6 percent of them wanted to examine by choice of gender (Ahsan et a|,2004). This is why, the Gender Sensitive TB Control Intervention study was implemented to compare the effectiveness of gender sensitive TB control intervention with non intervention community in terms of case detection, social problems in accessing TB Care and treatment outcomes of the sample TB patients particularly among the fernales. The cohort of sampled TB patients in the intervention and control communities were followed till the treatment outcomes, either as cured not cured.
i

MATERIALS AND METHODS

Study populotion and sampling process The Quasi- experimental study was designed to compare the effectiveness of gender sensitive TB control intervention with non intervention community in tenns of case detection, social problerns in accessing TB Care and treatment outcomes of the sample TB patients, particularly among the females. A carefully designed systematic Gender Sensitive Intervention package services were given to the intervention community @haluka) of Mymensingh district and the control community (Gaforgoan) was receiving regular TB services. A total of 350 new tuberculosis (TB) patients (age > 15 years), comprising of 175 TB patients from intervention and 175 tuberculosis patients from non intervention area were sampled following systematic sampling technique, during April 01,

2004 to April 30, 2005 and followed-up interviewed after having informed consent.

till completion of treatment.

The study sample was

The Gender Sensitive Intervention package services were comprised of, several important female friendly TB care activities such as, provision of TB care by choice of gender, optimize and sustain community awareness by providing regular educational messages, regular screening for TB suspects and patients, helping symptomatic women to bring up good quality sputa, sputum collection from the door step of women suspects and cases, providing health education and counseling, ensuring direct observation of intake of drugs by voluntary community TB workers, ensuring contact and defaulter tracing etc. The data collection tools was structured questionnaire, standard checklist and record collection sheets. All kind of ethical issue was tackled and there was continuous supervision, crosschecking and monitoring during data collection process. The data management system was developed. The data was verified, edited and clean properly. All the data was entered into the computer using standard data entry soft ware.
Statistical analysis
The collected data was analyzed both in qualitative and quantitative ways. Proportions of males and females were computed by using the chi-squire test with Yates corrections or Fisher's exact test as appropriate. Adjusted Odds Ratio with 95 o/o confident interval was computed by using multiple logistic regressions to assess statistically significant differences in case detection, treatment seeking behaviors and treatment outcomes between males and females or among factors of interest. Confounders were controlled by mathematical modeling and stratified

analysis as appropriate. (versionl 1.5) and Stata.

All statistical

analysis was performed

by

SPSS

for

window

RESULTS
The socio-demographic characteristics of sampled TB patients (table l) revealed thaL 45.4 percent of them were young adults of l5-34 years. But majority of the females (65.8%) and 36.7 percent of the males were within the age group of 15-34 years. On the other hand,45 percent of the males and l9 percent of the female patients were at the age of 45 years and above. Nearly l/3'o of the TB patients (30%) were females and 213'u of them were males (70%). The median age of female and male TB patients was respectively 25 and 40 years. More than half of the TB patients were uneducated (52.3) and the remaining were educated

l
from primary Q4.6%) to higher secondary level (2.6oh). Most of the TB patients were manied (81%), 16 percent of them were unmanied and only few (3.1%) were separated or divorced. Forty three percent of the TB patients had no income who were dependent on others and 36.3 percent of them had monthly income less than taka 2500 only. Most of the study populations were Muslin(92.3 %) and remaining (7.7%) of them were Hindu.
Table L. Comparison of socio-demographic characteristics of female and male tuberculosis (TB)
patients Female (n:105)
n 69
o/oo

Demographic Characteristics Age (Years) t5-34 35-44

45-54

Male (n:245)
n 90 45 34 76 123 90
aA LA

Tota
n 159 62 45 84
183

N=350)
o/ou

P-valueo

oho

6s.8

36.7
18.4 13.9

45.4

0.000

l7

ll

r6.2
10.5

|t.1
t2.9
24.0
52.3

55+ Educational status Illiterate

Primary High school

08 60

7.6
57.1

31.0
50.2 36.7 9.8

3l
13

29.5 12.4
1.0

t2l
37 09 56

34.6 10.6

Above lrish school Marital status

Unmarried

0l
24
75

08 JZ

2.6
16.0

22.9
71 .4

l3.l
84.9

Married
Separated

208
06

283

06 99 06

5.7 94.3 5.8

2.0
91.4 8.6

ll

80.9
3.1

Religion Muslim Hindu Income/month

224
21 JZJ

27

92.3 7.7

No income <Tk.2500 >Tk.2500

88

83.8
10.5

64

l1
06

l16
65

5.7

26.1 47.3 26.5

t52
127

7l

43.4 36.3 20.3

b:

Compare the significance difference between female and male

The table 2 summarizes the study findings indicate that the majority of TB patients (61.7%) of intervention community have good knowledge on tuberculosis. The female TB patients of intervention community have better knowledge (83.6%) than the control community (68.2%) which indicate significant association on knowledge on tuberculosis and the study communities (P-value < 0.05). The reason of having better knowledge of TB patients on tuberculosis may be resulted from intervention package services in the intervention community.

*fu* HSl* &nctiw*rsm*'y *'fl tfu* &Sfieru

,X*rst$tx"st*

S*r ffi*w$*$x ffi*v*$*g*r'n***

Table 2. Comparison of knowledge of TB patients on Tuberculosis between the study Communities

Bhaluka (n:175)
Knowledge
on TB
n

Gaforgoan (n=175)
Female

Total
(N=3s0)

Female (n=61)
o/-a /o

Male (n:1 14)

n
You 3

Male
n

(n:l3l)
o/
ao
a

Pvalueb

h=44)
n
o/ou

(%\
0.000

Poor Good

l0
5l

16.4

44

8.6

t4
30

r.8

66

50.4

134 (3 8.3)

83.6

70

61.4

68.2

o)

49.6

216 (6t.7\

The Line graph I indicates that the female TB patient's detection rate was approximately similar in intervention and control communities before intervention till 2003. The patient detection rate of females was remarkably increased in the intervention community (Bhaluka) after using Gender Sensitive Package Services during the year 2004 (34.37o/o vs 26.69%) and 2005 (35.05oh vs 2857%). There was little rise of male patient detection in control community. The graph is plotted using secondary data from the TB Patients register of the study areas during 2000-2005.

Graph

l. Comparison

of TB patients detection between the intervention and Control communities before and after intervention
Use of intervention ".*<-<1,--...4

- -- --.^___. _

,-_.

.{

o q

50

940
E30 o
o
.L

b20
10

2000
- +'

2001
Femalf

2002

2003

2004

2005

Bhaluka

Year Gaforgoan Female-r - Bhaluka Male --'' -' Gaforgoan Male

il.t.itl"rll!.|.l*l.l..,ii\'\rnltili:|i,l:..!ii'.}{J..{i,il,,:i:rilll{ll:l'|l{l\:l|l

The study findings indicate (table 3 & graph 2) the prevailing situations of social problem and stigma attach with tuberculosis in the rural community of Bangladesh. Half of the TB patients (49.7%) confronted rnild social problem and stigma in both of the study communities especially among the female TB patients. The female TB patients of the intervention community had confronted less strong type problems and stigma (20%) than the control community (25.8%) which is statistically significant (P-value < 0.05) and the reduction of the social problems and stigma in the intervention community rnay be due to the community education programs aiming to female TB patients and suspects. But the female TB patients of both the communities are confronted similar nature of rnild to moderate type of social
problems.

Table 3. Comparison of over all social problern and stigmas of TB patients in access to TB care between the study communities
Gaforgoan (n:175)
Female

Over all barrier of 'f B patients in

access to

Bhaluka (n:175)
Female

'I'otal
(N=350) N (%)
)
oh^

P-value

TB care

Male

Male

n
No Yes'
JZ

(n:61)
Yo^

(n:l l4)
n
39 15
IL-IJ

(n:44)

%oo

n
5

oh"
11 .4
8

n
43
88

(n:l3l

52.5

29

47.5

34.2 65.8

32.8

39
n=3 9

8.6

ot.z

r r e (34.0) 231 (66.0)

0.000

n:29

Mild barrier
Moderate barrier Strong trarrier

IJ

44.8 27.6
z /.6

4l
22

54.7 29.3 16.0

ll

n:88
28.2 25.6 46.2 46
52.3

N:231 111 (48.r)

08 08

l0
t8

zo

29.5
18.2

66 (28.6)

0.000

t2

l6

s4

(23.4)

Gfaph 2,

'

and stigrrtas of -fB Cornparason of over all social problern patients in access to -fB care Iret\ /een the strrdy cornrnr.rnities

Bharuka

E t\./lild barrier

Femare

ale

ED

Moderate

Gafordoan

barrier

Femal

El Strong

t)arrier

The female TB patients of control community confronted more social problems and stigma than the intervention community (table 4).One third of the all female TB patients had reported family member's hesitation in rnixing after getting TB. Of them, the female TB patients of control community had confronted more family member's hesitation (a0.9%) in mixing than intervention community (27.9%). Sirnilarly 39 percent of female TB patients in

J"

.,.:,:.: :

. :':r'i:. -::..':: i..::.. .

1:,,1,-;:.1:1.;;:,

both of communities had reported the neighbor's hesitation in mixing after getting TB, where the female TB patients of control community had confronted more villagers' hesitation in mix up (47.7%) than intervention community (32.8. Nearly three fourth quarter (73.3%) of female TB patients in both communities did not observed any fault findings behaviors of community members. Nearly three fourth quarters of female TB patients (733%) in both study communities reported sleeping with family members after getting TB. But more than one fifth of female TB patients (21.9%) in both study communities were not allowed to sleep with their family members after getting TB, where more female TB patients were in the control community (29.5%) than the intervention community (16.a%). The used cloth of one fifth of female TB patients in both of the study communities were refused to wash by the family members because of TB stigma. Nineteen percent of the female TB patients reported their family members used to keep distance with them after getting TB.

Table 4. Social problems and stigma confronted by female TB patients in intervention and control study area
Factors related to social nroblems and stisma hesitate in mix up
Yes

Bhaluka (n:61
n 17 9 o/ /al
tr

Gaforsoan
n

h:44\
oho 40.9
9.1

Total (N=105)
n /o

P-value"

27.9
14.8

l8
A

35
IJ

Sometimes

33.3 12.4
<,1
?

0.001

No
Villagers hesitate in mixing Yes Sometimes

l5
20
J

57.4 32.8 4.9

62.3 18.0
82

22

50.0

51

2l
5

47.7

4l
8

39.0
7.6 53.3

tt.4
40.9 31.8
68.2

No Hesitation in takingfood together

Yes

38

l8
t4
30
JJ

56
25

u
50 49
4
8
m em b

No Participate in ritual functions

Yes

80
82

23.8 76.2
78. I

80.3

75.0
13.6

Sometimes

6.6
lJ.t

6
5

t0
r3
77
5

No
S I eep w

tt.4
6s.9 A<
29.5

9.5 12.4
I

ith fam

ily

ers 48
3

Yes

Sometimes

78.7 4.9
16.4

29
2

J.)

No
Refuse to wash cloths Yes

l0
t2
4
A<

l3

z.)

4.8 21.9

Sometimes

19.7 6.6

9 6

20.5
13.6 65.9
I 3.6

2l l0
14

20.0
9.5 70.5 19.0 7.6
I

No Family members kepl distance

Yes Sometimes

73.8 23.0
J.J

29
6 6

1A It

20
8

z
45

13.6

No Findings matiage partners with cured TB girls/boy

Yes Sometimes

73.8

)z

72.7

7'7

J.J

14
5

23.0
8.2

il
6 25

26.2

25

t4.3
59.5

No

A1

il

24.3
10.7

68.8

67

65.0

b:

Compare the significance difference between female and male

The table 5 and graph 3 indicates the comparison of treatment outcomes of female TB patients between the study communities. Seventy nine percent of the sarnple TB patients in the study communities were completely cured, where the overall cure rate of the TB patients of the intervention and control community were respectively 85.7 percent and 71.4 percent. Similarly, the default, relapse, failure died and others outcome of the TB treatments of the sample TB patients were respectively 8.3 percent,0.9 percent,2.6 percent, 1.1 percent and 8.6 percent. The treatment failure (4%) and default rate (l1.4%) were more higher than in the experimental community where the treatment failure and default rate were Ll and 5.1 percent only. The treatment outcome of the female TB patients in regard to the cure rate was much better among the females (86.7%) than male TB patients (77.1%). The study findings that the cure rate of the female TB patients of the intervention corlmunity (91.8%) were even better than the cure of the fernale TB patients of the control community (81.9%). The treatment outcomes of female TB patients of intervention community in terms of default, failure died were respectively 4.9 percent, 1.6 percent and 1.6 percent. While the treatment outcomes of female TB patients in the control community of default, relapse, failure, died and others were respectively 6.7 percent, I percent, 2.9 percent, I percent and 6.1 percent.

Table 5. Comparison of treatment outcomes of females TB patients between the intervention and control community

Treatment outcomes
Cured

Bhaluka (n=175)
n 150 9 0 2
2
12 You

Gaforgoan (n:175)
ll

Total (N:350)
n
o/^a

Yoo

85.7
5.1

125

71.4

Default
Relapse

20
J 7

tt.4
1.7

275 29
3

78.6
8.3

0.0

Failure Died
Others

l.l
1.1

4.0

l.l
10.3
o

9 4

0.9 2.6

l.l
8.6
o

6.9
o/o

l8
Gaforgoan @:aa)
30 4

30

Treatment outcomes of Female TB patients Treatment outcomes

Cured

Bhaluka (n:61)
56
J 0 I
I

Total(N=105)
86 7
I I 7

9l

.8

8l.9
6.7
1.0

Default
Relapse

4.9 0.0
1.6 1.6

81.9 6.7
1.0

I
2
0

Failure Died
Others

2.9
1.0

2.9
1.0

0.0

6.7

6.7

Uto*2%''t' &,r:*iw*rs;,:ry

*f

??ts.:

fa!it-&?4 Xns{$tl*t*

{xr

?4*,*42fu ffi*vmiergxm*art

Percent Compliance

among the fomalo TE| patients in the study area

100 90 ao

g60 E50
b40 o30
20
10

o70

Bhaluka

Gaforgoan

L!
The compliance to the TB Treatment among the female TB patients in the intervention qrea was much higher than that of thefemale patients in the control area (9l.8okvs 81.2%o)

DISCUSSION
Tuberculosis (TB) is dreaded in countries like Bangladesh with huge reservoir of TB cases remains untreated in rural communities particularly among women who preferred to be treated by various traditional healers leading to spreading infection (Fair, 1997). The study on gender difference in treatment seeking behavior in similar situation revealed that 70 percent of the female cases had taken prior treatment from various traditional healers before attending to DOTS treatment where mean of patient delay was 63 days (Ahsan etal,2004). This study was conducted to promote the case detection and treatment compliance of the TB patients particularly among the females by using gender sensitive intervention in the experimental community. The findings indicate thatthe majority of the females TB patients (65.8%) were young adult of 15-34 years with the median age of 25 years. The age distribution suggests that TB affects mostly younger age group particularly among women in the rural communities which may be due to increase tendency of health care seeking among younger patients because of community awareness activities of intervention program. The female patients of control community confronted more social problems and stigma than the intervention community. The female TB patients of the intervention community had confronted less strong type social problems and stigma (20%) than the control community (25.8%) which is statistically significant (P< 0.05). The fernale patients of intervention community had better knowledge (83.6%) than the control community (68.2%) rnay be due to the awareness of Gender Sensitive Package Services. The female patient detection rate was remarkably increased in the intervention comrlunity after using Gender Sensitive Package Services. The treatment outcome of the female patients in regard to the cure rate was much better among the females (86.7%) than male TB patients (77.1%). The cure rate of the female patients of the intervention community (91.8%) was even better than the cure of the female TB patients of the control community (81.9%). The findings suggest that the Gender Sensitive TB Control Interventions could be effective in similar situations.

"'"')

ACKNOWLEDGEMENT
The authors would like to express their sincere appreciation and grateful thanks to all those who have contributed kind support and cooperation namely Bangladesh NTP, TTU, Damien Foundation, BRAC, ICDDRB, NSU etc. The grateful thank and highest level of appreciation goes to TDR/WHO, Geneva for financial support.

REFERENCES
Ahsan G.U et al, Gender difference in treatment seeking behaviors of tuberculosis cases in rural communities of Bangladesh Southeast Asian J Trop Med Public Health 2004;35: 126-t35

Atiqual Hoque Md, de Colombani P. Achievements of the national TB control programme. Bangladesh Med Res Counc Bull 1999; 25(3):71-82.
Cassels

A, Heineman E, LeClerq S, Gurung PK, Rahut in Eastern Nepal. Tubercle 63(3): 175-185.

CB. 1982. Tuberculosis case finding

Diwan VK, Thorson

A, Winkwist A (Eds). 1998. Gender and Tuberculosis: An

of
Public

international research workshop. May 24-26, 1998. The Nordic School

Health, Goteborg, Sweden.

Dolin

P. 1998. Tuberculosis epidemiology from a gender perspective. In Diwan VK, Thorson A, Winkwist A. (Eds) Gender and Tuberculosis: An international research worl<shop. }i4ay 24-26, 1998. The Nordic School of Public Health, Goteborg, Sweden.
of socio-economic
and

Hudelson P. 1996. Gender differentials in tuberculosis: the role cultural factors. Tuberc Lung Dis 77:391-400.
Jacobson

J. 2001. Women's Reproductive Health: The Silent Emergency. Worldwatch Institute. Washington DC: Worldwatch Paper 102.

Rangan S, Uplekar M. Gender perspective of access to health and tuberculosis care, Goteburg: Nordic School of Public health, 1998:29-40. Smith,

I. 1994. Women and Tuberculosis: gender issues and tuberculosis control in Nepal. MA dissertation, Nuffield Institute for Health.

World Health Organization Global Tuberculosis Control, WHO Report 2001. wHo/cDS tTB t2000.287 . 200r . World Health Organization. Review of the ational Tuberculosis Programme of Bangladesh, 16-28 November 1997, conducted by the government of Bangladesh and the World Health Oreanization.WHO/TB I99 .259. 1999.

ut-Z=*

ZIj"" &rz*4';*y:t?j{T {:t 7?+: *.-1>l}*,'r:i }ttstitrJt* {t*r ***,ta,Xz ***v*1*p:re**l

iiti#
i*ir,.i
,+,

ABSTRACT
post intervention study was conducted in a remote mountainous region in 449 community members to assess their perception about indigenously developed community health workers. The findings of the study show that 84o/o of the population was aware of the CHWs activities, 60% of the respondents believed that the CHWs were working properly and 63.5o/o had easy access to a CHW when needed.

Regarding the level of satisfaction, 88.5% of the respondents were satisfied with the CHWs performance. 74.8% of the population was happy with the programme and 95.8% wanted the work to continue.

On the whole the concept

of

developing human resource indigenously

is

widely

accepted and popular in the communities in remote mountainous regiorts.

INTRODUCTION DFID launched an integrated health programme in Neelum Valley (I'JVHP) in August 2001 in Azad Jammu and Kashmir. The unfortunate people living in this remote mountainous region had been victim of armed conflict for over five decades. No organization had ever tried to address their health issues due to volatile situation and insecure circumstances.
The health package introduced by NVHP was quite unique, as it had tried to incorporate self sustainability by capacity building of locals in primary health care. Training of Community Health Workers (CHW) had been the keystone in this programme. It was planned to train 45 CHWs to cater to the estimated 43,000 population and provide a CHW to population ratio of l:1000 as suggested by the National Programme for Prirnary Health Care (NP) of the Government of Paki stan.

The CHWs, extracted frorn the local communities, were included in the programme after fulfilling rigid induction criteria. The female CHWs were subjected to rigorous training for six months, at the Community Health Centre (CHC) located at Kuttan and managed by NVHP. They were irnparted training in Primary Health Care (PHC) as well as in midwifery skills (MW). They followed the NP laid down curriculum with additional MW skills incorporated by the NVHP through a standardized training manual. The teaching method was also quite unique. A problem oriented approach was used, and problem solving skills enhanced in the CHWs.
The male CHWs, were enrolled in Dispensers programme of the government run paramedical institutes in Mirpur and Muzaffarabad. Three batches of female CHWs graduated frorn the NVHP CHC at Kuttan. Forty five CHWs were reportedly serving their communities for various periods of time in the Neelum Valley. As the CHWs had been in the field frorn more

than 12 months, it was proposed to study the impact of their work in the community. In this regard a survey was conducted to answer the following research questions

Figure

1:

Map showing location of the study area

RESEARCH QUESTION
The research questions which the study aims to answer are:

o o

What does the community understand about the role of the Community Health Workers?

How well are the Community Health Workers performing their duties in the community?

RESEARCH METHODOLOGY
Study design

A cross sectional survey, using a structured questionnaire to collect data from the study population was used. The dataset was then analyzed using statistical analysis software for
analvsis.

Sompleframe ancl size

The programme area (PA) of NVHP comprising of three union councils (UC) viz., Shahkot, Neelum and Atthmuqam were selected by purposive sampling. From each UC, cluster sampling was performed selecting two, eight and twelve communities from the three UC respectively. Twenty respondents were selected by random sampling from each cluster. A total of 449 respondents were included in the study.

lnternatinnal Syxrpcsium *n "'SI***a* t"l*nl*h: Sord*r*ers fiove*n*nt *f **s*are'

ft:":,
.'.

Study tools structured questionnaire was adapted from the Griffith (2001) and Steel (2001) models, having four sections. Section I, comprised of ten questions addressing the socio demographic and economic status of the respondents. Section II, concerned the actual work being carried out by the CHW. Section III, dealt with the perception of the respondent about the role of the CHW, and section IV asked the respondent about their satisfaction with the various components of NVHP.

The interviews were carried out by trained interviewing staff, using a printed structured questionnaire. The data was collected and cleaned at site to minirnize data loss. FINDINGS
Heatth

facilities'

occess

in Neelum Valley:

NVHP is serving three union councils in the Neelum Valley area; vrz., Atthmuqam, Neelum and Shahkot. These communities currently have twelve, eight and two CHWs working in these areas respectively. Most of the people have to first walk down from their households to the road, often having to carry the sick or injured on charpoys. The time taken and the problems faced in such circumstances can not be fathomed or measured on any scale. However the approximate distances and money spent to reach the Community Health Centre, managed by NVHP and located at Kuttan is listed in table 1.
The average distance from Atthmuqam to CHC Kuttan varied between 17 to 25 km. Travel time by a dedicated vehicle hired for about 500 to 700 Rs ranges from one hour to one and three quarters of an hour. The cost of travel by public transport is about 30 to 40 Rs, but the time taken is phenomenal with frequent stops, overcrowding and unreliable service.

UC Neelurn is 25 to 40 kms away, and a transport can be hired for 600 to 1000 Rs to ferry patients to CHC Kuttan. The travel time can vary from one and three quarters to two hours. Public transport costs between 40 to 70 Rs per passenger with its accompanied problems of time and unreliability of service.

UC Shahkot is located about l5 km from CHC Kuttan. Private transport costs about 500 Rs and takes three quarlers of an hour to traverse the distance. Public transport costs Rs 30. Kundal Shahi, located on the main road, from where one has to take a side road to reach CHC Kuttan is 6 km away. It takes 20 minutes by hired transport costing 200 Rs to reach the centre. Public transport is available sporadically, and costs Rs 20 per person. Table
Area

Access frorn different areas to CHC Kuttan

Distance to CHC Cost of hired transport (Rs) 500 - 700 600

(km) Atthmuqam
Neelum Shahkot
11

Time by transport
60

hired (min)

Cost by public transport (Rs)

-25 -40
15

25

000

- 105 105 - 180

45 20

30-40
40

-10

500

30

Kundal Shahi

200

20

A total sample size of 449 respondents was extracted from twenty two communities living in Neelum Valley, having the following socio-demographic characteristics (table 2):
More than two thirds (71.4%) of the respondents who took part in the survey were females, while about one third (28.6%) were males. This is possibly due to the non availability of males at home, during the morning time, when most of the interviews were conducted. Moreover, the fernale population has more interaction and is in closer contact with the CHWs. This also signified the female empowerment in the communities surveyed.

Most of the respondents (76.4%o) were married, while l7A% were single and a negligible number (0.7%) were divorced. This shows the strong family fabric prevalent in the area.

Table

Socio-demographic characteristics of respondents Number Characteristic

Percentage

n:449
Gender

Males
Females

t28
321
78
a Aa J+)

28.6
7

t.4

Maritalstatus
Single
17.4

Married Widowed Divorced

Educational level
Uneducated

76.4
5.6

25
a J

0.7 36.3 r 8.0 2.7

16.1

163

Able to read Quran

Madrassa

8l t2
75

Primary level
Secondary level Intermediate
Graduate Postgraduate

54 26 30
8

12.0 5.8 6.7

1.8

Occupation Unemployed Farmer Governrnent servant Private service

Business

70 39
133
41

15.5 8.7

29.6
9.1
r

45

0.0

Other

l2l
88

27.0
19.6

Age groups
Less than 20 21 ro 30 31 ro 40

152
117

33.9
26.1 13.6

4l

to 50 More tlran 50

6l 3l

6.9

Mean: 32.26,5D:12.31, Median: 30 House hold size

6-

1-5
10
8

102

238
109

22.7 53.0
ai
1 z+.)

> l0
Mean: 8,36, SD: 3.73, Median;

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Table

Socio-demographic characteristics of respondents (continue) Characteristic

Number
n:449
5l
240
78 37 +J

Percentage

Monthly household income

< 1,000
,001 5,000 10,000 5,001 > 10,000
I

11 .4

53.5 17.4
8.2

Did not know

9.6

Out of the respondents included in the survey, more than one third (36.3%) were illiterate, 18% could read the Holy Quran, about one third (30.7%) had attended school while 14.2% had been to college. 1.8% of the surveyed population held post graduate degrees from a university.

In the surveyed population, less than one third (29.6%) were employed by the government, 155% claimed to be unemployed, 1006 were engaged in business, 9.lo/o were in private service and 8.7Yo relied on farming as a means of livelihood. A large number (27%o) were students, housewives, laborers and daily wage earners.
The population studied had a mean age of 32.26 years with a standard deviation of 12.37 years. The median age found in the respondents was 30 years. About 60% of the
respondents were between the ages of 27 and 40 years. 20.5% were over 40 years and almost a similar number (19.6%) were less than20 years old.

The average house hold size in the survey came out to be 8.36 persons (SD : 3.73) per household. The median number of residents in each house was 8 individuals. More than half (53%) of the population had 6 to l0 members living in a house, while almost a quarter of the respondents lived in houses with less than 5 and more than 10 occupants.
The average family income per month was determined to be 5,169 Rs (SD:6.31) and the median income was 3,500 Rs per month. More than half (53.5%) of the surveyed population earned between 1,000 and 5,000 Rs per month per household, about a quarter (25.6%) earned more than 5,000 Rs and 11.4% less than 1,000 Rs per month. About one tenth (9.6Yo),were not aware of their family's monthly income - mostly housewives. Perception about CHWs work: In response to the question that "Do you know what is a Community Health Worker?" alarge majority, 377 (84%) people responded in the affirmative, while 72 (16%) did not know what CHWs were (table 3). More than three quarters of people (78%), stated that they had a CHW in their village. A small number (10%) said they did not have any CHW in their community, while l2o/o of respondents were not aware of any CHW working in their area.

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Threequarters (75.1%) of respondentsknewtheCHWof theirareabyname,whileabouta quarter (24.9%) were unfamiliar with the name of the CHW working in the community. The high percentage of respondents being unaware of the name of their CHW was odd, as the CHW had been chosen through an intricate community organization network.
Regarding the training of the CHWs, about three quarters (73.7Yo) knew that NVHP had trained their CHWs, a small number of respondents (5.6%) attributed the training to the government while 193% were uncertain as to who had trained the CHWs in Neelum Valley.

Table

Table showing the perception of CHW work by the respondents

Statement

Number

Percentage

n:449
Do you know what is a Community Health Worker?
Yes

,h

)t I
72

84%

Don't know Do you have a Community Health Worker in your village?

Yes

t6%
78%
10%

350
45 54

No

Don't know
Do you know the name of the Community Health Worker in

r2%

your village?
Yes

Don't know
Who trained the Community l{ealth Worker in your village?

337 112

5.1% 24.9%
7

NVHP
Government

))z
32
85

Don't know
In your opinion, do these CHWs work properly? Yes

73.7% 5.6% 19.3% 60%

269
45
135

No

t0%
24% 59.2%

Don't know Do you think the CHWs are well trained?

Yes

No

266 67
116

Don't know Are you happy with the CHW in your area?
Yes

15% 25.8% 66.6%

11.1%
22.3y:o

No

266 67
116

Don't know
Can you easily see the CHW? Yes

285
63

No

63.5% 14.0%

Don't know Does the CHW visit your house?

Yes

l0l
244
109

22s%
54.3%

No

24.3%

Don't know
Do you have to go to the CHW's house for a health problem? Yes

t0l
246

225%
54.8%

No

I0l
102 246
101

22.5%
22.7Yo

Don't know
Is the CHW available 24 hours?

Yes

54.86%
22.5y:o

No

Don't know

102

22.7%

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Almost two third of the respondents (60%) felt that the CFIWs were working properly, while one tenth did not share this feeling. Almost a quarter (24%) did not have any opinion about the working of the CHWs.

As far as the perception of the respondents about the quality of training of the CHWs was concerned, almost 60%o expressed their satisfaction with the quality of training imparted. About l5o/o expressed their dissatisfaction, while over a quarter (25.8%) did not share any opinion about the quality of the training of the CHWs.
Two thirds of the respondents were happy with the CHWs working in their areas, I 1 . I % were not happy, while 22.3% abstained from sharing their opinion. The dissatisfaction with the CHW could be attributed to personal prejudices and dislikes. Coming frorn small comrnunities, where economic options are limited, this may have played an important role in determining the opinion of the respondents.
The CHWs easy availability was confirmed by almost two third (63.5%) of the respondents, however 14% did not find the CHWs easy to access while 22.5% were not sure about their availability. The CHWs visited the houses of more than half (54.3%) of the respondents, but did not visit about a quarter (24.3%), while 225% did not respond to this query. More than half (54.8%) of the respondents stated that they had to go themselves to the CHWs residence to seek health acre, while 22.5% did not have to go themselves and a similar number (22.7%) were not sure. When asked about the availability of CHWs around the clock, more than half (54.8%) stated that they were available all the time, 22.5% said they were not available all the tirne and 22.7% were not sure. Forty five respondents stated that the CHWs in their areas were available some of the time of the day. More than one third (37.8%) said they were available only in the morning, 600/o said they were available only in the evening while only one CHW was reported to be available during the nighttime. Regarding the provision of additional CHWs, half (50.3%) of the respondents voiced their desire to have additional CHWs for their communities, a quarter (26.7%) did not feel additional CHWs were required while 22.9% did not have an opinion about rnore CHWs.

Perception about job of CI.IWs:

The respondents were asked seventeen questions pertaining to the laid down job description of the CHWs as prescribed by WHO. The responses of the community members interviewed are listed in table 4.

In response to the first element of PHC, more than one third (33.9%) knew that educating the cornmunity on health issues was the job of the CHWs while almost two thirds (66.1%) did not know about this aspect of their function.

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Table

Responses to perception of respondents to

Statement

job of CIfWs
Yes 152 142
162 t)

No 33.9 291
307
66.1

Educating the people about health

Telling people about hygiene

Doing antenatal check of pregnant women Informing women about what to eat during pregnancy Telling women what not to do during pregnancy Telling women what not to eat during pregnancy Advising women to get tetanus vaccination during
pregnancy Checking anemia during pregnancy

3t.6
36. r 16.3

68.4 63.9 83.7

85.
1

281

Jio
382
388 398

67

l4.9
I

6l
)l
41

3.6

n.4
9.1

86.4 88.6

408

90.9

Checking for danger signs in pregnancy Referring women to CHC/Hospital

Checking the newborn baby

38
93

8.5

4t

9l

.5

20.7 23.2

356

79.3 76.8
8

104
66

345
383

Weighing the newborn baby

t4.7
8.9

5.3
.1

Visiting the new mother (after delivery)

Prescribing/giving rnedicines for common problems Giving drips or in jections Advising mothers to get the children vaccinated Other activities

40 166 69

409 283 380

395
401

9l

37.0
15.4 12.0 10.7

13.0
84.6

<i
48

88.0
89.3

Less than one third (31.6%) agreed that hygiene promotion was the activity of the CHWs while more than two thirds (68.9%) were not aware of this important fact. More than one third (36.1%) knew that CHWs were supposed to perform regular antenatal check up of pregnant women, while less tha two thirds (63.9%) did not know this. Regarding the dos and don'ts of pregnancy, a small amount (16.3%) knew that the CHW was supposed to inform the pregnant woman what to eat during pregnancy and 83.7oh did not know of this vital role of the CHW. 14.9% of respondents knew that CHWs were also supposed to inform the pregnant woman about what actions and things to avoid during pregnancy as apposed to 85.1% who did not know of this function of CHW. l3.6Yo of respondents knew that CHWs were also supposed to guide women what harmful substances to avoid eating during pregnancy whereas 86.4% were unaware of this activity.

A little more than one tenth (11.4%) of respondents knew that promoting antenatal
vaccination was the function of the CHWs, while a large number (88.6%) did not know it. 9.1% respondents knew that the CHWs were supposed to check for anemia in pregnancy, while an alarrning 90.9% did not know this crucial function of CHWs. A small number (8.5%) knew that CHWs were supposed to lookfor tell tale danger signs during pregnancy for timely referral to a hospital, while most of the respondents (91.5%) were not aware of this role of the CHW.

l.

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20.7% of respondents knew that CHWs were supposed to refer patients to CHC or a hospital

if they were at risk or could not be treated by the CHW, while 79.3% did not know this fact. A little less than a quarter (23.2%) knew that CHWs were to check all new born babies in
their communities, while more than a quarter (76.8%) did not know this.

of respondents knew that weighing the newborn baby was the role of a CHW as apposed to 85.3o/o who did not perceive this function of the CHW. 8.9% people believed that a CHW should visit the new mother after delivery while a large number 918% did not think it was their duty to do so. Only
14.7%o

More than one third (37%) respondents knew that CHWs were supposed to prescribe medicines for common health problems while almost three fourth (73%) did not know of this activity of the CHW. It was heartening to know that most of the respondents (84.6%) knew that giving injections and administering drips was notthe function of the CHWs, while only 15/% thought that they could perform this activity.
Unfortunately a large number of people (88%) believed that advising the mothers to get their children vaccinated was not the function of CHWs, as apposed to l2Yo who rightly perceived this to be an activity of the CHW. 10.7% of the respondents attributed various unlisted functions of the CHWs, out of which helping in the Polio campaigns was the most prominent.

Perception about Neelum Valley Health Programme:

In response to the satisfaction with the work of NVHP in Neelum Valley, 439 respondents participated, while 10 people declined to comment.
Table

Community acceptance of the programme

Question and response Number
Percentage

How satisfied are you with Neelurn Valley Health Programme?

n:439
238
53.0
3

Highly satisfied
Satisfied Not satisfied Highly unsatisfied Are you happy with CHWs work in Neelum valley? Very happy Happy Satisfied Unhappy Extremely unhappy Are you satisfied with NVHP's CHC in Kuttan? Highly satisfied Satisfied Uncertain Unsatisfied Highly unsatisfied Do you want the work to continue in Neelum valley?
Yes

t73
7
2

8.5
1.6

0.4
26.1 3 8.3 10.4
11.1

n:3 89
117 172

47
50
J

0.7 42.3
40. I 10.5

n:427
190

r80
47

l0
0

2.2 0.0
8

n:43
430
I 7

No
Uncertain

95.8 0.2
1.6

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t"';: i,e*{;tlry

{:}f

ttrt* A*T*,?4 nst$tt*t* {r*r ?4x*]lt\z S*w*$*prq}**t

Out o1'the respondents more than half (53%) were highly satisfied with NVHP performance in Neelum Valley, more than one third (38.5%) were satisfied, 4.2oh were uncertain while only 2oh of respondents were unsatisfied with NVHP's work in Neelum Valley area (table 5).
Regarding the satisfaction with the work of CHWs in Neelum Valley, 389 people responded, while 60 abstained from expressing their views. More than a quarter (26.1%) were very happy, more than one third (38.3%) were happy and one tenth ( 1 0.4%) were satisfied with the CHWs performance. Whereas, 11.8% of the respondents were unhappy with the CHWs work in their communities.

When asked about the Cornrnunity Health Centre run by NVHP in Kuttan, 427 people resporrded, while 22 refrained from commenting. Out of the respondents, majority (82.4%) were satisfied while 10.5% were unsure and only 2.2uh were unsatisfied with the performance of CHC in Kuttan. The respondents were asked about their opinion about continuation of work in Neelum Valley. 438 people responded, while 11 abstained. An overwhehning 95.8% of the respondents wanted NVIIP to continue work in their area. Only one respondent did not like NVHP to stay and seven respondents were unsllre.

DISCUSSION
The CHW impact survey was conducted to understand the actual working of the CFIWs in the communities, thc perception of the communities towards the CFIW ancl other NVHP activities in the region. Following salient features have emerged from the prclirninary data collected:

Access

ibility to h ea ltlt facilities :

NVHPs CHC is the only health facility available to the worren and children in the region. However. it is located in Kuttan, outside the prograrnme area, due to inclement firing and security reasotls. f'liis location \\,as chosen due to security concerns as firing had hit the 1'l IQ at Atthmuqam as well as the fact that one of the social workers of NVHP, was rtartyred while on duty in the area.
Most of health workers avoid insecure areas due to threat to life and lack of other amenities. This phenomenon is seen in other areas as well Chevalier (1993), and contributes to the drop out rates of community health workers.
The location of the CHC, is at an average distance o1 1 5 to 40 krns fiom the closest to farthcst UC served by the programme. These are enormous distances in terms of travel in hilly areas. Moreover, there are no regular, dependable lncans of public transportation in the area. 'l'hus the poor people fall prey to exorbitant charges levied by the private transporters. 'Ihe approximate cost of travel to CHC Kuttan frorn the PA varies from Rs 500 to 1000, per visit. This is a huge amount, even lbr the well off. The poor and irnpoverished people, who are vulnerable and need medical care, are in no position to pay this amount to travel to the CIIC.

Location of the referral point is imporlant as it can augment the programme's effectiveness, Gilson (1989). A strong backup gives the CFIWs confidence as well as the community an assurance that help is readily available if needed. Time, is another factor, which is of crucial imporlance in rnedical care. The time spent to reach the facility varies from 45 minutes to 3 hours by the quickest means of travel - private transport. This does not include the traveling tirne from the residence to the road, from where to catch the transport. In acute emergency cases, this time lag can and often does cause irreparable damage to the health of the expectant mother or her unborn child. Perception
a

bo

ut CIIW functions

The population surveyed had a broad background. Over 70%o were females, as the males were usually out at work during the interviews conducted in the mornings. The mean age of the respondents was 32 years, and over three quarters (760/o) were married. About 57Yo had no forrnal education, and 15.5% were unemployed. Sirnilar findings are reported by Kartikeyan (1991).

This sample gives a good cross section of the community under study. Most of the community knew about CHWs, the names of their village CHW and the fact that IR had trained thern. However the perception of the community about the functions of the CHWs
had a varied response.

Most of the respondents (60 to 90%) did not list any of the stipulated functions of the CHWs as provided in their job description. The only positive answer provided was, that the CHWs were not supposed to give injections or intravenous drips (84.6%). This poor perception of the community of the functions of the CHWs adversely affects service delivery and needs to be rectified.

CONCLUSION
Based upon the findings of the post intervention sulvey, it is apparent that most of the community was aware of the comrnunity health workers in their area. Majority of the people interviewed knew about the role of the CHWs and were monitoring them properly. Most of the population had easy access to these CFIWs and were highly satisfied by their performance. Almost three fourth of the population was very huppy by the programme and almost everyone wanted the programme to continue. The overwhelming positive reponse of the community to the indigenously developed CHWs, shows that people living in remote and far flung areas welcome locally developed health

workers and are keen that local communities are involved

programmes.

in the monitoring of

these

Sirnilar findings are reported by various researchers like Bhattacharya (19()7) in Ethiopia, Curtale et al., (1995) in Nepal and Frankel (19()2). Indigenously produced community health workers contribute to the success of the programme by building the capacity of the community, empowering them and assisting in the sustainability process Augustin (1986) and Boyd (1995). These locally developed health workers are a boon for developing countries, Stinson (1983), and must be promoted for effective health care Storm s (1979).

REFERENCES Augustin,

DA, and MM Pipp. Alternative Methods of Motivating Community Health Workers (abstract). Chevy Chase, Maryland: PRICOR/University Research
Corporation, 1986.

Bhattacharyya

K, P Freund, W Made, and D Teshome. Community Demand Stutly for the Essential Services for Health in Ethiopia Project. BASICS Technical Reporl. Arlington, Virginia: BASICS Project, 1997 .

Bhattacharyy?, K, and J Murray. Community Assessment and Planning: A Participatory Approach. BASICS Technical Report. Arlington, Virginia: BASICS Project, 1997.

Boyd, B, and WD Shaw. Unlocking Health Worker Potential: Some Creative Strategies from the Field. Washington, DC: Academy for Educational Development/HealthCom, t995.

Center for Policy Alternatives. Community Health Workers: A Leadership Brief on Preventive Health Programs. Washington, DC: Georgetown University Law Center, Harrison Institute for Public Law, Civic Health Institute, Codman Square Health
Center, 1998.

Chevalier, C, et al. Why Do Village Health Workers Drop Out? World Health Forum

l4(3):258-61,1993.
Curtale, F, et al. Improving Skills and Utilization of Community Health Volunteers in Nepal. Social Science & Medicine 40(8): 1117-25, 1995.

Frankel, S, and MA Doggett. The Community Health Worker: Effective Programmes Developing Countries. New York: Oxford University Press, 1992.

for

Gilson,

L, et al. National Community Health

Strengthened? Journal of Public Health Policy

Worker Programs: How Can They Be l0(4):518-32, 1989.

Gottert, P, R Roland, and R Alban. Streamlining Community-based IMCI: Six Guiding Principles. Project paper BASICS/JSVLINKAGES/Madagascar, 2000. Griffiths, M. The Manoff Group. Semistructured interview,200l.
Heggenhougan, K. Community Health l4/orkers: The Tanzanion Experience. New York: Oxford University Press, 1987.

Kartikeyan, S, and RM Chaturvedi. Cornmunity Health Volunteers: Resources? IVorld Health Forum 12:341-342, 1991.

Waste of Precious

Kaseje, DC, et al. Characteristics and Functions of Community Health Workers in Saradidi, Kenya. Annals of Tropical Medicine and Parssitology 81 suppl. l:56-66,1987. Ofosu-Amaah, V. National Experience in the Use of Community Flealth Workers. A Review of Current Issues and Problems. WHO O/fset Publication 7l:149,1983.

Ojofeitimi, EO, et al. Increasing the Productivity of Community Health Workers through Supervision in,the Rural Areas of Nigeria's Ife- Ijesha Zone (summary). Bethesda,
Maryland: PRICOR/University Research Co., I 987.
Pareek,

U. 1986. Motivational Analysis of Organizational Behavior (MAD-B). In JW Pfeiffer and LD Goodstein, eds. The 1986

Robinson, SA, and DE Larsen. The Relative Influence of the Community and the Health System on Work Performance: A Case Study of Cornmunity Health Workers in Colombia. Social Science & Medicine 30(10):1041-8, 1990. Ruebush, TK, et al. Qualities of an ldeal Volunteer Community Malaria Worker: A Comparison of the Opinions of Community Residents and National Malaria Service Staff . Social Science & Medicine 39(l):123-31,1994.
Steel, A. BASICS Project. Semistructured interview, 2001.

Stinson, W, M Favin, and B Bradford. Training Community Health Workers. An issue paper prepared for TINICEF by the World Federation of Public Health Associations, 1983. Storms, D. Training and Working with Auxiliary Health Workers: Lessons from Developing Countries. APHA Monograph Series 3. Washington, DC: American Public Health Association. 1979. Werner, D. The Village Health Worker: Lackey or Liberator? World Health Forum 68.1981.

2(l):46-

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j:-:

ABSTRACT
This study is a part of the joint study made where as the comprehensive study included other variables of socio-economic status like education, agriculture and social development. The study was done by HURDEC, Kathmandu under the financial support of GTZ, Kathmandu, Nepal during May 2005. This study was done in the remote villages of 7 Village Development Committees of Rukum district of Nepal where FSRP program was irnplemented. Rukum district itself is one of the remote district of the midwestern region of the country. The main objective of the study is to assess the existing nutritional status of children under five and pregnant women and the determinants in leading the causes, however the study also gave attention in finding the measures to improve the nutritional status and resources available.
The methods applied were conducting the series of workshops of the concerning experts for identifying the specifrc objectives, approaches, the contents of the study questionnaire, finalization of the questionnaire and orientation to the surveyors for data collection. Since the study was focused especially to the beneficiary community of the program (the houses near the road being constructed under food for work) of FSRP Project, almost all houses lying near the constructing road were taken as the sample. A total of 323 houses with 1911 household rnernbers of VDCs were surveyed.

After the orientation, the data were collected which was completed almost in November of the same year as it was very difficult to collect data during the rainy season of June August and the national festival in September/October. The study was done on the basis of sex, ethnic group (BCN, Janajati and Dalit), occupation, age and educational status. From the study it was found that ratio of t-ernale to male was not qllite different (49.8:50.2), however the proportions of female and male children was 54Yo to 460/o respectively. Sirnilarly, proportion of BCN was highest about 45Yo, where as the proportions of Janajati and Dalit were about 39.5% and l5o/o. The total literacy rate was only 40Yo with agriculture as the main occupation with 61oh. The study revealed that presence of all signs of malnutrition with anemia had been found in all rnothers indicating that anemia of pregnant mothers exist heavily. Similarly, the nutritional status of children is in between 60 to 80% of reference wt*. which is slightly under nourished but not marasmic. Ilowever average weight among BCN is slightly better off than other ethnic group.

KEY WORDS
Human

Resource Development Company, German Technical Cooperation, Food Rehabilitation Program, Village Development Committee, Ante Natal Care

t_:::':

lirilm $hr''.rt*llftl r

INTRODUCTION
This study on the assessing nutritional status was done in the area of Rukhum district where FSRP programme was implemented. The main objective of this study is to:

o o o o r

Assess the existing nutritional status of children under five

Assess the existing

nutritional status of pregnant women.

Identify the key causative factors to lead their existing status.

ldentify the key measures to improve nutritional status and thereafter health status of the concerning benefi ciary community. Identify and list the social organization which can contribute to improve health status the community.

of

Basic Information:

According to the plan made previously, the study was to focus on the area of Rukhum district where FSRP has supported. By target group, only the communities group where majority or potential group of beneficiaries from FSRP programme were selected as follows:
Selected

District: Rukhum

Selected VDCs: Pokhara, Kanda, syalapakha, Banki kot, Shova, Pipal and Pwang VDCs

No. of VDCs: 7

Total no. of houses studied:323 Total number of household members: 191I

Inter*ati*nm$ Syax'rp*xit"rm *n *'Slnhal *{enlthl $crSerl*ss

S,**vsrce*ra&

*f S*se**e"

ss

RUKUM

,il

the 1$t* &rrxr?var**rv *f th*

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Xms&[tr]ts

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Approach:
Step one: A one day workshop of concerning team members was conducted in HURDEC office, Kathmandu, where objectives and the methods of study were discussed. In the workshop, the content of study was also discussed.

Step two: Concerning health consultant developed the questionnaire tools on Nutritional status focusing mainly on under five cl-rildren and pregnant women. Step three: a second one day workshop was orgarlized for sirnilar team members where discussion was made on the contents and variables for the study. After thc discussion. the
tealn came to conclusion.

Stcp four: tl-re fir-ral questionnaire tool again was discussed with concerning team leader of sponsoring agency (G7'Z) to get the consensus. After the updating of the f-eedback, the tool was finalized for study.
Step five: the team members conducted a2 days orientation workshop in field area (Dhappe of syalapakha VDC, Rukhum) for surveyors to collect the infbrrnation in May 2005. A total of 18 surveyors were involved for the data collection. The surveyors also were made clear on
the questions.

Step six: Implemer-rtation of data collection started immediately after orienlation undcr the supervision of one team member. It took almost 6 rnonths to collect all the data due to local situation and technical problems.

Proportion of populntion by sex and ethnic wise l. The percentage distribution of fernale is almost similar with that of male (female 49.8% and male 50.2%). Arnong these under five children, girl child percentage is low than boy child. Male 54o/o, female 46oh 2. By ethnic wise: janajati comprises 39.5o/o, Dalit cornprises 15%o where as Brahmin, chhetri, Newari (BCN) comprises 45%. BCN is highest. 3. total literacy rate was found to be only 40% 4. major occupation of the colnmon work was agriculture 670/o

Knowledge of mothers 1. Mothers were asked which rnilk was the best for the babies uptill six months. About more than 94oh of rnothers told that breast milk was the best, which indicates that breast feeding was popular. However among literate and illiterate mothers, illiterate mothers were far bctter
than literates.

2. Regarding the knowledge of mother on supplementary foods, only 20o/o of mother knows that should be given between 4 to 6 months. 3. Regarding how mothers knew that their babies are growing well. Only 260/o of mothers knew that they can know it by taking weight, while 69Yo told they do by observing face.

Facts about pregnant women: A total of 42 pregnarlt mothers were in contact. Among 42 pregnant mothers, 42o/o of the pregnant mothers were between 20 to 30 years of age where as 52o/o of the mothers were frorn the ages of above 30 yrs. Data reveals that most of over aged pregnant women were from janajati and Dalit. Similarly, most of these over aged pregnant women were from illiterate. About number of gravidas, 80oZ and more pregnant mothers were having third or more gravidas. Similarly comparing with education level, 89o/o of illiterate mothers over only l7o literate mothers were having their third or more gravidas. Among the Janajati, Dalit and BCN, 78% of illiterate mothers over 28%o of literate mothers were from janajati. This situation is almost sirnilar with those amons BCN. where as there is no literate mother having pregnancy.

About 50Yo of the total population did not have the access of health facility within I hour of walking distance. Regarding sufficient availability of green vegetables, about 660/o of the members do not have sufficient quantity of green vegetables. This situation is almost sirnilar among all ethnic
groups.

Similarly, about 74Yo of the people do not have regular sollrce of income to buy enough food. Here in compare to the ethnic grolrp, BCN is slightly in better off position.

About 61oh of the pregnant women do not know what food they should take during pregnancy and this situation is almost indifferent among all ethnic groups. One thing is very strange that almost all (100%) of the mothers told that none of the HW has given any
nutrition education regarding this.
Regarding TT injection, only 67 percent of the pregnant mothers were found having taken TT during pregnancy. Almost in all ethnic groups, this situation is similar among literate and illiterate group.

Among 40 pregnant mothers, only 15Yo have gone for ANC checkup. The situation is worse among janajati and Dalit in compare to BCN. And this situation is also indifferent among literate and illiterate group. Only six women in number have taken for ANC check up for 2 or more times.

Nutritional status of pregnant women: There were five variables to assess the nutritional status of pregnant women, but data in gain in weight during pregnancy could not be found. Hence, only four variables like dry and scattered hair, colour of conjunctival being red or not, red tongue and tire some feeling of the motlrers are taken. All together 4l responses received, among which 54%ohad scattered hair, 40Yo of non red of the conjunctiva,29oA of non red of the tongue and 85% of rnothers felt tired with light work. Hence, presence of all signs of malnutrition with anemia had been found in all rnothers indicating that anemia of pregnant mothers exist heavily. Further only 12.5% of the (BCN) pregnant mothers were taking iron pills and none of the Janajati and Dalit took iron pills, however it was found that only 20o/o of literate BCN mothers had taken iron pills.

Tlre number of times a day the mothers took food was also studied, in which only 76oh of pregnant mothers used to take food 3 times or more a day which comprises 69% of illiterate and 100% from literate mothers. Regarding taking of green leafy vegetable and yellow fruits, about 24%o of pregnant mother used to take sr,rch foods regularly and among which only few mothers were literate. Similarly, only about 55o/o of pregnant mothers take rnilk and milk products. The distribution of ethnic group was however not so significant. 50o/o of illiterate group also take such foods. Among literates, this percentage is about 66oh. In addition 73%o from all group used to take calcium based soup during pregnancy among which 54Yo were from illiterate group. Further, 83% of the pregnant mother did not know that she should visit ANC clinics for times. This was insignificant to all ethnic group and literate women. Regarding personal hygiene:
3

About 59.5% of pregnant women knew the impoftance of personal hygiene during
pregnancy. Among them 7)oh of BCN group where as only 44oh and 7lo/o from janajati and Dalit occurs.

Knowledge of personal hygiene: Among the illiterate group, 59Yo of the mothers have basic knowledge on personal hygiene where as 66Yo of literate grollps has this knowledge. Knowledge on taking rest during pregnancy: About 57% of mothers know the importance of rest. 55% of janajati and 650/o of BCN do have this information where as only 43oh of Dalit has this knowledge. Literate of all ethnic groLlp are better off than illiterate. Knowledge on wearing loose and light clothes: About S}Yoof all rnothers know they should wear light clothes during pregnancy. BCN ethnic group are in better off than others. Sirnilarly literacy level is highly significant than illiterate.
Do family members support during pregnancy: OnIy 21 respondents have clear idea about tliis. This situation is very good as 62Yo mothers say they get support.

of all

Status of under - five children: Of 159 households surveyed, 67uh of household have only one under five children,3To/ohave 2 clrildren and only 2.SYohave three or more. This situation is almost similar in all ethnic groups.

Wt of child at birth: Not available. Only two respondents responded the weiglit of child
birth.

at

The weight of child at present: The average weight of children is as follows: at 600/o of median reference wt. 6kg 0-<l yr at 60 to 80% of median reference 8kg at 60 to 80% of median reference 9.5kg 2-<3yrs at 60 to 80% of median reference 11 kg 3-<4 yrs at 60 to 80% of median reference 12kg 4-<5 yrs

l-<2yrs -

wt
wt. wt. wt.

The above figure shows that the nutritional status of children is in between 60 to 80% of reference wt*. which is slightly under nourished but not marasmic. However average weight among BCN is slightly better off than other ethnic group. The height of child at present: Similarly, the average Height of children is
0-<1

as:

yr l-<2 yrs 2-<3yrs 3-<4 yrs 4--<5 yrs

The average ht. for

50 cms. 65 cms. 72 cms. 79 cms. 86 cms age is below 85%

below 85% of below 85% of below 85% of below 85% of below 85% of of reference ht.

reference ht. reference ht. reference ht. reference ht. reference ht. for age showing

all children

are

stunted*. * Compared with WHO median reference wt. for age. and height for age.

The measurement of nutritional status of children by ACMT: Out of 217 babies measured, 28.5% of the babies showed the length of arm circumference below 12.5 crns which means they are severely mal-nourished. Sirnilarly, 15% of the children's length of arm circumference is between 12.5 cms to 13.5 cms showing under nourished and only 56Yo of the babies have their arm circumference length more than 13.5 cms. showing well nourished.

Age difference between the present and the previous child (months): A total of children were assessed. Among them, 40o/o of the children were born below 24 months of difference than previous child.

l4l
age

Had the child been breast fed during earlier age: Ahnost all children were breast fed except 2. It indicates that there is no problem with breast feeding practice.
Breast feeding at present: Out of 2I2 chlldren, 560/o of the children are getting with breast feeding. This percentage is lower because of that other children may have crossed the age of 2 yrs. Only 4.7oh of the children are fed with other means of milking.

Literacy level of mothers of children z Of 204 children, only 23o/o of the mothers of children
are literate indicating that literacy level of mothers is very poor.

Age of babies for starting supplementary food: Ar-nong the 206 children assessed, only 24% of the children were given supplementary fbod at the age between 3 to 6 months and about 680/o of the children were given their supplementary at the age of 6 to 9 months. Furtlrer, 6%had started the supplementary food at the age after 9 months. This indicates that mothers do not have correct information to start the supplementary food and hence most of children in this area might have been malnourished at their early age.
Had the child any episode of diarrhea or pneumonia within last 2 weeks: Out of 213 children assessed,23yo of children had at least one episode of diarrhea or pneumonia within last two weeks. Among the ethnic group, 31Yo injanajati, 29oh in Dalit and only 14.8% of BCN have this kind of episode showing that BCN is in better condition. Episode of worm infestation within last 2 weeks: Outof 208 children, only 7.2o/ohad the worm infestation. Here also only 4oh of BCN,7o/uof janajati lrave round worm infestation showing better thanDalit 160/o

Night blindness: Out of 209 children, only

baby has night blindness showing no deficiency of vitarnin A at

all. Very few children (only 7) had lost their one of the parent (father or mother) indicating there is insignificance of nutritional status with that of loss of parents.

Conclusion

l: Ilealth

behavior

Breast, milk practice is very good. Majority of the mothers (80%) do not have correct knowledge to start supplementary food. Very few mothers (26%) know that by taking wt. they can assess whether their babies are growing well. Family planning practice is low as 80% and more had at least 3 or more children at the time of study. 50o/o of the comn.runity people do not have the access of health facilities witl'rin one hour walking distance. 74o/o or more people do not have regular soLrrce of income to buy enough food. 61% of pregnant mothers do not have the knowledge of what type of food they should take during pregnancy. 100% of the pregnant mothers say that none of health worker has given any ntttrition education about the food to take during pregnancy. 670/o of the pregnant mothers have taken at least one dose of TT injection. Only 15'Yo of the pregnant mothers have visited health facilities only one time for ANC check up. This situation is worse among janajati ar-rd Dalit. Conclusion 2: Nutritional status of prcgnant mothers
There is significant level of anemia among pregnant mothers as 29 to 85o/o of mothers have either scattered hair, or conjunctiva not red or tongue not red or felt tired afler light work. And only 12.5% of pregnant mothers (only BCN) were taking iron pills during pregnancy. The number of times of food taking is satisfactory as 76Yo mothers have this practice. Only 24Yo of pregnant mothers used to take green leafy vegetables and yellow frr"rits during pregnancy. And 55Yo of the total pregnant mothers have practice in taking milk and milk products, however 73o/o mothers have good practice of taking calcium based soup. 83% of another does not know they should visit ANC clinics 3 times during pregnancy. And only 595% of mothers know the importance of personal hygiene. This situation is worse among janajati. 59"/o of mothers have knowledge o1' pcrsonal hygiene. 62o/o of the total respondent mothers get support from other members of family.

Conclusion 3: Nutritional Status of under five children

23% of the children get either diarrhea or pneumonia within last two weeks and sirnilarly worm 7 .2o/o of the children had worm infestation. The episodes of diarrhea or pneumonia and vitamin A deficiency as only infestation might have led for malnutrition, however there is no one child had night blindness. By weight, almost all children have slightly under nourishments but not associated with marasmus. Similarly all children were seen to be
stunted.

Literature review: The initiation of studies on Nutritional status in Nepal is not very old. The first study in Nepal "National Nutrition Survey l975" was made which reflected the existence of 52o/o of chronic malnutrition. Although the 1975 survey used a different standard to measure chronic malnutrition, recent data imply a worsening of the nutritional status of children in Nepal (Children and Women of Nepal - A situational Analysis, 1996).
Poor nutrition in early childhood is the predisposing factor that leads to much of the morbidity and mortality in children under five. Protein -energy malnutrition (PEM) and iodine, vitarnin A and iron deficiencies increase the risk of death and disability from diarrhea, ARI, and vaccine preventable diseases, particularly measles. Conversely, diarrhea, parasite infestation and other childhood ailments dirninish children's ability to utilize what nutrients are are available in their diets.

While the immediate causes of malnutrition are inadequate dietary intake and disease, underlying causes include inadequate maternal and child care, insufficient health services, insufficient household food security and unhealthy home environments, particularly hygiene
and sanitation.

with an average duration of 30 months. However its quality is compromised by lack of exclusivity in the first three months of life (NMIS 1995). Further, newborns are usually not given colostrums in about one-half of the sites, according to Female Community Health Volunteers' (FCHV) response. In some sites there is a change from non-use to use of colostrums, sllggesting that appropriate
Breast feeding, a national resollrce, is universal and prolonged strategies may change certain ethnic group customs.

has been suggested that national nutrition program be focused to the younger age, emphasizing feeding practices as breast feeding is complimented and replaced with solid food. Frequency of feeding foods other than milk is far too low. Young children have small stomachs and cannot take in sufficient nourishment on these occasions for their growing needs, given the low energy density of most diets. The present study also reveals the sirnilar practice of breast feeding but with low frequency of appropriate solid diets.

It

Food consumption patterns for children are not well, but it is estimated that about 36 percent of the total population in Nepal consume less than minimum recommended levels (Children and Women of Nepal - A situational Analysis, 1996). While there is clearly an inadequate amount of food available for much of the population, such food as is available is underutilized due to inadequate supplementation with vitamin rich fruits and vegetables, and by the

presence nutrients.

of

diseases, particularly diarrhea related, which irnpair the body's utilization of

The Nepal Family Health Survey conducted in 1996 also reported that stunting in 48o/o of children under 3 years old (55% of children aged 6- 35 months) and wasting in ll% of them Qliepal Multiple Indicator Surveillance, Fourth Cycle, 1996). Another surveillance, the Nepal Multiple Indicator Surveillance, Foufth Cycle was conducted by HMG NepalAtrational Planning Commission Secretariat in collaboration with UNICEF Nepal during August - November in 1996. The sample for the NMIS was drawn by Central Bureau of Statistics(CBS); the 144 sites were representatives of the country, of five development regions, of the three ecological zones, of the l5 eco-development regions, and of urban and rural situation. A total of 18643 households were visited in the 144 sites between Septernber and November 1996. The data were collected from 16955 households, 95752 people, 15172 children of five years and below and 8060 children of 36 months and below. The rate of both acute malnutrition (low weight for height and chronic malnulrition (low height for age) were high. The result of the survev was found as follows: . 53o/o of children aged 6-36 months had chronic malnutrition (stunting) . 160/o of children aged 6-36 months had acute malnutrition (wasting)

with age, with the proporlion of children who are stunted and wasted rising sharply between 6-24 months and then leveling off or even falling in older children but no difference between boys and girls (NMIS 1996).
There was striking relationship

Over a third (38%) of children aged 12-36 months had a mid upper arm circumference (MUAC) less than 13.5 cm indicating moderate rnalnutrition. More than a tenth(l2o/o) had a MUAC less than 12.5 cm indicating severe malnutrition. However there was geographical variation showing that the stunting level was increasing from Terai (50%) to Mountain (63%). And the wasting is higher in Terai than in mountains.
Similarly breast feeding is almost universal; only 0.3o/o of children are said not having breast fed at all. For more than half (5401,) of children had been breast feeding started within the first two hours but some time delaying for 2-3 days. Breast feeding was generally prolonged with nearly half of children aged 36 months still being breast fed. However exclusive breast feeding did not last long after birth. Liquid or serni solid foods often are added within first three months. The commonest reasons for stopping breast feecling were pregnancy (59o/o) and birth of another child (12%).
The rnost recent data on the r-rutritional status of children indicate that nearly two-thirds (63 percent) of Nepali children aged six to 36 months suffer from chronic malnutrition, as indicated by low height for age, or stunting, while 5.5 percent of the children suffer fi'orn acute malnutrition (Children and Women of Nepal - A situational Analysis, 1996). Regional comparison of data shows a wide variation in the prevalencc of chronic rnalnr"rtrition among children. Among the development regions of the country, children in the Mid-Western

Development Region suffer most from chronic malnutrition. Children in mountainous regions of Nepal are often chronically malnourished than those in the southern Terai belt (Children and Women of Nepal - A situational Analysis, 1996). In this regard, the findings found by the present study also reveal the same as Rukum District is one of the mountainous district in Mid-Western region.

Nutritional status of the under-five children was assessed by taking weight for age at present and also the height for age at present. According to the WHO reference median weight for age (Manual on Feeding Infants and Young Children by Margaret Cameron and Yngve Hofuander 1983), a child having 60 to 80% of reference median weight for age is considered undernourished and that falling below 60% of reference rnedian weight for age is considered
severely undernourished (marasmic)

Similarly a child having less than 90%o up to 85% height for age is considered stunted and below 85% is considered verv stunted.

About two out of every three children (64%) were observed having stunting (chronic malnutrition affecting height of the child) in Nepal Q.{epal Multiple Indicator Surveillance Health and Nutrition - Cycle 1, 1995). A relatively low number (5.5%) are underweight -forheight (reflecting acute malnutrition) with little or no gender disparity showing of no discrimination between boys and girls. However, stunting by month of age reveals a dramatic increase frorn 6 to 18 months of life. It reaches to the peak and begins during third year of life revealing that food security being not as a problem but of feeding patterns associated with infection, diarrhea, and poor environmental conditions, including lack of clean water and
sanitation.

The nutritional status of the children aged 6-36 months as indicated by Nepal Multiple Indicator Surveillance (NMIS), Health and Nutrition - Cycle I in 1995 is shown in the following table:

Nutritional Status of children Ased 6-36 Months, 1995 (pcrcentase Acute Malnutrition Chronic Malnutrition Gencral Malnutrition
Nepal
63

49
35

6
3

Rural Urban Mountains

49 64 69
66

49
56

6 J / + 9 7

Hills
Terai Far West Mid West West Central
East

6l
)J 74 64
65 57

44 56
52 53

4
4 7 6

42
53

48

According to 1995 NMIS data,0.5o/o of children aged zero to 36 months and l%o of those aged 24 to 36 rnonths suffered from night blindness, a characteristic feature of vitamin A deficiency. Night blindness is comparatively more common in rural areas (0.9%) than in urban areas (0.2o/o\.

a'

..',,'

:. a: a:.,.

The 1994 Xerophthalmia Prevalence Survey (Children and Women of Nepal - A situational Analysis, 1996) conducted in five districts of Far Western and Mid - Western regions of Nepal, found that in approximately half of the clusters surveyed in each district, the prevalence of night blindness was greater than lYo, according to WHO the minimum prevalence indicating a "severe public health problem". Similarly, the prevalence rate of Bitot's spots exceeded the WHO severe health problem rate in 87 of the 100 clusters. But the present study does not reveal any significant prevalence of night blindness. This may be the result of subsequent half yearly vitamin A supplementation program campaign every year being conducted effective from 1996 in Nepal.

Anemia is a major nutritional problem among the women and children in Nepal (Annual Report, Department of Health Services, 1997-1998). Although no nationally representative data are available, hospital records and small scale studies have noted that more than 50% of women of child bearing age and 63% of pregnant and lactating mothers suffer from nutritional anemia. Vitamin A deficiency is a major problem in the children below five years of age in the country. This findings however do not match with the present study as subsequent half yearly vitamin a supplemerttatiou program campaign all over the country is being launched effective frorn 1996 resulting the very low prevalence of vitarnin A
deficiency.

The "Nepal Demographic and Health Survey 2001" conducted by Ministry of Health, Department of Health Services, Family Health Division, a total of 48Yo of children was found being underweight (below -2 standard deviation of reference weight for age). Similarly a total of 13% of children was found severely underweight (below -3 standard deviation of reference weight for age). Similarly overall, more than one child in two (more than 50%) children under age five was found to be stunted. Further, fi)ore than one in every five children was found severely stunted. This percentage increased with age, as l\oh of stunting children under- six months to 60Yo among 36 - 59 months were found. This status is not significantly different with the findings with the present study.
Recommendations: I . Availability of nutritious foods is to be made by proper agriculture extension. 2. Economic activities are to be raised to increase the regular income. 3. An extension program on nutrition education is to be launched locally especially in the area with coordination of local social organizations. 4. The monitoring of weight gain during pregnancy is to be extended and in future studies, longitudinal survey is to be conducted to assess the nutritional status of pregnant mother by taking weights.

ABSTRACT
From 16 February, 2004 to 14 March, 2006, a Leadership for Change programme (LFC) in Vietnam complemented successfully. It was a longitudinal study of a cohort of LFC's participants and it was a collaboration program between Ministry of Health (MOH), World Health Organization Western Pacific (WPRO) and International Council of Nurses (ICN). The aim of this study was to strengthen the capacity for nursing leadership and management in Vietnam-

This study's outcome was 30 nurses and midwives at senior and middle level of the health services. They were better equipped to improve the quality of nursing services and meet other critical challenges facing the health sector; then, l5 of them were trained to be trainers who later on helped train other nurses, thus enhancing the capacity for impact across the health care delivery system. The methodology of the study was based on action-learning principles and required full involvement by participants. Its components included (1) Activities undertaken by participants, these activities were to enhance "learning by doing" (2) Planning and implementation of a major project by participant teams, (3) Individual Development Planning, (4) Mentoring - Individual mentor and project team's mentor and (5) Workshops (4 workshops at six-monthlyintervals).

At the end of the programme, participants presented 5 team project results that impacted 60 mentors, ll5 chief/head & 650 nurses and health care professional. By LFC program, 30 participants' capacities were strengthened as evident by the following results: 17 participants completed and 4 participants continued their university program, one participant was enrolling in master program in paediatric nursing, l6 of whom obtained higher level of English, one obtained higher level of French. Six of them, who were nursing teachers, were involved in the development of nurse training program and curricula in their schools. All participants were involved in organizing training courses at their work places, developed, implemented, managed team projects, and became mentors to other nurses. Their communication and negotiation skills have also improved. Especially, all participants knew how to use the internet. They have also built their friendship and shared their experiences with other participants. They undoubtedly deserved to receive the prograrn certificates by MOH, WPRO and ICN.
can be concluded that LFC pparticipants should continue to build on successes. Employers should apply and expand LFC's outcomes. Health authorities at different levels should consult with, and make use of LFC program contents and methodologies. MOH (Vietnam), WHO & ICN should continue to invest in and expand LFC prograrns conducted by country trainers.

It

ii-|;;,:].l:.;j,,.illiiili.iil.l1iii..']]:!:':lt.rr::.i\illt"r\:1|l::'i,|i1.{l't.l.ill;.li:.l,:1:llll

I. INTRODUCTION

l.I

Rutionule and justification of the study

The political, technological and economic changes that have occurred over the past decade difficult to manage within the traditional framework of health-care, and the organization of health-care is seen to need radical reform to sweep away many of the internal barriers that now divide one form of health-care, and one profession, from another. Nursing must equip itself with skills in advocacy and political action to influence the direction the system will take. Nursing currently suffers from a weakness in self-concept that goes hand in hand with a weakness in political status, and nursing leadership must build the foundations for both advocacy for others and self-advocacy for the nursing movement.'
are increasingly

The Leadership for Change scheme aims to equip health professionals working in service improvement with the skills and knowledge to lead change and achieve lasting improvements in patient care. Leadership for Change engages accomplished faculty from the Boston College Carroll School of Mar-ragement and the Department of Sociology; Harvard Graduate School of Education and The Work and Learning Centre at North-eastern University with business practitioners from the great_er Boston area. All are engaged with the participants as rnembers of the learning cornrnunity.r

The profession faces tensions between different conceptions of its role and status, its relationship to rnedicine, and its relationship to health. Health indices are tightly linked to status, and to trust, hope, and control of one's own life. Could nurses help ernpower others when they are not particularly good at empowering themselves? What will the role of the nurse be in creating the inforraation flows that will guide people toward health? Nursing's long history of adaptation to an unsettled and negotiated status may mean that it is better
fitted to make this adaptation than other more confident disciplines.
The need was to better equip nurses at senior and middle level of the Vietnam health services with the knowledge and skills needed for effective management of nursing services, as well as for enhancing their contribution to national health developrnent. This will enable them to be able to irnplernent improvements in the quality of services, and to help mect other critical challenges facing the health sector.

By the year 2003, the Government of the RepLrblic of Vietnam requested technical assistance from the WHO Regional Office for Western Pacific for a capacity building programme in leadership and management developrnent for nurses. On the other hand, Vietnam Nurses Association also requested assistance from International Council of Nurses (lCN) for collaborating with WHO and MOH of Vietnam to run Leadership for Change Program in Vietnam. The collaborative approach to this programme involved a three-way partnership between the Ministry of Health of Vietnam (MOH), WHO (WPRO), and the International Council of Nurses (lCN) that assigned for 3 nurses as co-ordinators included Ms. Nguyen Bich Luu (MOII of Vietnam), Ms. Stephanie Ferguson (ICN) and Ms. Kathleen Fritsch (WPRO).

The research questions in of this study: How would be nursing leaders and managers'
capacities after training by ICN's LFC program?

1.2. Objectives:

a.The general objective was

to

strengthen

the capacity for nursing leadership

and

management in Vietnam, so that: - A group of nurses at senior and middle level of the health services was better equipped to

improve the quality of nursing services and meet other critical challenges facing the health
sector; and

Nurses from this group would later help train other nurses, thus enhancing the capacity for impact across the health care delivery system.

b. The specific objectives were to develop nurse leaders in the Vietnam health services who would have the ability to: - Influence policy and health system improvements; - Develop quality, cost-effective models of delivering services in hospital settings; - Be effective contributors to the broader health care team; - Contribute to ongoing leadership and management development programmes for others; - Influence changes in nursing and midwifery curricula.

1.3. Conceptual

frumework
Dependent variables

Independent variables

Participants' characteristics

Number
Gender Age Professionalqualification Nursing management qualification Working position

Leadership and management capacities

- Leadership and management Characteristics - Team project results

Learning components

Training workshops Learning activities Mentoring Team projects Individual development plans

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1.4. Operational definition :

it's including 4 levels of nursing qualification: bachelor (4 secondary (2 years) and primary (l year).

- Professional qualifications referred from nursing-midwifery education levels of Vietnam, years), college (3 years),

- Management qualification referred a 3 months-nursing management training curriculum of MOH of Vietnam or 3 months-administration trainins curriculum of Institute of
administration of Vietnam.

- Trainins workshops was one of 5 components of LFC that included 4 training workshop with a total of 20 days (5 days/workshop) during 2 years. It was adopted by International Council of Nurses (lCN)
- Learning activities was one of 5 components of LFC, it mean that participants learning by doing at the training workshop and at their daily working. It was adopted by International Council of Nurses (ICN)
- Mentoring was also one of 5 components of LFC, it mean each participant had at least one mentor and become to one mentor of other nurse. It was adopted by International Council of Nurses (lCN) - Individual development plan was one of 5 components of LFC. Each participant develop an individual plan that would be improved every workshop and applied at their life. It was adopted by International Council of Nurses (lCN) - Team project was one of 5 components of LFC training program that was one duty of each LFC participant. They studied how to manage project from writing proposal, implernenting and evaluating and reporting. It also was one of 2 outcome educators of at the end of LFC training program. It was adopted by International Council of Nurses (lCN)

- Leadership management characteristics were evaluation criteria of LFC program with l6 characteristics of nurse leaders and managers. It was adopted by International Council of
Nurses (ICN).

2. LITERATURE REVIEW

Many countries are faced with critical need to develop managers and leaders with the skills and knowledge needed to contribute to health planning, policy, management, education and delivery of effective health services, including nurse managers. In today's world, nurse managers cannot live with the status quo. They may need to make major changes in thinking
and behaviours.

Nurses in top-level management must develop new roles in policy advice and development in order to contribute to the aims and desired outcomes of health reform. This rneans giving up much of the operational management that has been their focus in the past, as that role often

becomes redundant when organisations, this has meant the loss power.

of previously held positional

Some of these nurses have made the transition to policy from operational management; other has not. In a number of instances, the jobs have been lost (or under threat) in the restructuring process, because people (including some nurses) have not suffrciently understood the role and contribution of nurses leaders in policy as opposed to operations.

ICN is a Geneva-based organisation representing over 129 national professional nursing associations worldwide with more than 13 millions of members, and had been involved with a global project for nursing leadership and management development for the last 12 years with training program named LFC. It was first started in 1996 and has been thought since in over 60 countries with more than 2000 graduates and 200 national facilitators. All programme participants received regular "LFC Bulletins" from ICN. This helped them be aware of global initiatives and developments, and to have the opportunity to network with others. ICN had developed and tested a methodology that was showing some important outcomes in many countries. A major evaluation study commenced in 2000 to evaluate the impact and sustainability of the programme results. Data from this study had been used to help strengthen the programme for Vietnam. Results from programmes and the evaluation study to date, attest to the methodology being extremely suitable for multi-disciplinary
programmes.

in Western Pacific Region are sponsored by WHO and the Vietnam is the first Asia country to have graduates from LFC. Other countries involved in the region are Mongolia, Papua New Guinea, Bangladesh and China. Singapore is running the program by
Several countries

national government funds. Currently, LFC consists of the basic program and Training of Trainer program that in charged by Dr Stephanie Fergusson who is Director of the LFC program of ICN. She has trained in most instances the first basic training LFC course in the country and for the follow up courses those are taught by the in-country certified trainers by ICN. ICN faculty, after the basic LFC course, gives technical support and assists in evaluation to the in-country trainers.
The LFC consists of the 5 following components totaling to minimum

of 250 credit hours: Workshops with strong emphasize on action learning methodology,20 days, usually

. o . o

consists of four one week workshops Learning activities are expected to take place in between workshops

Team projects must be implemented in each working environment rninimurn of 60

hours.

Individual development plan, 30 hours. Mentoring; each participant must have seasoned leader as mentor, meeting once week or at least once a month, minimum of l0-20 hours mentoring

During contact periods, participants learn main principles of leadership and management skills. Strong emphasize was in improving services and systems change aiming to have impact into policy changes. Nurses were trained to be more research / evidence oriented. Considerable amount of time is spent in development of a project plan which includes teaching of negotiation-, budgeting-, proposal making- and communication- skills. Trainers form teams that developed project plans for concerned hospitals focusing in nursing area. As
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part of successful completion of the training prograln projects had to be implemented and reported of activities written. The individual development plan was composed by using self assessment leadership tools. Later on individual developrnent would be reviewed by peer review, by mentor and LFC trainers. The plan was supposed to be used continuously even after the completion of the LFC training.

The target group was nurses who had leadership and management components in their positions at hospital, community health agency or higher administrative level. It also targeted people who had the demonstrated potential to develop further as leaders in their national health services. A mix of people at different levels was important to facilitate sharing and understanding ofthe different roles and priorities, and factors affecting these.

3. RESEARCH METHODOLOGY

Study design: A longitudinal study of a cohort of Vietnamese nursing managers Study area: Nursing managernent of Vietnam

Population: Nursing managers at provincial, hospitals and nursing departrnents of

nursing schools.
Sample size: 30 participants.

Data collection: from team project results and evaluation of participants' leadership and management characteristics.

4. RESULTS 4.1. Participsnts: 30 participants were selected based on the following criteria:

Being a nurse/midwife who were trained

program

> 3 year nursing or midwifery

training

Being a Chief Nurse of the provincial health department / hospital or head of nursing
f-aculty.

Having a certificate on nursing management or administrative governance. Having at least 3 year experience of nursing management
Female < 45 years. Male < 50 years

Having personal and employer commitment letter. English: the first level (primary understand reading and listening).

There were 25 females and 5 males with l4 persons under 40 years, l2 persons from 4l - 45 years and 4 persons from 46-49 years. 26 of them were nurses and 4 were midwifes. l0 persons were chief nurses of provincial health departments, l4 chief nurses of the hospitals, 6 nurse educators.

nurses,24

<

40

4145

> 45 -

49

Age

Chart 1: Participants' position 4,2. Leadership and manogement copacities:

Chart 2: Participants by age

leadership and management characteristics to evaluate nurse leaders and managers. The way to evaluate was using the questionnaire to ask 4 persons (supervisor, sup ordinate, colleague and self.l fill up questionnaire. Each characteristic ranked from I to 5, with one meaning the leadership characteristic is minirnally evident and needs considerable development, and five meaning the leadership characteristic is well developed, consistently evident and very effective.

ICN have developed and used

l6

Table 1A comparison of the participants'leadership and management characteristics before wlLn alte LFC trai ith after ralnrn
No. ision Cha racteristics
V

Average Score Before*

3.78
3

After* *
4.21

2
3

xternal awareness

.84

4.23 4.43 4.59 4.64 4.64 4.35 4.42 4.74 4.52 4.44 4.53 4.63 4.54

iustom orientatioll )olitical skills

v4otivation

4.34
3.97 4.26 4.64 3.85 3.93 4.35 4.22

4 5 o

lonfidence and trust

nfl uence and negotiation

7
8

lreative thinking
nterpersonal

l0

leam building

ll
t2

)ral communication
Wrinen communication

4.t9
4.04
4.21

l3 t4
t5

ielf - direction
lecisiveness

4.45 3.94
4.01

)roblem solving
{evier.v and change

t6

4.44

* Evaluated at the interval between the first and the second training workshop +* Evaluated at the iuterval between the third and the fourth training workshop Nole.' l-able I showed that in overall, l5l16 Ieadership characteristics of participants were improved, except cl.raracteristic number 6 (Contrdence and trust) was not changed. This result mean that one ofexpected outcomes ofthe training program was meet the general ob.jective of the study.

4.3. Team projects: 30 participants were divided into 5 teams to develop and implement team projects as belowi:

Team l: Improving management capacity for 49 district level chief nurses in 4 provinces of Vietnam, 2004-2006
This project was done by 6 chief nurses of the provincial health departments from Lam Dong, Vinh Long, Nam Dinh, Quang Ninh, Phu Tho, Hai Duong. There were 49 chief nurses of 4 provinces: Phu Tho, Quang Ninh, FIai Duong and Nam Dinh in order to be provided with knowledge & skills of nursing management and teaching, acquire scientific and plan-driven working habits. Thus, this project is creating positive changes in nursing work and articulating nurses and nursing works

Team2'. Preventing occupational accidents caused by sharp objects among hospital staffs.

This project was done in the National Pediatric hospital and the Phu Yen Traditional hospital and run by participants from Bach Mai I-lospital, National Pediatric Hospital, Central Tuberculogy Hospital, Phu Yen Traditional Hospital, Quang Nam Provincial General Hospital, and MOH.

The participants of this project developed a nurse training program and curricula on the prevention of exposure to sharp objects. Then, they trained 481 Health care personnel from the National Pediatrics & Phu Yen General Hospitals by using above training program and curricula. Thus, health care personnel applied knowledge & skills to nursing care practice then reducing risks, increasing correct management.
Team 3: Improving management capacity for head nurses of 6 hospitals in Vietnam, 20042006. This project was done in 6 hospitals: Saint Paul (Hanoi), Relationship, Bac Thang Long, Hue Central General Hospital.

There were 60 head nurses of 6 hospitals to be provided with nursing management knowledge and skills, be able to apply management processes into their work and acquire scientific and plan-driven working habits. This project was creating positive changes and articulating images of nurses and nursing work.
Team 4: Collaboration between schools care training.

hospitals to improve clinical practice and patient

This project was done by 6 participants who are nursing teachers from schools: Can tho University, Bach Mai, Nam Dinh Nursing University, Nghe An College , Kien Giang Provincial medical school, Pharmaceutical and Medical University in Hochiminh city. The participants developed a collaborated model for 6 pilot hospital departments and 6 nursing faculties by provided clinical practice training knowledge and skills for 60 clinical nurses. So, the outcome of this Nurse students apprenticing in pilot dept and correctly

implemented care procedures, then patients, students & nurses more satisfied with the care. This result is improving the quality of care and nurse' image.

Team 5: Improving communication skills of nurses Vietnam, 2004-2005.

/ midwives

working in 6 hospitals of

This project was implemented by 6 participants in 5 hospitals: Dack Nong provincial, Thai Nguyen Central, Hai Phong Maternal, Dong Thap provincial, Tu Du maternal.

By the project, there were 135 nurses working at 9 departments of 5 hospitals were provided with effective and appropriate communication knowledge, skills and attitude. They were able to apply good communication knowledge, skills and attitude when taking care for patients...So, colleagues and patients satisfied with nurses. This project is improving the quality of care in hospital settings and improving image of nurses.
Other results: After submitting this study result (in August 2007), we have completed the LFC program phase 2 (from July 2006 to September 2007) by 15 national educated facilitators and produced more 32 participants with 5 team projects. Later on, we was
accepted by ICN and WPRO to do the third LFC training course in 2008-2009 for 30 nursing

educators. We hope that 30 participants of the third phase

5. CONCLUSIONS

generations of LFC participants that impact to quality of health care in Vietnam."

will multiply .quickly next

chief/head & 650 nurses and health care professional. By LFC program, 30 participants' capacities were strengthened as evident by the following results: 17 participants completed and 4 participants continued their university program, one participant was enrolling in master program in paediatric nursing, l6 of whom obtained higher level of English, one obtained higher level of French. Six of them, who were nursing teachers, were involved in the development of nurse training program and curricula in their schools. All participants were involved in organizing training courses at their work places, developed, implemented, managed team projects, and became mentors to other nurses. Their communication and negotiation skills have also improved. Especially, all participants knew how to use the internet. They have also built their friendship and shared their experiences with other participants. They undoubtedly deserved to receive the program certificates by MOH, WPRO and ICN.
6.

The result of this study showed the LFC program in Vietnam completed successfully and made advertising nurse images by doing 5 team projects which impacted to 60 mentors, I 15

RECOMMENDATION

continue to build on successes. Employers should apply and expand LFC's outcomes. Health authorities at different levels should consult with, and make use of LFC program contents and methodologies. MOH (Vietnam), WHO & ICN should continue to invest in and expand LFC programs conducted
bv countrv.

It can be recommended that LFC pparticipants should

a..aaa:::a

REFERENCES

l. 2. 3. 4.

International Council of Nurses, Leadership For Change resource module, 2002

Health Foundation.2007 , http://rvwrv.health.org.uk/current work/leadership schernes/

leaders_for_change.html, access available on
3

October, 2007

Ministry of Health, Graduation reports of LFC participants phase I in Vietnam, March 2006. Ministry of Health, Minutes of the WHO-ICN-MOH meeting, 27 September
2007.

ABSTRACT
Listening is an essential component of communication and more than 60o/o of time each day is spent in listening. Active listening is vital in health care delivery, because studies show that less than 25o/o of messages are understood by the listener. This can have serious effects on patient care. A cross sectional study was conducted to assess the self perception of active listening skills in the doctors working in Rawalpindi and Islarnabad'
One hundred and fifty three doctors were included in the study. The self perception of their active listening skills was recorded, using the model proposed by DeVito. The data were collected and analysed, comparing them with the socio demographic and work related characteristics of the respondents. The results revealed that 68.\Yo of doctors had a high level of self perception of active listening skills. The actual scores in the pre intervention listening skills test showed 56.9% of the doctors had high listening skills. A strong association was found between self perception and ethnicity (p-value < 0.001) as well as between self perception and type of practice of the doctors (p-value < 0.001). Sirnilarly strong associations were witnessed between the actual active listening of doctors and many of the independent variables.

In conclusion, the results indicate that most of the doctors perceive their listening skills to be high, whereas the actual listening skills test results do not conform to their self perception. Some independent variables have a statistical effect on the listening skills of
the target group.

KEYWORDS
Active Listening, Doctors, Communication, Perception

INTRODUCTION
Listening is an important part of everyday life. It plays a vital role in communication process. This is especially true for health care personnel and patient interaction, according to Swash (2003). Although interpersonal communication in doctor - patient relationship has been investigated extensively, the role of doctors in the process has not been investigated. The literature is full of articles on patients' satisfaction, in the health care setting. Factors leading to patient dissatisfaction with health personnel have been studied in detail. The focus has been on the "patient" in the communication cycle, and the doctors have always escaped scrutiny. This study explores the listening skills of doctors, how they perceive themselves to be active listeners.

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Significance and justilication

All living beings communicate with each other to survive. Human communication mostly is the exchange of information in the form of messages. This is done by speaking, listening, writing and reading. Communication comprises composition, transmission and reception of messages according to Adler and Towne (1978). But there is no guarantee that messages are received, processed and retained in the same form as the speaker intended. Even very simple messages are often distorted. Sometimes this distortion is caused by problems in attitude, in motivation or in the physical settings as stated by Adler and Towne, (1978). Many times problems occur due to individual differences in processing ability. These processing abilities according to Bostrom (1990) are in reality "listening" abilities.
Listening is an integral part of human communication. Siebert (1990) estimates that typically 9o/o of time is spent in reading, l6Yo in writing, 30Yo in talking and 45Yo in listening each day. In another study Barker, Edwards, Gaines, Gladney, and Holley, (1981), found that students spent 53% of their time in listening, out of which 32Yo was spent ir.r face to face listening. A study in North America of oniob listening by Wolvin and Coakley (1991), shows Ihat600/o of the time is spent in listening in a typical American workplace.
Research suggests that most people are not very good at listening. Communication experts have found that people generally comprehend25% of a typical verbal message. This maybe

due to the fact that an average speaker speaks 125 words per minute while our brain can process 500 words per minute. Poor listeners use this time gap to day dream and think o1' other things, thus missing imporlant messages according to Kreitner and Kirricki (2000). Undoubtedly doctor - patient relationship is important, but fbr health care to be effective, the ability to listen and remember the information exchanged is much more significant. Whereas it is irnportant for the patient to remember what instructions have been given to him, the role of the doctor in listening with attention to the problerns of the patient are also vital. Paying attention to the words of the patients narrative at the time of history taking helps the doctor reach the correct diagnosis, whereas rnissing out a minor but vital detail may end in a faulty diagnosis.

Bush, (1985) found out that although patients understanding of doctors' advice has been studied extensively, almost no work has been done on studying the listening skills of doctors during the patient interview. The International Listening Association bibliographic database (2005) does not list a single study on the active listenir-rg of doctors. This study is intended to observe the understanding of the message of the patient by the physician through recall. Problem identification and purpose

The health profession relies heavily on patient doctor interaction. History, or description of the symptoms by the patient, is the keystone in reaching a diagnosis. However, according to Swash, (1989) the overworked doctor often listens partially to what the patient says, and sometimes makes assumptions which may affect the rnanagement of the patient. Most of the people realize the importance of communication, but the focus has always been on the patients. No evidence of any study about the listening skills of doctors was recorded in the International Listening Association (ILA) Bibliographic database (2005).

The purpose of this study is to explore the active listening skills of doctors. To learn what is the self perception of listening skills in doctors, and determine any relationship that may exist between the perception level of listening in the doctors and their socio demographic and work related factors.

Research question The study explores the question that; How do doctors perceive their own listening abilities?

Research design

The study is a cross sectional study of the level of perception of listening in doctors using a self administered questionnaire designed by DeVito (1995).

Study population Doctors of Rawalpindi and Islamabad from both public as well as private sectors, willing to participate in the study have been included. A total of 153 doctors were selected by simple random technique, from those doctors willing to participate in the study and working in Rawalpindi and Islamabad region, both in public as well as private sector. The study used the same sample as the self control, where the pretest results were used as the baseline. Then the group was retested using the posttest after the intervention.

Research instrument

The research instrument comprised a self administered questionnaire having three

sections.

Section I; comprised of an "informed consent" portion, which was signed by all participants in the survey. Section II; comprised of five questions dealing with the socio demographic characteristics and work related information of the respondents. While section III; comprised of questions about the self perception of listening developed by Joseph DeVito

in

1995.

The DeVito questionnaire comprised of ten questions, about the self perception of listening. It was scored using a ranking scale from I to 5 scores. Where the scores represented;1-always,2-frequently,3 -sometimes,4-seldom,5 -never. Thesuggested interpretation by the author is "Low level of active listening" if the score was less than 30,
and "High level of active listening"

if the scores achieved were 30 or more.

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METHODOLOGY
Data collection and testing procedure The DeVito test is a standardized instrument and has been already tested for reliability and validity therefore, these tests were not required for the test instruments. However, prior to the actual study, a pilot study was conducted to test the procedure and process of research methodology. The following steps were carried out for the pilot as well as formal study.
Step 1: All respondents were asked to fill out a self administered questionnaire containing the Self Perceived Active Listening test. To ensure confidentiality, they were asked not to disclose their names; rather they were requested to write the last 3 digits of their telephone number or any other unique number on all the tests and questionnaires. These unique numbers were needed to correlate the results of each respondent only. The identity was not disclosed to anyone. However, if any respondent wanted to know their own score, they could find out by telling the unique number entered by them on their test questionnaires.

Step 2: The responses of the participants were entered in a statistical package, SPSS and
analysed.

RESULTS

A total number of 153 respondents participated in the study, belonging to different

hospitals and private practioners of Rawalpindi and Islamabad as given in table 1. Two thirds (66%) of the respondents were female and one third(34%) were males. The age distribution ranged from 20 to 58 years, with an average of 29.4 years and a SD of 7.678 years. Almost three fourth of the respondents (72.5%) were below 30 years and about a quarter (27.5%), belonged to the 3l to 50 years age bracket. The sample was predominantly young as 87 .5Yo of the respondents were of 40 years or less age.

The ethnic background of the respondents varied with more than two thirds (68%) belonging to Punjab, followed by 15.7% from the Frontier Province, 7 .8Yo from Baluchistan, 6.50/o from Sindh and 7.3o/o from Kashrnir. This breakup reflects the distances of their native areas of origin from Islamabad as well. About two thirds (62.1%) of the respondents resided in Islamabad while a little more that one third (37 3%) lived in Rawalpindi. More than three fourth (77%) of the respondents were fresh doctors having graduated recently possessing the basic MBBS degree. Almost one quarter (22.9%) had postgraduate degrees and were specialists. One tenth (10.5%) of the respondents or 43oh of the specialists were having membership degrees or equivalent, while 7.8% had done FCPS part I and 4.6Yo completed their FCPS, (32.4o/o and 18.9%o of specialists) respectively.

ii*l

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Table

Table showing the socio demographic characteristics of respondents

Test item

Frequency

Percentage
o

n=153
Gender
Female

l0l
52

66.0 34.0

Male Ase
Less than or eoual to 30

lll
23

72.5
1

3l

to 40
50

5.0

41to

l7
2

ll.1
1.3

More than 50
Range min: 20, max: 58 vears

Mean age: 29.37 SD: 7 .678 Median 27

Ethnicitv
Sindhi Baluchi
Pathan

l0
t2 z1
104 2

6.5 7.8

t5.7
68.0
1.3

Puniabi

Kashmiri
Other

0.7

Domicile Rawalpindi
Islamabad Other

)I
95

)t.t
62.1

0.7

Level of education MBBS MCPS/equivalent

FCPS l/equivalent FCPS/equivalent

ll8
l6
t2
7

I t -l
10.5 7.8

4.6

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Work related characteristics

Out of the 153 respondents, a little more than one third (35.3%) were consultants or
specialists, less than half (43.8%) were medical officers and less than a quarter (20.9Yo) were resident house officers as seen in table 2. About two thirds (64.7%) were junior doctors compared with36.3%, senior practioners. Similarly the experience also varied, with7l.9% having less than 5 years of working experience compared with 28.loh who had 5 or more years of experience, the mean being 4.95 and SD of 6.358. The monthly income declared ranged from 5000 to 100,000 per month, with a mean income of Rs. 2t,105. Almost half (51%) respondents had less than 15,000 income, one third (34%) had between 15,000 to 30,000, and l50h had more than 30,000 monthly income.

Among the 153 respondents, 60.8Yo were government servants, while 26.8% were private practioners and l2.4Yo were govemment servants who also practiced privately. About a quarter (25.5%) worked in Obstetrics and Gynaecology department, 20.9Yo in Medicine, 183% in Surgery, l9%had a General Practice and 16.3%o worked in other departments.

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Table 2: Table showing Work related Characteristics of Doctors

Tesl item Frequency
Percentage
oh

n=153
Status/designation Consultant Medical Officer
ResidenVHouse Officer 54

5.3

b/

43.8
20.9

)z

Expcrience
Less than 5 years 5 years or more

ll0
43

t.9

28.1

Mean: 4.95. SD: 6.358

Monthly Income
Less than Rs 15,000 78 52 23

51.0
34.0
l s.0

Rs 15.000 to 30.000 More than Rs 30,000 Mean income: 21,105 SD: 14,352 Type of practice
Publ iclGovernment Service

93

60.8

Private Practice Both

4l l9

26.8

t2.4

Discipline/deprrtment OB/GYN
Medicine
Surgery General practice Others 28 39

ZJ.J 20.9
18.3
t 9.0

29 25

l6.3

Number of patients per day

Less than 20 20 ro 40

l6
IJ
53

10.5

49.0

4l

to 60

346
5.9

More than 60 Mean: 40.08 SD: 19.947

Working hours per day

Less than or equal to 6 hours

102

66.7 33.3

More than 6 hours

5l

Mean:6.88 SD: 1.644

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Regarding the workload, 10.5oh of the respondents handled less than 20 patients each day, almost half (49%) managed between 20 to 40 patients a day, about one third (34.6%) saw between 40 to 60 patients and 5.9%o respondents saw more than 60 patients each day. The average number of patients was 40.88 with a SD of 19.947. Two thirds (66.7%) worked for six hours a day while one third (33.3%) worked more than 6 hours each day. The average working hours were 6.88 with a SD of 1.644. Self Perception of Active Listening

The 153 respondents answered the questionnaire on self perception of active listening, using the Likert type five point ranking scale. The responses for each item reveals a pattern as follows;
The responses to the individual items in table 3, show that 8lo/o of the respondents admitted that they try to simplify the messages they hear by omitting details. Mean 2.65 and SD 1.15. This variation can cause problems where the history of the patient, taken by interview, contributes to more than three fourth in diagnosis of the disease and its subsequent management. (Item 303)

About three fourths Qa%) of respondents admitted that they allow their attitude towards the topic or the speaker influence their evaluation of the message, Mean 2.71 and SD 1.18 (item 305). This again is of significance in the doctor patient relationship. the respondents stated that they evaluated what the speaker was saying before they fully understood the meaning intended (item 309). Mean 2.85 and SD 1.12. In history taking, the doctor can make mistakes if s/he does not understand the meaning of what the patient meant in his history, if the above statement is applied.

ln

72%o cases

71.2% of respondents thought about their own performance during a conversation and as a result acknowledged that they missed out some of what the speaker was saying (itern 301). Mean 3.16 and SD 0.95. In doctor patient interaction, such a large proportion of doctors not listening completely to their patient reflects poorly about the quality of care offered.

the respondent accepted that they listen to the literal meanings that the speaker communicated and did not look for hidden or underlying meanings (item 310). Mean 3.36 and SD 1.086. In case of patients who are not too educated or eloquent, this would mean that many wrong messages are received by the doctor and the management of such

In over

600lo cases

cases can be inadequate.

In table 3, 69.30 of the respondents focus on a particular detail of what the speaker was saying instead of on the general meanings of what the speaker wished to communicate (item 304). Mean 2.79 and SD 1.29. In history taking, a doctor can easily miss out irnportant details if she focuses on one particular aspect. A holistic approach is ideal in managing a
patient, rather than having a tunnel vision approach to the disease entity. Over half (51%) of the respondents accepted that they listen passively, letting the speaker do the work while they relaxed (item 307). Mean 3.46 and SD 1.38. If the doctors do not make an effort to listen actively to their patient, then they are sure to miss out important information, which could be vital in the case management.

Almost half (49%) of the respondents admitted that they allow their minds to wander away from what the speaker was talking about (item 302). Mean value 3.55 and SD 1.118. In the doctor-patient interaction, this is critical, because s/he can easily mismanage a patient if s/he is not attentive to what the patient is saying.
47,8% of respondents said that they listen to what others say, but do not feel what the speaker was feeling (item 308). The meanvalue was 3.52 with a SD of l.22.In the case of doctors and their patients empathy and feelings are important, and cannot be neglected.

Table 3: Table showing the responses in self perception test

Statement
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q)
83

c) a

301

I think about my own performance during an interaction: as a result. I miss some of what the
speaker has said

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8

l.r)
15

(s4.2)
52

re.0)

29

15

(e.8)
37

302

I allow my mind to wander away from what the speaker is talking about I try to simplif, messages I hear by omitting
details

(5 2)
26 (r 7.0) 29
(

(e 8)
45

(34.0)
53

41 (26.8)

(24.2)

303

(2e.4)
40

(34.6) )t (24.2)
A1

(e.8)
28 (18.3)
(r

15

t4
(e 2)

304

I focus on a particular detail ofwhat the speaker is saying instead of on the general meanings the
speaker wishes to communicate

t9
(r2.4) t2
(7 8)
60

1e.0) 26

(26.1)
45

305

I allow my attitudes toward the topic or speaker to

influence my evaluation of the message

(r7 0)

(2e.4)

(27.s)
JZ

I hear what I expect to hear instead of what is actually being said

307

l9
(r2.4)
21
(

l2
(7 8)

28 8.3) 30

(20.e)
44

(r

e.6)

(3e.2)
50

I listen passively, letting the speaker do the work

while I relax

l3
(8 s)
20

13.7)

(28.8)
42

308

I listen to what others sav. but I don't feel what they are feeling
I evaluate what the speaker is saying before
I

ll
(7.2)

(13.1)
45

(27.s)
48
(3 r.4) 68

309

t7
(r

fully understand the meanings intended

310

l.l)
l0

(2e.4)

I listen to the literal meanings that a speaker communicates but do not look for hidden or underlying meaning

t4
(e.2)

(6 5)

(44.4)

25 6.3) 38 (24.8) 30 ( l e.6) 33 (2t.6)

(r

(32.7)
42

(27.s)
13

(8.5)
28
(r

8.3)

* Frequency ofresponses and percentage in brackets; n (%)

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In 41.loh of cases the respondents acknowledged that they hear what they expected to hear instead of what was actually being said (item 306). Mean value of 3.65 and SD of 1.36. This is a common practice in the doctor-patient interaction, where the doctor only sees what he wants to see. This is appropriately quoted in the Hutchison Handbook of Bedside Manners by Swash, (1989) as: "The eye does not see what the mind does not know".
80 70 60
AN

40
30

20
10 0

Low perception

High perception

Figure 1: Figure showing Self Perception of Active Listening

In the self perception portion of the questionnaire, 49 respondents or about or-re third (32%) of the respondents scored less than 30 and were adjudged to have low self perception of active listening according to tl-re criteria proposed by DeVito (1995). The remaining two thirds (68%) or 104 of the respondents, perceived themselves to have high level of active listening skills. The mean score was 31.69 with a Std Dev of6.60, as seen in figure I. Association between self perception and socio-demographic factors Less than a third (30.7%) of the l0l female respondents had scores showing low self perception of active listening, while more than two thirds (69.3%) had high self perception. In males, a little more than one third (34.6%) had low self perception while less than two thirds (65.4%) scored more than 30 and were adjudged as having high self perception of active listening. However, there was no significant association (p value :0.622) between the gender of the respondents and the scores obtained in the individual items, or the cumulative score in self perception. In the under 30 age group of 111 respondents,2S.So/, were having low self perception, while 71.2% secured scores of high self perception. Out of the 23 respondents in the 3l to 40 years age group, 39 .l% had low and 60.9Yo had high self perception. In the I 7 respondents in 41 to 50 years age group, 41.2% had low and 58.5% had high self perception. In the over 50 age group an equal distribution of 50Yo respondents, was observed in the low and higl-r groups of self perception. However, no statistical significance (p value:0.571) was observed in the association between self perception and age groups.

Table 4: Table showing the association between Self Perception and Socio Demographic characteristics
Test item Self Perception

High
Gender
Female 31 (30.7) 70 (6e.3) 34 (6s.4)

Male
ChiSq: 0.243 p value:0.622 Age
Less than or equal to 30

l8 (34.6)

32 (28.8) e (3e.1) 7 (4r.2)

79 (11.2)

3l

to 40

l4 (60.e)
r

4l

to 50

0 (58.5)

More than 50 ChiSq:2.005 df 3, p value:0.571

(50.0)

(50.0)

Ethnicity
Sindhi 3 (30.0) 7 (70.0)
1

Baluchi
Pathan

(8.3)

(er.7)

t5 (62.s)
28 (26.e) 2
( r 00.0)

e (37.s) 76 (73.r)

Punjabi

Kashmiri
Other

(100.0)

ChiSq: 19.31 I df 5, p value:0.002*

Domicile
Rawalpindi
Islamabad

23 (3e.7) 26 (27.4)

35 (60.3) 6e (72.6)

ChiSq:2.497 df

l,

p value=O.114

Level ofeducation

MBBS
MCPS/equivalent
FCPS I/equivalent FCPS/equivalent ChiSq: 3.157 df 3, p value:0.368

38 (32.2)

80 (67.8)
12 (7s.0)

4 (2s.0)
6 (50.0)

6 (50.0) 6 (85.7)

(14.3)

In the ethnic groups, out of the l0 respondents from Sind,30% had low andT}yo had high self perception of active listening. There were 12 respondents from Baluchistan, out of which, 8.3% had low and 9I.7 had high self perception of active listening. 26 people responded from NWFP, out of which 62.5% had low and37.5o/o had high self perception of active listening. 104 people responded from the Punjab, 26.9% had low and73.1% had high self perception of active iistening. The 2 respondents from Kashmir had low self perception. A statistically significant association was observed at a p-value of 0.002 between the ethnic groups and self perception of active listening.

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Cornparing the domicile of the respondents, 58 people belonged to Rawalpindi. 39.7o/o had low and 60.3% had high self perception. 52 respondents resided in Islamabad out of which, 27.4% had low and 72.60/o had high self perception of active listening. However, no statistically significant association (p value:0.114) could be established between domicile and self perception.

education and its effect on self perception revealed the following. 1 18 respondents possessed basic MBBS degree. 32.2% had low while 67.8% had high level of self perception. l2 respondents possessed MCPS or equivalent degree, 25Yo of whom had low and 75Yo had high self perception. 12 FCPS part I holders participated, and an equal number (50%) had low and high self perception. 7 FCPS degree holders responded, 14.3% had low while 85.7% had high level of self perception of active listening. However, with a pvalue of 0.368, no statistically significant association could be established between level of education and the level of self perception of active listening.

The level

of

Association between self perception and work related factors

The results showing the association between self perception of active listening in the doctors with their work related factors show that there is no significant association between self perception of active listening (p value 0.407) and the cadre of the respondent. However all the levels of doctors seem to have a high self perception of their own active listening abilities. In the case of Senior Registrars, the difference was not much while all the rernaining cadres scored highly in their self perception of active listening ranging from 57.1 Yo to 100 % in some cases. This shows the importance of the fact that the doctors uniformly believe that they are very good in active listening skills. There seerls to be an increasing level of believing of high self perception in the hierarchy within the cadres of the doctors. I'he junior doctors scored 62.5% compared to senior doctors who scored 100%. This trend can be linked to the seniority in the profession.

The experience of the respondent had no significant association (p value 0.213) when cross tabulated with their self perception. Irrespective of tl"reir experience in the profession 60 to 71o% assessed themselves to have high level of self perception of active listening skills. However, their seems to be reversal in the high level of self perception between the older and younger professionals. 60.5% of doctors who had less than five years experience scored in the high category compared with70.9o/o who had more than five years of work experience.
The data shows that the income of the respondent also does not have significant association with the level of self perception (p value 0.512). The respondents with increasing incotne appear to be more confident in their active listening skills as the range varies from 66.7Yo in the respondents having income less than 15,000 to78.3Yo in those earning more than 30,000
per month.

There appears a statistically significant association (p value 0.034) between the level of self perception and the type of practice of the respondent. 60.2% of the public sector doctors scored in the high category while 78% of the private practitioners rated themselves to have high active listening skills. In thc case of those doctors who worked both in the private as well as public sector, 78% thought they had high active listening skills. There is a signilicant correlation between the level of self perception and type of practice Pearson Correlation (p value 0.047).

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Although there is no significant association between level of self perception and the discipline of medicine of the respondent (p value 0.274). However there is variation between the various departments. More detailed analysis can be conducted and further studies organized to assess the variation, however, it would cause concern for a department to be
labeled as poor listeners compared to others.

Table 5: Table showing association between Self Perception and Work related factors
Test item Self Perception

Work related factors

Status/designation
House Officer

Low

High

t2 (37.s)

20 (62.s) 27 (60.0)

Medical Officer
Registrar
Sr Registrar

l8 (40.0)
7 (31.8) 3 (42.e) 2 (16.7) 0 (0) 7 (21.2)

l5 (68.2)
4 (s7.r)

Asst Professor Assoc Professor Other

l0 (83.3)
2 (100)

26 (78.8)

Chi Sq 6.148 df Experience

p value 0.407

Less than 5 years 5 years or more

32 (2e.t)

78 (70.e) 26 (60.5)

l7 (39.s)

ChiSq 1.549 df

p value 0.213

Monthly Income
Less than Rs 15,000

26 (33.3)

s2 (66.7) 34 (6s.4)

Rs 15,000 to 30,000

l8 (34.6)
s (2t.7)

More than Rs 30,000 Chi Sq 1.339 df

l8 (78.3)

p value 0.512

Type ofpractice Public/Government Service

Private Practice

37 (3e.8)
e (22.0) 3 (1s.8)

s6 (60.2)
32 (78.0)

Both Chi Sq 6.784 df

t6 (84.2)

p value

0.034 Pearson Correlation 0.161 p value 0.047 l4 (35.e)

e (28.r) 6 (21.4) 8 (27.6)

Discipline/depa rtment

OB/GYN
Medicine
Surgery General practice Others

2s (64.r) 23 (7t.e)
22 (78.6)

2r (72.4) l3 (52.0)

l2 (48.0)

Chi Sq 5.130

df4

pvalue0.274

the 25th Anniversary of the AsEAil rnrtitute firr Health Development

Table 5: Table showing association between Self Perception and Work related factors (Continue)
Test item Self Perception

Work related factors

Number of patients per day
Less than 20

High

e (56.3)

7 (43.8) 50 (66.7) 40
(7 5 .5)

20 to 40

2s (33.3)
13 (24.s)

4l

to 60

More than 60 Chi Sq 6.138 df

2 (22.2) p value

7 (77.8)

0.105 Pearson Correlation 0.256 p value

0.001

Working hours per day

Less than or equal to 6 hours

30 (2e.4)
1e (37.3)

72 (70.6) 32 (62.7)

More than 6 hours Chi Sq 0.961 df

p value 0.327

The data showed no significant association between the level of self perception and the number of patients seen each day (p value 0.105). However there is an increasing trend in level of self perception and there is a direct correlation between the two variables Pearson Correlation 0.256 (p value 0.001).
The data analysis revealed no statistically significant association between the level of self perception and working hours of the doctors (p value 0.327). There also does not appear to be any correlation between the two variables (p value 0.739).

CONCLUSIONS This study was designed to explore the active listening skills of doctors. This brings into light the important communication skills of doctors during the doctor - patient interaction, which is vital to proper health delivery service. Many studies have hinted on the poor communication skills of doctors leading to patient dissatisfaction and alarming incidences of legal suits, which could have been avoided had the doctors explained the situation to the patients and their relatives. This state of affairs has prompted many insurance companies to advocate addition of interpersonal communication skills to rnedical curriculum, and refresher training programs for in-service doctors. This study has explored the self perception of the in-service doctors about their own active listening skills. From the evidence provided by the tests, the following conclusions are
deduced:

The doctors have a high sense of their self perception of their active listening skills. However, the actual active listening skills of the doctors are less than what they perceive them to be. A significant association exists between Self Perception and Ethnicity of the respondents. Similarly a significant association exists between Self Perception and Type of Practice of the respondents. In case of all other variables there appears to be no significant
association between the self perception of active listening and the independent variables.

RECOMMENDATIONS
Rec
o

mme n d atio

ns

fo r furt

res earc It :

it is proposed that further studies be conducted More studies requiring association between factors on the actual level of active listening.
Based upon the evidence of the study,

affecting listening and the perception can be carried out.

Reco mme n d atio ns

for

do cto rs

From the analysis of the data collected, it is proposed that the doctor community should focus on developing better active listening skills to benefit their patients as well as help themselves in diagnosing disease correctly.

REFERENCES

Adler, R., and Towne,

N.

(1978). Looking out/looking

in (2nd ed.). New York:

Holt,

Rinehart and Winston. Baker, L., Edwards. R., Gaines, C., Gladney, K., & Holley, F. (1981). An Investigation of Proportional Time Spent in Various Communication Activities by College Students, In Journal of Applied Communication Research 8:101-9.

Bostrom, R. (1980, May). Communication attitudes and communication abilities. Paper presented at the Annual Meeting of the International Communication Association,
Minneapolis.

Bostrom, R., & Bryant, C. (1980). Factors in the retention of information presented orally: The role of short-term listening. Western Journal of Speech Communication, 44, 137-145. Bostrom, R., & Waldhart, E. (1980). Components in listening behavior: The role of shortterm memory. Human Communication Research, 6,271-227.

Bostrom, R., Waldhart, E., & Brown, M. H. (1979, May). Effects of "motivational" instructions on listening behavior. Paper presented at the Annual Meeting of the International Communication Association, Philadelphia, PA.

Bush, D. F. (1985). Gender and nonverbal expressiveness in patient recall information. Journal of Applied Communication Research, I3 (2), 103-117

of

health

DeVito, J. A. (1995). The Interpersonal Communication Book. Tth edition. Harper Collins College Publishers. New York.Pp 69

ILA Bibliography Database. (2000). Accessed July 2005. http//www.ila.com

Kreitner, R., & Kinicki, A. (2000). Organizational Behavlor. Irwin McGraw Hill

il

Siebert, .f. H. (1990). Listening in the Organizational Context. In R. Bostrom (Ed.), Listening Behavior Measurement and Application. (pp. I 19-127) New York. The Guilford Press.

Swash, M. (2003). Hutchison Clinical Method. 19'h Society/Bailliere Tindall. London. (pp. 2-3)
Wolvin, A., & Coakley, C. (1982). Listening
13'd

Ed. English Language

Book

Edition). Dubuque, IA: Brown

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ABSTRACT
The WHO frame work on Tobacco control was developed in response to the current globalization of the tobacco epidemic. The spread of the tobacco control epidemic is being facilitated through a variety of complex factors with cross-border effects, including trade liberation, foreign direct investment, and other factors such as global marketing, transnational tobacco advertising, promotion and sponsorship, and international movement of contraband and counterfeit cigarettes. Tobacco is the second major cause of death in the world. It is currently responsible for the death of one in ten adults' world wide (About 5 million deaths each year). If current smoking patterns continue, it will cause some l0 million deaths each year by 2025 (WHO FCTC,2OO3) The most cost-effective strategies are population wide public policies, like bans on direct and indirect tobacco advertising, tobacco tax and price increases, smoke free environments in all public and work places, and large clear graphic health messages on tobacco packaging. All these measures are included in the provisions of the WHO Framework Convention on Tobacco Control (WHO, Tobacco Free Initiative,2004) Framework Convention on Tobacco Control was officially signed by the Lao government on 2610612004 and has signed this instrument of ratification at Vientiane capital on 5"' September,2006. The National University of Laos (I.{UOL) is a multi-campus institution encompasses a structured within a 35 km radius of Vientiane capital. The official meeting among l2 Faculties and related institutions to draft a regulation of Smoke Free University was conducted since 2005 and currently the regulation was approved by the Rector of National University of Laos ( 21", Septernber of 2006) After a regulation was approved, many kind of advocacy trainings has been implemented in order to enforce a regulation of Smoke Free University such as workshop to disserninate this regulation for faculties' staff and students, Students activities to perform their Drarna show, Mini-concert, rally, smoking cessation unit and set up a Big sign/banner of Smoke Free faculty within the National University of Laos. A regulation of smoke free in the National University of Laos will reduce exposure to Second Hand Smoke (SHS) among students and faculties reduce social acceptability of smoking and establish model for other smoke free environments in educational institutions in Laos. Key words: Smoke free regulation, Advocacy project, National University of

Laos

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I. BACKGROUND

The WHO frame work on Tobacco control was developed in response to the current globalization of the tobacco epidemic. The spread of the tobacco control epidemic is being

facilitated through a variety of complex factors with cross-border effects, including trade
liberation, foreign direct investment, and other factors such as global marketing, transnational
tobacco advertising, promotion and sponsorship, and international movement of contraband
and counterfeit cigarettes. "The FCTC negotiations have already unleashed a process that has

resulted in visible differences at country level. The success of the FCTC as a tool for public
health

will

depend on the energy and political commitment that we devote to irnplementing it,

in countries in the coming years. A successful result will be global public health gains for all"

(wHo, FCTC,2003)
Tobacco is the second major cause of death in the world.
death of one in ten adults' world wide (About 5

It is currently responsible for

the

million deaths each year). If current smoking

deaths each year by 2025. Experience has

patterns continue,

it will

cause some

l0 million

shown that there are many cost-effective tobacco control measures that can be used in

different setting and that can have a significant impact on tobacco consumption. The most
cost-effective strategies are population wide public policies, like bans on direct and indirect
tobacco advertising, tobacco tax and price increases, smoke free environments in all public and work places, and large clear graphic health messages on tobacco packaging.
measures are included

All

these

in the provisions of the WHO Framework Convention on Tobacco

Control (WHO, Tobacco Free Initiative,2004)

Smoke free zone application is one way to reduce new smokers and second hand smoke, this

kind of intervention will become policy and educational intervention for tobacco control
project and providing for protection from exposure to tobacco smoke indoor workplaces,
indoor public places and, as appropriate, other public places. Framework Convention on Tobacco Control was officially signed by the Lao government on
2610612004

and has signed this instrument

of

ratification at Vientiane capital on

5'r'

of smoke free Ministry model at the Ministry of Foreign Affairs and Mahosoth hospital is only one that has implemented smoke free
September, 2006.
success

In Lao PDR,

workplaces of Ministry of Health.

$rt:x*nti*g a $rt,t*kr* flr*e K*gulxti*n it'l **e lH*ffi*n*l $x'l*v*rsit5* *f National University of Laos (l\.IuOL) consists

$-:**s

of

12 faculties, 4 main campuses, centers,

hospitals and five attached campuses. The central Administration of NUOL (Head quarter) is located at Dongdok campus, which consists of the Rectorate Cabinet and five divisions. The

official meeting among 12 Faculties to draft

regulation for Smoke Free University was done

and currently the regulation was approved by the Rector of National University of Laos.

it is necessary to support smoke free environment in the National University of Laos in order to reduce exposure to Second Hand Smoke (SHS) among students and
Therefore faculties, reduce social acceptability of smoking and establish model for other smoke free
environments.

II. OBJECTIVES:
The main objectives of this advocacy project were to:

I I

To advocate a resulation of Smoke Free

(NUOL)

areas

in the National University of Laos

To reduce new smokers and SHS amone students & Faculties

III. STAKEHOLDERS /NETWORK

This project consisted of both government and NGOs sectors, the more details are as the

following:

l. Internal stakeholders:

The National University of Laos: Faculty of Medical Sciences acted as a key messenger
to run this project and lobby the Rector of The National University of Laos then set up the

inter-faculty task force to draft and develop a smoke free regulation. The inter-faculty

task forces on smoke free regulation are deputy-dean

organizations of The National University of Laos.
2. External Stockholders:

of 12 faculties

and

mass

Department of hygiene and disease prevention and its members of tobacco control task force (Inter-ministerial ) assisted this projects in terms of technical issues such
trainings.
as

the national references on tobacco control issues and local trainers for advocacy

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WHO/Laos, ARDA Laos and mass Medias worked closely with this project, they
helped to provide some international references to present in advocacy trainings and mass

Medias disseminated the out put of each advocacy training for society.

IV. ACTIVITIBS IMPLEMENTBD

The implernentation of this project was classified in to 2 phases and has started to implement
since November of 2005. The rnore details as follows:

A. Creating a smoke free regulation of the National University

2005-5eptember of 2006)

of

Laos (November of

1. Meeting with about the concept, strategic plan of this project. The result found that
among key persons of faculty of Medical were agreed and willing to support for creating
smoke free university.

2. Meeting with Rector and board committees of the National the dean and mass organization with faculty of Medical Sciences
The main objective of this meeting was to inform University of Laos

Dean, faculty

of medical

sciences and advocate team played as key messengers to

advocate and lobby Rector by showing them the steps of implernentation, why we need to

conduct this project and what is the main out put/goal of this project. The team also discussed and show some evidence based

for the impact of tobacco

consumption,

especially for second hand srnoke issues and finally the rector approved about this projecl

for implementing.

3. Meeting with the chairman of National Tobacco Control taskforce, Interministerial task force Laos.
The main objective of this meeting was to share the work-plan and develop some contents

of advocacy training to match with current situation of tobacco control issues in

National level and task force also gave some comments and effectives reference for
implementation.
4. Meeting

the its

with WIIO/Laos, ADRA Laos and mass Medias.

The two international organizations that directly work for tobacco control issues art WHO/Laos and ADRA Laos. The meeting focused on action plan and sources
o

international evidence based such as WHO FCTC, TFI issues and related materials tr
support of advocacy implementation

5. The small survey about opinion of staff and students for creating smoke free zone

regulation
The survey for staff was conducted in 3 faculties as the representative

of l2 faculties of

the National University of Laos (n:142, year 2006), the main finding found that current

smoke was 3.5o/o, strongly support hopefully smoke free regulation

to create smoke free regulation was 80% and

n:386) the result showed that

will

reduce new smokers was 7}oh. The other survey

among students in Faculty of Medical Sciences (year 2005,

ex-smokers:30.7yo, current smoke:l .3o/o and family member smoke:41.2%. These local
evidences based also presented and submitted to the National University of Laos. 6. Meeting

with the inter-faculty task force

The inter-faculty task force was established by the Rector of The National University of
Laos. These committees are deputy-deans

of

12 faculties, centers, mass organization in

the University level. The first meeting was advocacy training on tobacco control. The
second rneeting was

to draft a new regulation for smoke free university and the

last

meeting was to develop and prepare for final draft to submit to the Rector for approval.
7.

Training for students for their advocacy

The main objective was to train about tobacco control issues for a group of students who

are the representative

of

12 Faculties then they can perform their activities as drama

show, songs, questions and answers about tobacco control. The student's activities mainly
focused and targeted among students as peer education. 8. Meeting among Rector, Deputy-rectors and its committees

After the final draft of a smoke free regulation of the inter-faculty task force, this draft
regulation was revised / edited again among Rector and board committees then officially
approved

it on 2l Septernber,2006. The committees

suggested the Faculty of Medical

Sciences should conduct a comprehensive smoke free area as a good model then expand

to the other faculties respectively.

B. Supporting a new regulation by advocacy campaigns (October of 2006-January of 2007)

The advocacy campaigns were conducted after a regulation was issued:
1. Dissemination

workshop

The meeting and workshop was conducted to disseminate about a new regulation of
smoke free university. The faculty of Medical sciences organized a workshop for staff on updated information of tobacco control, especially impact of second hand smoke and

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sign of smoke free areas with in the faculty of Medical Sciences. The out put found that

main key persons and lecturers of faculty of medical sciences agreed to have a big sign of smoke free area in the Faculty and smoking areas who can not yet quit smoking.
2. Students activities

A group of students who trained about tobacco control were performed their activities to their students friends and staff in Faculty of Medical Sciences, school of foundation
study, head quarter and neighboring faculties. The main activities that they performed were Q and A, songs, drama show. For those who can answer the question correctly the
team gave them T-shirts with Logos of smoke free zone and other things.

3. Meeting with dean, faculty of Medical Sciences

The rneeting with dean, keys persons (Heads of departments and other division) and
mass organization were conducted

to discuss about the way of establish of smoke free

areas in the Faculty including smoking area. The rneeting concluded that

it should have

enough sign of smoke free areas and provide only one smoking areas for who can not quite smoking. 4. Sign/banner of smoke free areas in each faculty

Actually after a regulation was issued the stickers of smoke free area were done in each faculty of the National University of Laos. According to the recommendation of the inter-faculty task force, the faculty of medical sciences will have a big sign of smoke free faculty on January of 2008 and also in Head quarter (Rectorate cabinet) of The
National Universitv of Laos.

V. KEYS FACTORS FOR ACI{IEVEMENT

Many sectors supported this advocacy project but the main key factors to achieve objectives of it were to:

l. 2. 3. 4.

Worked closely with Rector and deputy-deans of each faculty, Mass organizationof the National University of Laos.

Moral support and facilitate from decision makers from the National University of Laos
Technical support/assistance from MoH, WHO, ADRA Laos and mass medias
Funding and technical support from SEATCA

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VI. CONSTRAINTS OF IMPLEMENTATION

According to the time frame of this project was only 1 year and at the beginning of the
project, the tobacco control issues was not put in the account of health priority, so it was quite

difhcult to negotiate with high ranking decision makers. There are some constraints in terms
of implantation as follows:

l.
2.

Lack of specific coordinators in each Faculty level in order to organize and conduct any
advocacy campaigns.

Limited budget for such activities, therefore

national University of Laos.

it could not cover all faculties of the

3. All faculties are scattered all over the city ( In different place and quite far each other) 4. The advocate and team have more responsible such teaching and another research 5. Lesson and experience in terms of advocacy was limited
VII. VALUABLE LESSON LEARNT
This is the first advocacy project, especially for tobacco control issue that advocate and
team conducted; there fore
leant as follows:

it was faced with many problems but it can conclude for

lesson

l.

How to conduct an advocacy project in the University level

2. How to work with decision makers at University level 3. How to disseminate tobacco control issues in different aspects in the country 4. Working as a team and different sectors 5. Make any faculty campus of the University is indoor smoke free and Faculty of Medical
Sciences is indoor and outdoor smoke free

6. How to adjust a budgeting and timing to cover all activities 7. Shared ideas and experience with other participants from different countries

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VIII. FUTURE PLAN

For the sustainability of the project the advocate and team plan to:

l.
2. 3.

Find sources of funding to continue supporting smoke free any University in Laos (
Government and private sectors)
Set up working team/group in each faculty of the National Set up some indicators to monitoring and evaluation

University of Laos.

ACKNOWLEDGEMENT
On the auspicious occasion it comes as great pleasure for us, and for this opportunity,

I would like to express my sincere thanks to all experts and trainers who train and guide
through the programming and realization of this advocacy project.

me

I am obliged and indebted most profoundly to my respected facilitators, Ms. Bungon

Ratthiphakdee

a SEATCA coordinator, Ms. Mary Assunta ASEAN fellowship program

coordinator, Ms. Menchi G.Velasco a research program coordinator and trainer team for their outstanding, praiseworthy contributions. They helped a lot by carefully reviewing my project proposal and offering valuable advices.

would like also to express my appreciation to Dr.Bounlonh

Ketsouvannasane

WHO/Laos, Dr.Maniphanh Vongphosy ADRA Laos and trainers from MoH for their helpful
assistance, suggestions, comments and good experience for our project.

I am also taking this opportunity to express my wannest thanks and good wishes

to

Assoc.Prof. Lammai Phipakavong, Vice rector, chairman of inter-faculty task force of the National University of Laos, Assoc. Prof.Dr. Som Ock Kingsada, dean of faculty of medical
sciences, Assoc. Prof.Dr. Bounsai Thovisouk former dean, Faculty

of medical

sciences,

Assoc.Prof.Dr.Sing Menorath Vice-dean, faculty

of medical

sciences, Vice-deans

of

each

faculty and mass organization for moral support, helpful contributions during
implementation.

the

Highly appreciation to working team of Faculty of medical sciences, students team for
their strongly support this project.

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Fr*mnting a $m*ke Fre* Regulation in the Naticnal lJnivers{ty af Laos

REF'ERENCES

1.

National policy on Tobacco Control Program. Ministry of Health, Lao PDR., 2001

2. WHO FRAMEWORK CONVENTION ON Tobacco Control. WHO, 2004 3. Tobacco Free Initiative. Regional Action Plan 2005-2009. WHO,2005 4. The Role of Health Professionals in Tobacco Control. WHO. 2005 5. Tobacco Free Initiative. WHO.2004

ffiil
iii,$l

the 25th Anxiversary of tke &SfrAIt Institute f*r flealth Development

DEFINITIONS
WHO defines an emerging disease as a disease that "has appeared in a population for the first time, or that may have existed previously but is rapidly increasing in incidence or geographic range". US Institute of Medicine defines emerging diseases as those "whose incidence in humans increased in the last 20 years" and re-emerging diseases are those conditions that "have reappeared after a significant decrease in incidence". These definitions are useful but sometimes too restrictive.

SITUATION AND TREND

Half a century ago many people believed that the war with infectious diseases would be over soon because of antibiotics. However, during the past 20 years or so, we have identified more and more new infectious diseases, which mostly new to public health workers such as AIDS (Acquired Immune Deficiency Syndrome), Ebola hernorrhagic fever, Flanta virus pulmonary syndrome and the very recently SARS (Severe Acute Respiratory Syndrome) and H5Nl. Interestingly some non-communicable diseases have been recognized to be associated with infectious agents such as peptic ulcerwith Helicobacter pylori, Kaposi's sarcoma with Herpes Simplex Virus 8, cervical cancer with Human Papilloma virus. The more we think we overcome the war, the broader the battle field is. Identification of prion, which causes several illnesses including mad cow disease has urged public healtl'r workers to be more vigilant on new types of infectious agents and be more careful before declaring victory. Figure
decade

I Outbreaks of viral diseases

in Southeast Asia and the Western Pacific over the past

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llltt) {l!$t}

hfl!w1l{ll9X:)

Source: J.S. Mackenzie, K.B. Chua, P.W. Daniels, et al, Emerging

Viral

Diseases of Southeast Asia and the Western

Pacific.

Apart from communicable diseases, behaviours have been included in the scene. Various types of traffic accidents have been major causes of mortality and morbidity especially among people at their productive age. Hard drug use, imbalance nutrition, violence and homicide are increasing probably due to changing life styles including migration and urbanization. After shocking news of a violence case or an innovative method of suicidal attempt, similar cases happen here and there. Global communications have contributed to mimicking of both productive and destructive actions. Should these be regarded as emerging and (psychological) contagious?

conditions fall into a simple model of epidemiological "host-agent-environment triad". We all live in the equilibriums of several conditions, which are inter-linked. Once one triad is affected, it does not only cause changes in the incidence of a disease but also affect other equilibriums. The "butterfly effect" of emerging and re-emerging diseases is intensified by increasing communication and transportation, which are parts of the "Globalization".

All

Figure

The epidemiological Triad

Host--Agent--Environ ment Relation ship

Environment
RESPONSE STRATEGY For policy and programme purposes nothing is better than being vigilant to new conditions including extra-ordinary utrlization of medical services or supplies, report of clusters of similar cases. Several factors including geographic and chronological dimensions of disease distribution need to be taken into consideration.

SURVEILLANCE The US Centers for Disease Control and Prevention (US CDC) defines public health surveillance as"the ongoing, systematic collection, analysis and interpretation of health data essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those who need to kno. The final link of the surveillance chain is the application of these data to prevention and control. A surveillance system includes a functional capacity for data collection, analysis, and dissemination linked to public health programs."

The concepts of public health surveillance has evolved from communicable to

non

communicable and emerging conditions. Surveillance, thus, includes more than reports of illnesses or deaths but also unusual strains of micro-organisms, change in utilization patterns of medical services and supply etc. In general ,there are four types of surveillance, passive, active, sentinel and special systems. To be more specific, surveillance includes, among many
others, the following aspects'.

Halperin W, Baker EL, Monson RR (Ed), Public Health Surveillance, Van Nostrand Reinhold, 1992.

a a a
a a a

Sentinel health event o Medical records o Vital records Hazard surveillance Vaccine preventable control surveillance Surveillance for AIDS Surveillance of nosocomial infections Chronic disease surveillance Injury surveillance Surveillance of birth defects

Therefore information sharing is critical in detecting emerging and re-emerging diseases at the beginning. Similar to the warning systems for natural disasters (e.g. Tsunami warning), being watchful for changing environment that disturbs the host-agent-environment equilibrium would obviously give us sufficient preparation and sensitivity to detect changes of disease patterns. For example, how the global warming and climate change would result in vectors and existing / new infections, how much expanding transportation and communication would affect spread of a mutant strain of micro-organism (multi-drug resistant TB), how much the GMO (genetically modified organism) would increase vulnerability to epidemics of existing disease (Avian Flu). There are concerns we have together to early detect these conditions and we need to build the system and share information.

Finally, given current situation we cannot avoid emerging and re-emerging of diseases and health conditions as we.have disturbed the environment so much. To reverse the trend. let's address them in a harmonized way.

il

the 25th Anniv*rs*ry

ep{

the &$fiAfd Xffistit$te fer *{e*lth Sewe*nprn*nt

l. MPHM Alumni Attendant (International participants)

Name

Batch
J

Dr. Md. Mansur Elahi

(Bangladesh)

Position/Address Upazila-Health & Family Planning Officer Sub-District Hospital Chatmahor, Health Complex P.O. & Thana: Chatmohor

District: Pabma, Banglagesh Tel: 088-0171 1586014 Fax: 088-02-8130273 Dr. Seemin Jamali
(Pakistan)
8

Deputy Executive Director and Incharge Accident and Emergency Department Jinnah Postgraduate Medical Centre (JPMC)

Karachi 75510 Pakistan Tel: 9221-9201 352 Fax: 9221-9201370

E-mail: starseem in@hotmail.com Dr. Eni Gustina (lndonesia)

l8

Head of Family Health Section

Karawang District Health Office Parahiyangan Street No.39 Adiarsa Karawang Barat, Karawang District
West Java, Indonesia
T el: 62-267 -40227

E-mail:

6 F ax: 62-267 -404556 inkeskarawang@yshoo.com

Dr. Nguyen Huynh Ngoc (Vietnam)

l6

Head of Training Management Department Technical Collage of Medicine No.2 99 Hung Vuong St. Danang, Vietnam Tel: 84-15 1 l-829062, 051 l-644515, 0988-526009 Fax: 84-051 l-835380 E-mail: ngocnhq@yahoo.com Section Chief of Facilitating and Monitoring Eye-Ear Health and Ageing Sub Directorate Eye, Ear Health and Ageing Directorate Community of Health Block B-7'n Floor, H.R. Rasuna Said Block X5 Kav no.4-9
Jakata 12950

Ms. Saurma Ida Pasaribu (Indonesia)

l0

Tel: 061-21-5296147 Fax: 061-21-5203116, 5296147 E-mail: indera03@centrin.net.id, idapsb@centrin.net.id

Dr.Khattak Fakhr-Ud-

l5

Din
(Pakistan)

House No.4 Sector C2, Street No.l0 Hayat abad Peshawar, Pakistan Tel: 92-91 -8 I 8138, 92-927 -222020

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Name

Batch

Dr. D.M.A.B.
Sumanasekara

t6

Position/Address Assistant Secretary (Medical Services) Ministry of Health-Uva

69 Bankaranayaka Road

(Sri Lanka)

Uva Provincial Council, Badulla, Sir Lanka

T el: 94-5 52223263 F ax: 9 4-5 52222803

E-mail : amithsu@yahoo.com

Dr. Somphou
Outhenoackda

(Lao PDR)

National Training Coordinator The PMU-HSIP Project Lao PDR

E-mail : southensackda@yahoo.com

Dr. Najib Nasser

Alawi Al-Humaikani
(Repuplic of Yemen)

Hi-Omer Almoktar, Ashaik Othman Building No.25 (A) Flat No.4, ADEN Governorate REPUBILC OF YEMEN Tel (home): 384682 Mobile: 777384682
E-mail : na-eib_200 7_5 @hotmail.com

l0 Dr. Rajendra Saroj

Prasad

(Nepal)

Public Health Administrator Health Sector Reform Unit Policy planning & International Cooperation Division Ministry of Health & Population
Ram Shah Path, BhadrakaliPlaza Kathmandu, Nepal
T el: 97
7

-l -4262489

ax: 97 7 -1 -4262896

E-mail: hesru(4wl ink.com.np

I

Dr. Charan Singh (India)

t4

Joint Director National Vector Borne Disease Control Program 22 Shamnath, Marg-Delhi 54 India Tel: 0091-l l-23967780 Fax: 0091-l l-23968329 E-mail: drcsingh@yahoo.corn
Nepal Family Health Program

l2 Dr. Dirgha
Shrestha

Rai

(Nepal)

l3 Dr. Angkham
Ounavong

17

(Lao PDR)

P.O.Box 1600 Kathmandu, Nepal E-mail: dshrestha@nfhp.ors.np Lecture, Head of Division Department of Pharmacology Faculty of Medical Sciences, Ministry of Health Vientiane, Lao PRD Tel: 856-21 -222883 Fax: 856-21-214055
E-mai I : ouna2 | a(E,hotmai l. com

l4 Mr.

Southa

t7

PHC Programme Office

Danish Red Cross

Chanthalangsy (Lao PDR)

Vientiane, Lao PDR TeI: 856-21-21 9559 Fax: 856-21-213983 E-mail: southa chanthalanssv@vahoo.com

Name

l5

Batch

Position/Address
Director, Sub-District Hospital Sub-District: Nawabgonj, District: Dinajpur
Bangladesh

Dr. Md. Imar Uddin

Kayes (Bangladesh)

Tel:053-33-56009 Mobile:01712-231463

16

Dr. Penina Regina B (Indonesia)

t2

Head Section of School Age & Adolescent Health Directorate of Family Health, Ministry of Health 8'n Floor Block B. JL HR. Rasuna Said Kav. 4-9 Jakata Selatan Indonesia Tel: 001-62-5221227 Fax: 001-62-5203884 E-mail : elnina_75 @yahoo.corn

17

Ferinawati Al
Muchtar
(Indonesia)

Head Section of Monitoring & Evaluation Sub Directorate of Reproductive Health

Directorate of Family Health, Ministry of Health 8'n Floor Block B, JL HR. Rasuna Said Kav. 4-9 Jakata Selatan Indonesia Fax: 62-21-5265002 E-mail: rina_muchtar@yahoo.com
9

l8
19

Dr. Fatmawaty

Arifin
(Indonesia)

Dr. Sam Sina

(Cambodia)

t8

Chief of Continuing Education Bureau, HRD

Ministry of Health

l5l-153 Avenue Kampuchea Krom Phnom Penh. Cambodia

Tel:

855-12-93l3ll

Mobile: 855-12-8ll9l3

E-mail: sams inabrd@yahoo.com

20

Dr. Swa Hla (Myanmar)

t5

Director

Lifeline Co.,Ltd.
No.39, Room 5, Bahosi Housing Complex Lanmadaw township, Yangon, Myanmar Tel: 951-223144.951-227 174 Fax: 951-253378
E-mail : I i fel i ne@myanmar. com.mm, swe963 hl a@yahoo.cgm

21

Dr. Xiaolin Cheng

(China)

l6

Director of Medical Affairs Department

Jinan Second Hospital 148 Jinyi Rd., Jinan City Shandong Province, 250001, P.R.China

Tel: 86-531-87930188 Fax: 86-531-87930188 Mobile: 86-13006591290 E-mail: incxl@yahoo.com, incx14S@hotmail.com

22

Dr. Sichanh Himpaphanh

(Lao PDR)

Director Luang Prabang Provincial Hospital Luang Prabang, Lao PDR Tel: 856-20-5570850 Fax: 856-71-254027
E-mail : sichanhtou@hotrnai l.corn

23

Dr. Phisith
Phouthonsy

tz

Ministry of Health
Lao PDR

(Lao PDR)

il
:i..

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Name

Batch
20

24

Dr. Sooraphonh
Kongsap

Position/Address Kenthao District Health Office

Sayaboury Province

(Lao PDR)

Lao PDR t3
Head of Malaria Station Luang Prabang Province

25

Dr. Virasack
Banouvong

(Lao PDR)

Lao PDR

Tel

856-7 l-212125 Fax: 856-71-260202 E-mail : vira_sack@-yahoo.corn

26

Dr. Hu Qiang (China)

l9

Chief, Department of Pediatric Surgery Weifang people's hospital l5l Guangwang St., Weifang Shandong Province, China Tel: 0086-5368192157 Fax: 0086-5368610536 E-mail : Huqian95660@hotmai l.com Deputy Director of Provincial Health Department Xiengkhuoang Provincial Health Department Xiengkhuoang Province, Lao PDR Tel: 856-61-3 12019 Fax: 856-61-312017 ' E-mail : vinyanh@yahoo.com
Secretary of Rural Health Project (ODA) Provincial Department of Health 70 Nguyen Dinh Chieu, TanAn Town Long An Province, Vietnam T el 84-72-838242 F ax 84-72-838244
E-mai
1:

27

Dr. Vinyanh
Cheryangsaijou

16

(Lao PDR)

28

Dr. Ngo Thi Nguyen Phuong (Vietnam)

l6

phurln ssytla@yahoo.corn

29

Dr. Babu Ram Gautam (Napal)

t2

Department Chief

Kathmandu Metropolitan City (KMC) Public Health & Social Welfare Department P.O.Box 7938 Kathmandu, Nepal Ph: 00977 I 435368 I (R), 4228272, (O) 424217 0

Cell:00977 9851077490

Fax:917-1-277576 E-mail:

30

Dr. Ghulam Farrooq Hoth

(Pakistan)

l3

Deputy District Health Officer Government of Balochistan, Pakistan Tel: 92852-4 I I 397 Fax: 92852-413359 E-rnail: ghulamhoth@hotmail.com
Research Assistant

3l

Assistant Professor

t9

Yoko Aihara

International University of Health and Welfare I -2-25 Shiroyama, Odawara city, Kanagawa, Japan 250-8588 Tel 8l-465-21-6625 Fax: 8l-465-21-6501 E-mail: y-aihara@iuhrv.ac jp t4 Deputy Director
Department of Health Planning, Ministry of Health

32

Ms. Aye Aye Sein (Lao (Myanmar)

No.4, Nay Pyi Taw, Myanmar Tel:95-67-41 I 140 Fax: 95-67-4lll39 E-mail: seinsi@.mptmail.net.mnr

l)**

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Name

Batch
7

33

Dr. Htay Win

Position/Address Director
Department of Health Planning, Ministry of Health No.4, Nay Pyi Taw, Myanmar Tel: 95-67 -411305 Fax: 95-67 -41 ll39 E-mail: htaywinn@gmail.com

(Myanmar)

34

Dr. Tin Tun (Myanmar)

l5

Deputy Director Department of Medical Science, Ministry of Health No.4, Nay Pyi Taw, Myanmar Tel: 95-67 -411145 Fax: 95-67-4 I I I 50 E-mail: tintundms@gmail.com Project Manager CARE International in Cambodia Health Seotor Support Project, Koh Kong Province P.O.Box 537 No. 255, Cornor street 63/\4ao Tse Tung Blvd, Sangkat Tonle Bassac, Khan Chanka Morn Phnom Penh, Cambodia Tel:85512333955 E-mail: Frederick.alli @care-cambodia.org East Nusa Tenggara(NTT) Provincial Health Office Head of Referral Section-Medical Service Division Jl. Palapa No.22 Kupang, NTT
Indonesia

35

Dr. Frederick Beda

C.

T4

Alli (Philippines)

36

Dr. Maria Silalahi

l3

(Indonesia)

62-380-822049, 821240 Mobile : 62-8 | 1 -3 8-3266 E-mail: mariasilalahi@g$ail.com

Tef :

37

Dr. Nguyen Viet Hung (Vietnam)

t6

Medical Correspondence Bangkok International Hospital E-mail: hungmd2002@yahoo.com

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Batch
I

Name

Position/Address
8

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Assoc. Prof. Dr.Chutima Sirikulchayanonta

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asat

tRryU?yrU1

nilVdlt1tflrd1flldgr:

rJ.ilYAn

Tel:089-1422175
E-mail : chutimabk@),ahoo.com
9

2.

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Dr.Kanokporn Poehom

sa"

I: { il ur u r a a? : : drj : v vr fn d o.rn*o.r
Mobile :089 6445025
E-mail : kanokpoml 965@yahoo.com

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4.

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Ms.Yupapan Munkratok

Mobile:081 9677868
E-mail : ymun2003@yahoo.com

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Ms.Duangkamol Natrawong

Tel: 036-21 1015 fiiO 125,121,11 | E-mail: duangkamol@asia.com

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Ms.Kanokpom Pongcharoen

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5il.lJfi 1:lry 0.un::11dul

Tel:081-7095130 Fax:044-295612

Mobile:081 7095130

6. urr.firio

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ll

Health Center 29 (Chuang Nuchanetre)

27121 Soi Wutthakad 49 Wutthakad Road

Dr. Phinai Luanloet

Bangkhaw Sub-District Chom Thong District Bangkok 10150

Tel:0 2476 6493, 0 2476 6495-

96

Fax: 0 2476 6628 Mobile : 081-81 80491 E-mail : pinai ll(dhotmailsom

pinaiIl(CDyahno.com

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Dr. Jinnapipat Choopanya

Tel:045-712233

086-4605021

E-mail : archanjinn@yahoo.com

Mobile : 086 4605021

8. nq.flur^orr dryil:eil:sQsr
Dr. Piyathida Smutraprapoot

l1

t{o.no{I:nro9ld nvru.
AIDS Control Division
124116 Kim-Luan Noiwat Building Krungthonburi Road

Khlong San District Bangkok 10600 Tel: 0 2286

87

5l-6,

084-1582480

Fax: 0 2860 8760 E-mail : smutr@yahoo.com

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Dr.Araya

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Roongruangratana

Mobile:081 4525599
Tel: 0 29107314 Fax: 0 29107313
E-mail : hcl9 _bma@yahoo.com

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Ms. Anchaleepom Wuttipek

12

ddo.14u0.:n1u

Mobile:085 8514286
Tel. (042) 46s067-70
E-mail : rukanchaleepom@gmail.com

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Dr. Lawan Boonyamanond

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13

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Health Center 54 Tudaeim

54 YrflurourJ

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364179 Moo 2 Phutthabucha Road

Bang-Mod Sub-district Thung-Khru District Bangkok 10140

Mobile:081 9309161

Tel:02-4263514 Fax:024263321
E-mail :dentlawan@yahoo.com

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51I.U9r00r?ry

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10170 10170

Dr. Duangta Graipaspong

0.4vrrlJolfla d1u4 rlstvriigilul n.il.u.

Mobile 086 7862346

Tel:02

8899191

E-mail : duangtag@yahoo.corn

13. lrluqfurafl t6u?q?r:il

Mr Boonlert Tiewsuwan

l6

Health Technical Officer

Office of the Primary Health Care

Department of Health Service Support

Ministry of Public Health

Nonthaburi I1000

Tel02-9659174
E-mail : mrpoo
I0

Fax:02-9659175

l2@yahoo.corn

14. ufl.'[n:dr ?:66

Dr.Kraisorn Voradithi

l6

I:.:ilurtlrav{:vrJ'rfl0
Mobile:081 4148830
E-mail : kvoradith@hotmail.com

15. ufl.oiU qiuUrqmr^n1t

Dr.Charun Boonyarithikam

l8

tstz rirumfimFty v.rnaura l8 o.rfio{ o.drsud? 27000 Mobile:087 1334820

Tel

(037)220133

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Dr.Wungchun Kittipadakul

Mobile: 086 3341344

Tel:036-51 1614
E-mai I : rvr.rngoh unk(@yahoo. com

wuCshur)kf@Cmail.com
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Ms. Pakakrons Kwankhao

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E-mail: pkwankhao@yah<lo.com

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Ms.Rajitphan Jantarach

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Dr.lsares Chantrakul

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E-mail : nok:rajit(@yahoo.com

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E-mail : chantrakul.is@chaiyo.corn Mobile :0869767979

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Honorary Advisors
Prof. Dr. Krasae Chanawongse Assoc. Prof. Dr. Yawarat Porapukkham Prof. Dr. Som-arch Wongkhomthong Assoc. Prof. Dr. Orapin Singhadej Assoc. Prof. Dr.

Sirikul

Isaranurug

Organizing Committee
Prof. Dr. Pantyp Ramasoota
Assoc. Prof. Dr. Boonyong Kiewkarnka

Chairman

Vice Chairman

Prof. Dr. Santhat Sermsri

Dr. Jumroon Mikhanorn

Assoc. Prof. Dr. Jirapom Chompikul

Dr. Wirat Kam'srichan

Dr.Nate Hongkrailert Dr.Jutatip Sillabutra

Ms.Bang-on Thepthien
Ms. Narumol Jantarajerd Ms. Poungern Thanupunt

Ms.Sumalee Ampairat
Ms. Pranee Suttisukhon

Mr. Somchai Viripiromgool

Ms. Chawewan Sriburapapirom
Ms. Jitrisa Chaisaen
Secretary

Ms. Sirilak Lyesakul

Asst. Secretary

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the 25ft Anniverrary of the *$EAN Institute for Health Development

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Alumni and Benefactors Coordinating Committee

Ms. Sirilak

Lyesakul

Chairman

Ms. Chawewan Sriburapapirom

Mr. Somchai Viripiromgool

Ms. Monruedee Wongkaew

Ms. Thip-rada Kongtapan

Mr. Lerpong Wongsuthichoti

Ms. Chatchata Ruangkachorn
Secretarv

Awards Committee
Assoc. Prof. Dr. Boonyong

Kiewkanka

Chairman

Prof. Dr. Pantyp Ramasoota Dr. Nate Hongkrailert

Dr. Jutatip Sillabutra Ms. Chawewan Sriburapapirom Ms. Sirilak Lyesakul

Mr. Lerpong

Wongsuthichoti

Secretary

Fund Raisirig Committee

Dr. Jumroon Mikhanorn
Prof. Dr. Santhat Sermsri Chairman

Ms.Sumalee Ampairat

Mr. Winai Sao Ong

Ms.Sukhon Hongkrailert

Mr. Adul Purngtho

Ms. Warura Boonsrimuang
Ms. Rujirarat Banjong

Dr. Manit Teerathanthikanon

Mr. Pannyawat Santhiwet

Dr. Pradit Winijakul Dr. Prateep Thonkitjaroen Dr. Winai Chamnanpun Dr. Wanasara Chaowaniyom Dr. Kanokporn Raksawin

Internationxl *yrxp*siurn *n ""6*sbal H*alth: Ssrdsrfe*s Mcv*me*'rt *f *isease"

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Dr.Ittipol

Sungkaeng

Dr. Supakit Siriluk Dr. Jinnapipat Chupanya Dr. Kraisorn Totaptieng Dr. Jarun Boonrittikan Dr. Peeraphong Saichua Dr. Sudaporn Bithiporn Dr. Lawan Boonyamanon Ms. Somchai Viripiromgool
Ms. Patnaree Tierakittana Secretary

Asst. Secretary

Academic and PublicatiOn Committee

Assoc. Prof. Dr. Jiraporn Chompikul

Chairman

Dr. Wirat Kamsrichan

Dr. Nate Hongkrailert

Dr. Jutatip Sillabutra

Ms. Bang-on Thepthien Ms. Pranee Suttisukhon

Mr. Sakesan Siriphadung

Dr. Donald Scott Persons

Mr. Tumnoon Charaslertnantsi

Ms. Piyachatr Tragoolvongse Ms. Parinda Tasee
Secretary

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the 25th Anniverscry of the &sEAlu In*titute for Health Development

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Facilities and Audio-Visual Committee

Dr. Nate Hongkrailert Chairman

Mr. Paitoon Klunpaitoon Mr. Sarawut Preechadej Mr. Prasit Suajui Mr. Manas Supkaeowyod
Ms. Ratchadaporn Charoenvaravut

Mr. Surachai Laoui Mr. Adul Phuengto

Secretary

Event Management Committee

Dr. Wirat Kamsrichan
Ms. Jitrisa Chaisaen Ms. Pitsanee Pienanukulbud Ms. Nuannoi Boonchusong Chairman

Mr. Jareh Komarom

Ms. Rachadaporn Jaroenworawut

Ms. Sukhon Hongkrailert

Secretarv

Public Relations Committee

Dr. Wirat Kamsrichan Ms. Sumalee Ampairat
Ms. Pitsanee Pienanukulbud Ms. Naruemol Chantharacherd Ms. Karn Chantawongse Chairman

Mr. Paitoon Klunpaitoon Mr. Prasit Suajui

Mr. Manas Supkaeowyod
Ms. Kamonwan Rakpan Ms. Raweewan Veraponchai

Mr. Somchai Viripiromgool

Ms. Rujirarat Banjong Ms. Kesaree Wuttisaksakul

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Ms. Tithirat Dechaprom Ms. Tiraltrk Pitak Ms. Ladda Prapunpongchai

Mr. Sorawut Preechadej

Secretarv

Registration and Finance Committee

Ms. Poungern Thanupunt Ms. Wanna Boonsrimuang
Chairman

Ms.Sukhon Hongkrailert
Ms. Natjira Narkjinwong

Ms.Mesinee Sareekaputi
Ms. Junya Phuengto
Secretary

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the 25th Annivensary *f t*:* AsrAN rnrtitute &r Hcalth Development

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Profiessor Dr.

Pafip

Ramasoota

Dr. Donald S. Persons Assoc. Prof, Dr.

liraporn Chompikul

Designerc! Jrls.Piyadratr T;agoolvongse lls. Parinda Tasee

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