International Conference on New Directions for Public Health Education in Low and Middle Income Countries Processes, Proceedings

and Proposed Next Steps

Public Health Education in Thailand

Pattapong Kessomboon, PhD Nusaraporn Kessomboon, PhD

Country background
The population of Thailand was 64 million in 2007. The official language is Thai, although Chinese and Malay are also spoken. Buddhism is the national religion, with 95% of the population practising it; Islam, christianity and hinduism are also practised freely. 1 Thailand is a middle-income country with a gross national income (per capita) of PPP international $ 9140 in 2006,2 and despite being largely agrarian has been seen to rapidly urbanize in recent decades. In the past 40 years Thailand has changed from an agrarian into an export-oriented, industrialized economy. This transformation has had considerable impact on its society and the way in which its peoples and the State have responded to the rapidly changing political and health needs.

cess of transition. A significant improvement has occurred in the health of the nation over the past 4 decades. From 1964- to 2006, life expectancy at birth increased from 55.9 to 69.9 years in men, and from 62.0 to 77.6 years in women. Infant mortality rate declined from 84.3 to 11.3 per 1000 live births, and the maternal mortality ratio also declined from 317.3 to 9.8 per 100,000 live births during the same period. 3 This epidemiological transition began in the early 1970s and corresponded with a decrease in diseases associated with poverty, those that were preventable with vaccination and those that were non-communicable. In the 2006 Burden of Disease Study using DALY (disability-adjusted life year) as the indicator, it was found that the top three causes of DALY loss for men were HIV/AIDS, road traffic injuries and alcohol abuse-related diseases.4 In women, these causes were cerebrovascular diseases, HIV/AIDS and diabetes.4

Health situation and trends

Thailands public health system is also in the pro-

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Fig. 1. Mortality rates due to major causes of death in Thailand, 19672006

Source: Thailand Health Profile, 200507 3

Public health and healthcare services in Thailand

The Thai health service systems are dominated by the public sector. They have evolved from a system of self-reliance, based on local wisdom, to one of up-to-the-minute professional services. The number of people using the health services increased from 38.5% in 1970 to 77.5% in 2004, whereas those on self-medication decreased from 51.4% to 20.9%
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during the same period.3 Several health sector reforms have been implemented to increase accessibility, improve quality control, contain costs and increase efficiency.5,6 The Ministry of Public Health (MOPH) is the main national health agency. It owns the majority of health resources, particularly in the rural areas. Its major role is in providing comprehensive health services, ranging from individual care for out-patients and in-patients, to public health outreach activities. Doctors, dentists, pharmacists and nurses,
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as well as paramedical personnel (e.g. graduates from Public Health Colleges), are expected to be able to take public health roles for promoting health and preventing disease. Provincial and district health offices oversee public health planning and implementation at the local level. Regional offices of the MOPH supervise the provincial and district offices. In recent

years local governments are taking an increasingly active role in public health as a result of the Decentralization Act. Private hospitals have grown rapidly, with an increase from approximately 10% of total beds in 1985 to 21% in 2002. The services they offer are mainly profit-based. After the economic crisis in 1997, many private hospitals were closed down or

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reduced in size. Recently, some have re-oriented their services to attract more foreign patients. They have been so successful that in 2001 it was estimated that there were 1 million foreign patients.7 Thailands annual health expenditure rose from 4.47% of GDP in 1983 to 6.12% in 2002. Public spending increased during the same period, from 31.5% to 34.09%. The MOPH shares more than two-thirds of public spending on health.8 Before October 2001, 75% of Thai people were insured under major health insurance schemes, such as the Civil Servant Medical Benefit Scheme, the Social Security Scheme, and the scheme for the poor, the children, the elderly and the disabled. In October 2001, the government started to implement the universal coverage of healthcare (the 30 Baht scheme), which covers previously uninsured persons. The health insurance coverage was raised by up to 95% in 2006.3

fied into two main groups, viz., health service providers and public health managers. A new category of health personnel has emerged, viz. the healthcare purchasers, since the introduction of the 2001 National Health Security Act. The distribution of main cadres of HRH is shown in Table 3. It should be noted that information on the numbers and distribution of public health managers at central, regional, provincial and district levels is lacking. This reflects a gap in human resource planning. The high economic growth together with increased opportunities in higher education, greater urbanization, an increase in the population of the elderly, a higher prevalence of chronic diseases, greater coverage of and access to essential healthcare services, and a greater usage of these services by foreign patients have all resulted in the increasing demand for and, hence, a shortage of HRH, particularly in the rural public health facilities.

Situation and trend of human resource for health in Thailand Multiple cadres of human resource for health (HRH) are produced in Thailand. They are classi-

Situation of public health and medical education institutions in Thailand There are many types of public health education programmes in Thailand, ranging from a certifi-

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cate course to a PhD programme. The programmes are mostly organized by the public sector. MOPH and the Ministry of Education are playing a major role in devising these programmes.

hometown placements after graduation were factors that led to the balanced distribution of nurses and other paramedics in Thailand. An important strategy to improve the health services in rural areas, particularly in the health centres, was to produce lower-level professionals whose capacity is being continuously enhanced. Patients with minor problems are adequately cared for by the health centre staff. The extensive investment since the early 1980s for developing rural paramedical personnel has greatly reduced the number of outpatient visits to hospitals and the demand for doctors services.3 The continuing education programmes for lower-level professionals are organized in various ways and by different educational institutions. A few of the paramedical personnel usually take a Bachelors degree in Public Health in an open university or in the special programmes run by university-based colleges of public health. Some students choose further study on the MPH programme of the university-based College of Public Health or Department of Community Medicine (in three universities in Thailand there is no separation between the College of Public Health

Roles of the MOPH

The MOPH, the major healthcare provider in Thailand, is also playing a significant role in producing health personnel for its healthcare facilities. It has nursing colleges and public health colleges nationwide. The main cadres are professional nurses (4-year course), technical nurses (2-year course), health workers for health centres (2-year course), dental hygienists (2-year course), assistant pharmacists (2-year course) and mid-wives (2-year course). Recently, the increasing numbers of traffic injury cases have forced the MOPH to produce a new cadre of emergency medical assistants who will provide medical services prior to hospitalization and assist medical staff in emergency rooms. The MOPH produces most of the paramedic staff (2-year study) for its health centres at sub-district level. It is also important to note that rural recruitments, training in rural health facilities and

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and the Department of Community Medicine). The objective here is to become a district health officer or a public health manager at provincial or regional public health offices. The MOPH public colleges also provide continuing education for their alumni by training them for health promotion activities. The first-, middleand high-level public health administrators are given training that corresponds to their ranking. This facility for continuing education for promotion motivates staff to undergo further education. The MOPH health facilities provide practical experience for the trainees as well as improves the service provision of healthcare If there is a persistent shortage of medical doctors or a maldistribution of doctors in an area, the MOPH steps in to provide medical doctors. Ten regional hospitals have been given more money and staff to better fulfil this new objective in collaboration with university-based medical schools. Medical students spend 3 years in a medical school for their basic medical studies and another 3 years in a regional hospital for their clinical rotations. The successes and failures of this practice need further evaluation. Various MOPH departments and units organize continuing education and training courses on specific topics for their staff. Some of these courses, such as the International Field Epidemiological Training Programme organized by the Bureau of Epidemiology, Department of Disease Control, and MOPH,9 and the Epidemiology of Injury and Injury Care Management organized by the Trauma Centre at Khon Kaen Regional Hospital (one of the WHO collaborating centres) enjoy mixed participation by both Thais and international participants. 10 The health training and Health Institute of the MOPH are having a significant impact on the attitudes of Thai healthcare providers and medical educators through their training courses and learning aids. The training provides participants with new perspectives on health, disease, death, primary care, providerpatient relationships, cultural aspects of
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illnesses and so on. The slogan of these courses is humanized healthcare as opposed to modernized healthcare. The theories and thinking from the discipline of medical anthropology have made a significant impact in developing the Thai community healthcare models.11

Roles of university medical schools

Medical schools in Thailand produce mainly specialists. Although the general consensus is that more general practitioners are needed to meet the increasing needs of primary care services, most medical schools are reluctant or unable to realise this goal. As a result there is an imbalance in the numbers of medical specialists versus general practitioners. A programme has been in instituted since 1972 to increase the numbers of doctors in rural areas by ensuring that all new graduates work in public hospitals, particularly in rural district hospitals, for the first 3 years. If they breach the contract, they have to pay a fine of approximately US $10,000. However, the higher salaries paid in the private sector and increasing inflation rates have made the programme less effective.12 Community Medicine Departments of medical schools are responsible for the primary care and public health education components of the medical curriculum. Medical students tend to find specialties other than these subjects more appealing, although a small proportion of medical graduates do choose a career in these disciplines. To address this problem, the Khon Kaen University (KKU) has developed initiatives to make primary care and public health more attractive to medical students (see Appendix 1). The fact that doctors are generally looked upon as the team leaders in the public health services, in spite of having inadequate attitudes, skills and knowledge of the subject, makes this initiative all the more important. Ultimately, doctors who are hospital directors or public health mangers at provincial health offices will eventually choose to study public health because of its relevance to their work.
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These doctors can choose to do an in-service training programme in preventive medicine and then take a final examination organized by the Thai Medical Council Royal College of Preventive Medicine. If they pass the exam they will be given a certificate in Thai Medical Council Board of Preventive Medicine. A small number of medical doctors choose to study a Masters in public health or a PhD in the subject in a university-based college of public health. Some prefer taking government scholarships to study the subject abroad. Others may even prefer to opt for a course in business management, such as an MBA. The KKU is planning initiatives for medical graduates to study public health, such as a Masters degree and a PhD in health systems development. The key stakeholders, such as the National Health Security Office, the Society of Rural Medical Doctors, the MOPH and faculties from other universities, are presently discussing the design of the programme. A module-based curriculum is preferable to suit the needs of the often busy medical doctors. This programme is expected to strengthen ties between the public health education department and doctors who work in rural areas. An MSc in community medicine at KKU has also been developed as an international programme to provide greater opportunities for the exchange of experiences between students from different cultural backgrounds (see Appendix 2). A 4-week intensive course on community healthcare and research is organized annually to provide learners with a comprehensive understanding of community health development in Thailand. The students are expected to write a health systems research proposal by the end of the course (see Appendix 3).

of public health usually provide a Bachelors, Masters and PhD degree in the subject. The oldest Faculty of Public Health in Thailand is Mahidol University in Bangkok where workshops and short courses on specific public health topics are offered frequently. In view of expanding industrialization and the limited number of jobs in the MOPH, there is an increasing trend for the university colleges of Public Health to focus their Bachelor programmes on industrial hygiene and occupational health and safety. The Masters in public health and PhD programmes of many colleges of public health are similar. They offer core courses and electives. A dissertation or thesis is required to graduate. The only differences stem from the differences in the quality of teaching, the practical elements, educational support, and the learning environment (see Appendices 4 and 5). There is a tendency to organize a PhD programme with dual tracts. Students will spend 2 years in Thailand and another year abroad to study at the collaborating universities. The PhD programmes with reputable professors are likely to be supported financially by the Golden Jubilee PhD programme of the Thai Research Fund and grants from donating agencies.

Roles of the university Faculty of Pharmacy

One of the major health expenditures is on drugs. Pharmacists are one of the key players in public health. They also have a responsibility to protect consumers from substandard medicines. The collaborative module-based Master of Pharmaceutical Science in Pharmacy Management run by a consortium of four faculties of Pharmacy in Thailand, with close collaboration with the MOPH, has shed some light on how to efficiently organize a Masters programme nationwide (see Appendix 6).
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Roles of the University College (or Faculty) of Public Health

Old universities with a separate college (or faculty)
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Roles of the University College Faculty of Nursing

Nurses constitute the majority of health personnel in Thailand. They are known for their management skills and a tradition of strong group work. They are capable of undertaking both therapeutic and public health work, as well as immunizations and mother and child health. Their responsibilities have now extended to disease management and home care of patients. University Faculties of Nursing also provide Masters programmes in Public Health and Community Nursing. These programmes are structured in a similar way to that of other university courses. The 4-month Faculty of Nursing course on Nurse Practitioner is very popular among practicing nurses. The students are taught clinical diagnosis and treatment of patients with common conditions in primary care. Office-based disease prevention, health promotion, home healthcare and chronic disease management are among the key subjects.

need of re-evaluation. There need to be less clearcut boundaries of tasks between public health and other development activities and programmes. All those involved in this endeavour must redefine their roles. 3. Past experience has proven Thailands capability of establishing new types of public organizations with a higher efficiency and accountability, such as the Health Systems Research Institute, the Health Security Office, the Thai Health Promotion Foundation, and so on. These organizations have demonstrated that the most challenging of tasks can be staffed with people of the highest capability. It would thus be judicious to form a similar public health organization with a new cadre of public health workforce at the provincial level. 4. The Thai Health Promotion Foundation has been a key promoter of many health campaigns by civic groups in that country. They have a regular source of revenue from 2% of taxes from tobacco and alcohol sales with which they fund their health promotion activities. The Foundation is keen to support public health education programmes. As such, a cooperative effort between the government and the Foundation should be made to plan degree and non-degree-based courses in public health to strengthen the public health workforce. A module-based curriculum for parttime students, organized in collaboration with a number of colleges and university departments, could offer a favourable choice for students. 5. Civic society groups and non-governmental organizations (NGOs) play a key role in public health improvement. Various types of NGOs and a vast number of community leaders are actively engaged in improving the health of the nation. These social activists could be a valuable asset for planning public health educational programmes and providing resources. Religious groups are also among the majors social activists which employ modern management techniques to implement their religious campaigns. A Masters degree in Buddhism offered by the Chulalongkorn
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Discussion
1. Globalization and the transitions and reforms in the healthcare system in Thailand have had major influences on human resource planning, production and utilization. The public health workforce is seen as one of the key players in health planning and improvement programmes. This role has erstwhile been dominated by medical practitioners. The Faculty of Public Health in educational institutions should be involved in and take a more active role in promoting the role of public health workers. 2. The need for new cadres in the public health workforce and their greater involvement in public health has been necessitated by the complexity of emerging health problems in Thailand. Traditional public health programmes are in urgent
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International Conference on New Directions for Public Health Education in Low and Middle Income Countries Processes, Proceedings and Proposed Next Steps

Rachawittayalai Buddhist University might be accepted as an elective course for the Masters degree in a public health programme. Peace of mind of the public health workforce should be one of the required educational goals.

References
1 2 3 Pramualratana P, Wibulpolprasert S. Health Systems in Thailand. 2006. WHO.World Health Statistics 2008. URL: http:// www.who.int/whosis/en/index.html. Wibulpolpresert S (ed). Thailand Health Profile 20052007. Bureau of Policy and Strategy, Ministry of Public Health. Nonthaburi: Printing Press. 2008. The Thai Working Group on Burden Attributable to Risk Factors MoPH. Thailands Risk Burden in 2006. 2007.

Towse A, Mills A, Tangcharoensathien V. Learning from Thailand's health reforms. BMJ 2004;328:1035. 6 Pannarunothai S, Patamasiriwat D, Srithamrongsawat S. Universal health coverage in Thailand: Ideas for reform and policy struggling. Health Policy 2004/4. 2004;68:1730. 7 Wibulpolprasert S, Pachanee CA, Pitayarangsarit S, Hempisut P. International service trade and its implications for human resources for health: A case study of Thailand. Hum Resour Health 2004;2:10. 8 Tangcharoensathien V, Pitayarangsarit S, Vasavid C. Universal healthcare coverage and medium term financing implications. Nonthaburi: International Health Policy Program, Thailand; 2002. 9 www.moph.go.th 10 www.kkrh.go.th 11 www.shi.or.th 12 Wibulpolprasert S, Pengpaibon P. Integrated strategies to tackle the inequitable distribution of doctors in Thailand: Four decades of experience. Hum Resour Health 2003;1:12.

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Appendix 1

Field Practice in Community Medicine for Medical Students at Khon Kaen University
Introduction
Community healthcare is an essential component of any healthcare system, without which the nationwide delivery of healthcare becomes inequitable and inefficient. It is therefore crucial to train medical and health personnel in appropriate and adequate attitudes, skills and knowledge to provide appropriate quality health services at the community level. This paper presents an overview of the field work components of the current Community Medicine curriculum at the Faculty of Medicine at Khon Kaen University (KKU), Thailand. A description of the courses is given here; the results of the evaluation of the course will be presented later. Medical students at KKU undertake five courses in Community Medicine over the 5-year study period. The course consists of both theoretical and experiential components. Students are then divided into small groups of 10 12 and are made to plan specific objectives of their visit to the field, as well as to think of any questions they might wish to ask the directors or staff of the facilities. Each group spends half a day in one facility. The facilities include community health centres, the regional hospital, mental health hospital, university hospital, rehabilitation centre for disabled children, and schools for the blind, the deaf, poor girls from rural communities, and so on. The groups present their findings to the whole class the following week. Discussions are encouraged during the presentation. Faculty staff correct students misconceptions and give additional lessons, particularly on the importance of the facilities in serving people in the community.

The programme
Year 1: Visits to community and health service facilities in the region of Khon Kaen Objective: To introduce students to the societal and health service facilities, define their roles and activities in serving target groups, as well as their relationship with the healthcare profession.

Evaluation 1. Attendance 2. Participation in the group processes 3. Peer assessment 4. Staff assessment 5. Written examination 6. Presentation.

Year 2: Studying community health needs in urban areas

Objective: Students learn how to use qualitative research methods in studying the health needs of
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Learning processes A brief introduction is given to the whole class.

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patients with chronic illnesses in urban communities.

6. Written examination 7. Field-work report (group activities) 8. Students opinions about the activities.

Learning processes Lectures on the basics of qualitative research methods are given. Group practicals are also given under staff supervision. Rapid community survey, indepth interview and focus group discussion methods are taught in the class. Baseline health data of the communities are given by health personnel responsible for health services in the area. Students are divided into small groups of 1820, with a staff member as their adviser. Each group is further sub-divided into 45 groups. Each sub-group is assigned the name and address of a patient with a chronic illness, such as diabetes mellitus, hypertension, chronic obstructive pulmonary disease (COPD), heart disease, gouty arthritis, chronic liver disease, chronic kidney disease, schizophrenia, and so on. The students research the diseases and receive guidance from staff. They then plan specific objectives of their study and prepare an outline of questions for the patients and their families in the communities to be visited. They organize a focus group discussion with community health volunteers and community leaders. Each group visits patients and their families two to three times during the one-week study period. The groups present their findings to the whole class the following week. Discussions are encouraged during the presentation. Faculty staff correct students misunderstandings and give additional lessons, particularly on the importance of the holistic approach to understanding the health needs of the patients. Evaluation 1. Attendance 2. Participation in the group processes 3. Peer assessment 4. Staff assessment 5. Presentation
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Year 3: Studying community health needs in rural areas and working together for health
Objective: Students learn how to use both quantitative and qualitative research tools in studying the health needs of people in rural areas. They also learn how to work together with students from the other four health science faculties of the KKU and the local people to improve the health of the communities.

Learning processes Lectures are given on basic themes of community health surveys, quantitative methods, advanced qualitative methods, basic data analysis skills, and community health development. Group practicals are also provided with staff supervision. For the advanced qualitative methods, the seven tools for studying community ways of life are taught. The tools applied are from theories of humanities and social science. Early in the semester, groups of students will go to target rural communities once or twice over weekends to collect baseline health data of the communities from the healthcare facilities in the area. They plan their work with community leaders and health volunteers. Secondary data is used as a basis for planning the community survey and health services. Students spend 2 weeks in the target communities. The quantitative and qualitative methods are used during the survey. A conference with community leaders and health volunteers is organized. Survey results are presented, followed by a process of co-planning for health development; the A-I-C (appreciation, influence and control) technique is used for this. A prioritization exercise is performed because of restraints in time and resources. Students and local
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people then work together on the agreed plan of action. The groups evaluate their work, and simultaneously prepare their reports and presentations. At the same time, the sub-groups of students make three or more visits to patients with chronic diseases from both poor and rich families. They then make comparisons on the quality of life between the rich and poor families. The groups present their findings to the whole class during the following two weeks at KKU. Community leaders are also invited to give their opinions. Discussions are encouraged during the presentations. Faculty staff correct students misunderstandings and give additional lessons, particularly on the importance of community participation and cultural issues in health development.

basis. During the first 3 days, lectures are given on the basics of the roles community hospitals play in providing comprehensive health services, principles of primary care and family medicine, occupational health, and new approaches to health promotion and management of healthcare resources at the district level. Standardized cases are used for teaching medical consultation skills at a special skills laboratory. Four to five students spend two weeks in a community hospital to learn, from adjunct medical teachers, the themes already discussed. Students observe the comprehensive services provided, such as ambulatory care, disease prevention and health promotion at the health services facilities, health education, medical consultation and in-patient care for non-serious conditions. An outreach programme for occupational health services is also provided. Students have a chance to hold discussions with distinguished farmers who have transformed their lives from poverty to a better situation. Students discuss the management of healthcare resources with various mangers at the hospitals and the director, who is usually a medical doctor. Data on the issues and problems arising from the hospital records are studied. Students are required to attend four half-days at primary care units. They practice medical consultations with close supervision of the faculty staff. On returning to the department, students share their experiences with peers in a series of seminars. Discussions are encouraged. Faculty staff correct students misunderstandings and give additional lessons, particularly on the roles of medical doctors in community hospitals and primary care.

Evaluation 1. Attendance 2. Participation in the group processes 3. Peer assessment 4. Staff assessment 5. Presentation 6. Written examination 7. Field-work report (during group activities) 8. Students opinions about the activities.

Year 4: Studying roles of community hospitals and a new approach to health promotion
Objective: Students learn the role community hospitals play in providing comprehensive health services, management of healthcare resources at the district level, and a new approach to health promotion. They also learn how to provide holistic healthcare to patients at primary care centres. (Note: Community hospitals in Thailand have 10 120 beds, depending on the size of the population they serve; this ranges from 30,000150,000 people.)

Learning processes Fifteen to 18 students study on a 4-week rotation

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Evaluation 1. Attendance 2. Participation in the group processes 3. Peer assessment 4. Staff assessment 5. Examination on skills
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6. Written examination 7. Hospital practice report 8. Students opinions about the activities.

results through understanding of translational research in learning. All students are required to attend two halfday practice sessions at primary care units. They practice medical consultations with close supervisions of the faculty staff. Home healthcare consultations are provided at home by medical students and staff. Discussions with peers and staff of the primary care unit are carried out to ensure the continuity of care. Health screening services for workers in a factory are provided in the outreach programme.

Year 5: Studying and conducting health systems research and home healthcare
Objective Students learn how to conduct a health systems research project, starting from developing research questions through writing a research article. Comprehensive health services at primary and community care level are also emphasized, particularly on home healthcare.

Learning processes
Twelve to 14 students study on a 4-week rotation basis. Tutorials on health systems research methodology and advanced data analysis using statistical computer software are provided. Students are divided into two small groups. Each group has to conduct a research project with close supervisions from two faculty staff. The project is expected to serve policy-makers information needs. The students learn how to communicate with policy stakeholders at the beginning of their project to assess their information needs. The needs vary from information concerning health issues (such as identifying or prioritizing community health needs, identifying risk or protective factors, evaluating the effectiveness or responsiveness of a health programme) to information about organizational problems. Scientific rigor is emphasized. Literature reviews with critical appraisal exercises are performed. Students are expected to write a publishable article. During the research presentation, stakeholders are invited to ensure utilization of research

Evaluation: 1. Attendance 2. Participation in the group processes 3. Peer assessment 4. Presentation of research results 5. Research reports (written and poster) 6. Staff assessment (oral examination) 7. Computer skills examination 8. Written examination 9. Students opinions about the activities. Summary Education at the Department of Community Medicine at KKU has some unique features compared with other medical schools. A long-term evaluation of the programme is being performed currently; further discussions on its effectiveness will be described at a later date.

References
1. Department of Community Medicine. Community Medicine in the KKU Medical curriculum. Faculty of Medicine, Khon Kaen University. 2006. 2. Kessomboon P, Kessomboon N. Medical education reform to produce more primary care doctors. Health Care Reform Project. Nonthaburi: Ministry of Public Health; 2000.

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