HIV AND HEALTH-CARE REFORM IN PHAYAO
Item
- Title
- HIV AND HEALTH-CARE REFORM IN PHAYAO
- extracted text
-
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■ HIV and health-care
■ reform in Phayao
HHH From crisis to opportunity
-T
t' ’
3 UNAIDS
.
Case study
3 -
UNAIDS
3
3 April 2000
UNAIDS Best Practice Colli
HIV and health-care reform
in Phayao
Photographs by:
Shezhad Noorani
Illustrations by:
Phayao Provincial Health Office
I
Cover photo: HIV-positive mother tvbose daughter escaped contracting the virus
UNAIDS/Shezhad Noorani
I
From crisis to opportunity
UNAIDS/00.04E (English original, April 2000)
© Joint United Nations Programme on
HIV/AIDS (UNAIDS) 2000.
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Geneva, Switzerland
2000
■BL
Table of Contents
Foreword
4
Acknowledgements
6
Executive summary
8
The HIX and Reforms for Health Agenckr
io
HIV/AIDS in Phayao: the crisis
Phayao province
HIX' spreads in Phayao Province
A tremendous impact on the people
14
PassingtheJHIVjtest
Linking HIX with health-care reform
How HIX7A1DS challenges health-care reform
Making the health centre the cornerstone of success
Conclusion and next steps
A great learning experience
Action without delay
17
Preparing for the future_________
21
Combining the two sides of the brain
Individuals adapt their sexual behaviour
The Phayao health care system
3-i
Government and NGOs respond
36
crisis into opportunity
45
Mainstreaming AIDS_________
The HIX7 and Health-Care Reform Study
The secrets of an ‘integrative understanding' of HIX' AIDS
Progress in Phayao may be stalling
Changes in the dynamics of HIX7 transmission
Much remains to be done on the social front
Now comes the hard part
Annex 2: framework used to analyse the response
to HIX' AIDS in Phayao province
45
46
The response by institutions
'I
84
89
89
92
94
95
99
102
102
103
57
Annex 3: Epimodel projections of
HIX7 AIDS cases in Phayao (1986-201)1)
58
References
106
107
62
63
2
--•’•r-’-npr-w TF«7-
The health-care reform plans
The private response
76
94
At the cross-roads of need and opportunity
45
I
89
Annex 1: Ik'.ihli care rclorm in Phayao
27
"5
89
14
Phayao peop 1e!_niake great progress
Communities respond
Z5
3
I
Foreword
How do we cope when we find that we cannot solve some of the health
problems that we are facing although we have the most advanced science tech
nology and very modern institutions to provide answers to those health problems
in our hands? Or when we suddenly find that some difficult health problems could
be improved without any solutions from the presently available advanced science
technology or very modem institutions. In this rapidly changing world, none of
these circumstances is unusual.
The world is currently possibly facing another health resolution. Many
health problems are teaching us to rethink the ways of health management that
base been implemented for so long. There are no more magic answers which
come only from advanced science technology or modern institutions, but the
importance of the role of people and the community, is now more and more rec
ognized as the essential factor to the solutions. The battle with HIX' AIDS is a good
example for (his phenomenon. The realization of the role of people and commu
nitv in health development, is not a new idea, it was advocated before in the Alma
Ala Declaration. Neglecting the involvement of people in the past might only result
in (he slowing down of progress in solving health problems, but with HIX’ AIDS
epidemics, failing to take proper action to ensure the involvement of people will
rapidly expand the problems. The situation will be difficult to tackle later. This
present health revolution cannot happen only through advocacy as in the past, but
it will be forced to happen from the rapid expansion of the problem, and it will
make us realize more and more that rethinking and reforming the management ol
health-care is inevitable.
•
I would like to thank people in Phayao, from the Phayao AIDS Action
Centre, especially Dr Petchsri Sirinirund and Dr Aree Tanbanjong with their teams,
and more importantly people from the community, who all are vigorously playing
their important role for the progress of HIV/AIDS prevention and control in
Phayao. I would like to thank also UNAIDS, especially, Dr Jean-Louis Lamboray
and Dr Agnes Soucat. who have untiringly contributed their efforts to search and
document things that had happened. All of these people have provided us all the
knowledge that we can learn, and this is a valuable learning process for us not
only with the reform of health-care for the HIV/AIDS problem but also for the
more proper health-care reform in the whole system. We learnt that we need to
always involve the existing potential of people in every step of the reform, to guar
antee the sustainable development of the reform. And these lessons are very
important lessons, which most reforms recognize, but often do not consider when
the process of reforms starts.
i
Dr Sanjuan Xilayartimpbong
Director, Health Care Reform Project.
Experiences of HIX’ AIDS prevention and control in Phayao province are
good examples of the rethinking of health-care management. Progress in battling
with HIX’ AIDS in Phayao had provided a good lesson: people, not institutions, are
the ultimate contributing factor to the progress attained. Government and non-gov
ernmental organizations will be important, when they can facilitate and not con
strain people in responding to HIV and AIDS.
When we had the idea to start the project on "HIX’ and Health-Care Reform
in Phayao". we wanted to explore some merits of HIV/AIDS prevention and con
trol on health care reform. We finally realized, however, that effective health-care
reform is a must if we really want to efficiently fight HIV, AIDS. This study has doc
umented how our conclusions came about.
5
Acknowledgements
Is your bealth-care system passing the HIV test?
While exploring this question, I met a lot of people who came to my help.
I owe them great thanks. First of all there is Peter Piot, Executive Director of
UNAIDS, who gave me carte blanche. Awa Marie Coll-Seck, Director Department
of Policy, Strategy’ and Research (UNAIDS), gave me her unstinting support. Dr
Sanguan Nitayarumphong, director of the Health Care Reform Project, welcomed
the challenge and was always there to discuss possibilities to turn our undertaking
into a success.
Thanks also to the Directors of the AIDS Division from the Ministry of
Health, Dr Wiput Phoolcharoen and to Dr Chaiyos Kunanusont. They were always
supportive and always there to discuss on strategic questions related to HIV/AIDS
and health reform. Thanks to Drs Daveloose and Soucat for their comments and
advice.
My deepest gratitude to Dr Petchsri Sirinirund. She welcomed us in Phayao
Provincial Health Office for a whole year. We were challenging past, present and
future, raising more questions than providing answers, "let she was always there
when the team needed her.
I
science team composed of Ms Saowanee Panpattanakul. Ms Suttiporn Chompoosri
Mrs Somsorn Sookguy and Ms Jureerat Saipang; Dr Kaemthong Indaratna and Dr
Mingkwan Suphanaphong led the economic team composed of Mr Suwat
Lertchayantee, Mrs Sujit Sittiyuno and Mr Somchai Sapankaew. In addition Dr
Napaporn Havanon provided outstanding advice and information on the quantita
tive aspects of this report.
Dr Heidi Larson interviewed key actors and gave us very insightful help in
structuring our approach. The study was no small logistical task. Mrs Piyanat I
Kimnual in Phayao. Mrs Lawan Sarovat in Bangkok and Marthe Mpendubundi at
UNAIDS made it all possible.
Final thanks to Robert Walgate. David FitzSimons and Krittavawan Boonto
for editing the report. Andrea Venvohlt for coordinating all production aspects, and
Marlou de Rouw lor administrative support.
Jean-Louis Laniboray.
Senior Adrisor to Director. De/xtrtment of Policy. StratenY ami Research.
UNAIDS Geneva
Dr Aree Tanbanjong was the moving spirit of this report. She headed the
Study’ Team, composed of Phayao Provincial Health Office staff. Despite a very
heavy workload, she took upon herself the correction of the study report. A
national panel of experts came to Phayao for• one day to discuss study findings and
recommendations, to review the report.
Dr Toru Chosa and his team from Japan International Cooperation Agency
(JICA), Dr Masami Fujita and Ms Yuko Kondo, were discussing their agency's sup
port to Phayao while the report was being developed. In a remarkable show of
flexibility and understanding, they adapted JICA support to the report’s findings
and are now assisting Phayao in implementing its recommendations.
Dr Brian Doberstyn, WHO Representative and Head of the UN Theme
Group, was always there to share ideas. Three teams of Thai experts came in sup
port of the Phayao Study Team. Dr Narumol Silarug led the epidemiological team,
composed of Mr Chatchawan Boonreong, Mrs Chamchun Leongwitchajareon, Ms
Pattiya Jeerajariyakul and Mr Reunrom Kochang; Dr Aree Tanbanjong led the social
6
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Executiv^ummary
Executive summary
Executive summary
yvyTiat is the secret behind
W the observed progress on
HIV/AIDS in Northern Thailand? While
at first. HIV/AIDS hit people in Phayao
Province (population 500.000) very
severely, they have responded in
remarkable fashion. HIV seropreva
lence among pregnant women
decreased from 11 per cent in 1992. to
4.9 per cent in 1997. Among military
conscripts,
HIV
seroprevalence
decreased from 20 per cent in 1992 to
around five to seven per cent in 1997.
In 1997, 66 per cent of male workers
declared consistent condom use with
commercial sex workers. Use of com
mercial sex services seems to have
decreased, as shown by the decrease of
the number of direct and indirect com
mercial sex establishments, and by par
allel decreases in the total number of
commercial sex workers. Communities
are adapting their culture to the pres
ence of HIV AIDS. People with
HIX’ AIDS recognize that the quality of
their lives has improved. Governmental
and nongovernmental agencies have
been very active: in 1996. Phayao
Province allocated two USS per capita
to 75 projects in response to HIV/AIDS.
In 1994, it set up the Phayao AIDS
Action Centre (PAAC) to help imple
ment a multisectoral response.
dients in managing support to the
HIV/AIDS response. The Centre could
then foster further progress on
HIV/AIDS and influence the design of
health-care reform in that Province.
What main lesson did Phayao Province
learn over the past ten years?
•
Recently, the PAAC reviewed existing
data and reflected on its experience to
identify lessons learned and to articu
late '‘factors of progress ’, or key ingre-
8
the continuous adaptation of strat
egy as the province was learning
how to deal with AIDS, and
of couples use premarital counselling
services.
•
a human development strategy
emphasising not only technical
skills but client-oriented attitudes
as well.
Now comes the hard part. To move from
progress to success on HIV/AIDS, the
province will organize the combined
support to key participants to the
response to HIV/AIDS. Among tliem,
people with HIV and AIDS could make
the greatest contribution to further
progress in die short term. Such contri
bution hinges on the generalization of
access to early testing and counselling,
and on the combined, effective support
from various sectors to their response.
The long-term challenge consists in sup
porting the youth in adopting sustained
behavioural change in response to HIV
and AIDS.
While progress in responding to
HIV/AIDS in Phayao is evident, the time
is not ripe for celebrating victory.
Indeed, progress has been stalling over
the past few years. After a rapid decrease
in the early 1990s, HFV prevalence levels
among pregnant women and among
conscripts are levelling off.' at seven per
cent and five per cent respectively since
early 1995. More progress is needed on
the social front as well. People living
with HIV/AIDS (PWHA) observe that
unaffected families still kx>k down on
them. Fundamental causes of vulnerabil
ity persist. Very few people are informed
about
(heir
own
HIV
status.
Communication within families about
sexual matters remains difficult. Alcohol
abuse, while poorly documented,
appears widespread. The lack of oppor
tunity still drives many men and women
outside the province. Some social
norms, both old and new, are ill adapted
to HIV AIDS. Support from institutions
to individuals, families and communities
is still fragmented. Specific risk situa
tions. such as anal sex and injecting drug
use. are not addressed. In only two out
of seven districts does youth have access
to life-skills training. About five per cent
The outcome of the battle against AIDS
is decided within the community.
People, not institutions, ultimately
decide whether to adapt (heir sexual,
economic and social behaviour to the
advent of AIDS. Governmental and
nongovernmental organizations can
only influence, either constraining or
facilitating, people's responses to HIV
and AIDS. Hence, their single most
important role is to strengthen the
capacity of people to assess how AIDS
affects their lives, to act if needed, and
to learn from their actions. Supporting
communities in such a process repre
sents a major challenge to institutions
involved. The PAAC considers that the
following institutional factors may
have contributed to progress over the
past ten years:
•
•
the combination of short-term
action to reduce risk and longerterm action to reduce vulnerability.
the establishment of partnerships
across sectors whereby planning,
decision making and resources are
shared.
I
To enable further progress on HIV/AIDS,
profound health-care reforms are
needed. The advent of AIDS is challeng
ing the health sector at the level of pur
pose and roles. AIDS reminds us that the
purpose of the health sector is not just to
achieve better health outcomes through
the delivery’ of health-care packages.
Society does not only expect the health
sector to provide care. The health sector
has to counsel individuals and commu
nities, and catalyse other sectors towards
action for health. These latter roles have
been advocated since Alma Ata. Now.
however, it is a matter of life and death
that "health" effectively plays those roles:
no other sector will jump in. It will not
be an easy task.
9
Executive summary
Executive summ^y
Eirs! the counselling of individuals and
communities throughout the province
requires major changes in structure and
process of a system used to control dis
ease rather than influence other peo
ple's behaviour.
ceuticals management, purchase and
delivery, is based on mo complemen
tary approaches (see Figure 1):
•
Secondly, reaching out to authorities
and colleagues from other sectors con
stitutes a hard task for health workers
who are used to vertical chains of com
mand.
Thirdly,
the
incorporation
of
HIV/AIDS-related procedures into “the
core health service”, the standards for
health-care system output in Phayao,
remains a challenge. The key for this
triple adaptation of the health sector
has to be the health centre. Al the inter
face with communities and close to the
tambon (sub-district), the health centre
is ideally placed to effectively imple
ment the required changes. To develop
AIDS-competent health centres. Phayao
will restructure its district health sys
tems, and further develop its human
resource strategy'.
The “HIV and Reforms
for Health Agenda”
The UNAIDS HIV and Reforms for
Health Agenda, which has been devel
oped from the experience of Phayao,
together with that of the Bamako
Initiative for community-based pharma-
•
•
Does the health reform cover all
three goals (lower mortality and
morbidity rates; less suffering; less
dependence, more autonomy)?
•
Does the health sector perform the
three roles: provide health care;
catalyse community action; support
integration of health concerns in
society?
•
Are the three principles in health
care organization addressed: inte
gration; continuity; people-centred
focus?
•
Does human resources develop
ment for the health sector address
technical, attitudinal and spiritual
issues?
•
W - -
———■< Expanded response to HIV/AIDS
/
Are the processes of achieving
reforms documented as importantly
as the output’
----------------------
action
F Implementing
| the expanded
The 'HIV test' would consist of a set of
criteria against which to review
national reforms. For instance the HIV
test to the health sector would include
the following questions:
10
'W F
local implementation of an effec
tive and sustained expanded
response to HIV/AIDS, and
review of ongoing reforms for
health with respect to the 'HIV test'
Local
governments
Other sectors
Education
sector
Based on experience from
action, constraints
constraintslor
action,
for
achieving the expanded
response will
will be
bfidentified
response
identified
and programme managers
can request for policy reforms
to remove the constraints.
Health sector
. ijn
REFORM MEASURES
un.. ■
I
■
theory
Review of
policies: do they
pass the
"HIV—
TEST
--- - ”
When policy makers conduct reviews of
national policies for health, they should
put these policies through the ‘HIV test’
and determine whether they make
society more competent to deal with
and with AIDS. In those areas
where the policies do not pass the test
Recommendations for reforms are
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hiv/aids in Phayao:
the crisis
HIV/AIDS in Phayao: the crisis
"yvyelcome to Phayao Province! The peoW pie of this beautiful rural province,
struck by the disaster of AIDS, are turning the sit
uation around for the better. In fact, this province
has seen the highest HIV levels than anywhere in
Asia. It is also witnessing the greatest declines in
HIV levels. Progress, however, is not limited to
reductions in HIV seroprevalence levels.
Individuals, communities and institutions have
responded to the crisis in remarkable fashion.
Parr of the Mekong Basin. Phayao has
been a gateway for much of its histon'
K was built in 1095 by
Chiang Saen, and the people led
perous life as pan of thu
!
dom in 1340 for 2-iS ■
g’
years. Between
1558 and 3843, Phayao
history, as the result of vanished from
Burmese invasion. Some chrtmicles
reP<>n that at
........
P<>st of the
Ja. krngdom. The administnuixe
status
,ha>'ao varied greath
t. .. .Jy over the fo|O'ving century, to l^ome
-..... J •* Phayao
Province in 19'- Joday. some half a
million people lixc jn
il'' <dghl districts
(Figure 2, Table 1).
1
Tabfe 1; Population Djstrjbut.on per
Phayao province
Figure 2:
Map of Phayao province
CHIANGRAI
DOKKAMM
Phayao is a relatively small province. It is adjacent
to Lio People's Democratic Republic (Lio PDR)
and to the provinces of Chiang Rai. Limpang. Nan
and Phrae. Chiang Rai is a 90-minute drive away.
Coming from Chiang Mai. after a three hours drive
on a mountainous
road, one discovers
Phayao Municipality,
LAO PDR
IgOXSWG
spread along Kwan *
Phayao, a beautiful !
lake, in the middle
of rice fields, against j
a backdrop of the ■
majestic mountains .
IftQWGl
of Doi Mae Jai. ,
Indeed, observing :
the sunset over the
mountains across ;
the lake is a rare
experience of natu
ral beauty.
14
District
Tambon
Muang
18
^Municipal area
-Non-Mumcipal area
Maejai
Dokkamtai
Jun
Chiangmuan
.Poosang
district!
76
6
7
Chiangkam
10
I
T
176
_ 2
12
7
Pong
Village
3
5
68
776
61
117
68
79
110
29
48
688
Household
46,16
7,495
~38,669
10,888
22,268
Total
Population
^153,1151 ”
Highland
population
38,892
77,717
597
311
15,915
55,288
14,042
54,317
7.659
81,334
3.982
20,257
1.117
22,397
6,216
_ 9,646
'147,532^
■
430
27,757
-131,358
36.928
"siTss
|
r
368
14,464
1
I
i
i
HIV/AIDS in Phayao: the crisis
HIV/AIDS in Ptiayao: the crisis
Figure 3: Population pyramid of
Phayao province
Figure 4: Population pyramid of
Phayao province
(1996) from household survey
(1988) from household survey
-74
up 75
-69
0-64
0-64
MALE
FEMALE
0-54
5-49
2.3
1
Z2
I
0-34
5-29
I
0-24
_EZ 5.2
4.5
5-29
5-19
0- 14
lZZ 5.55J_____
____
rrz
0-24
5-19
0-4
5-39
37
5 - 39l
5-9
5-49
|
2.4
0-441
0-341
Its
6
5
r. I
4,7
4.5___ T
4.2
4
3.0
3
2
1
0
1
2
"1
3
4
4
The population of Vhavao is ageing, lhe
age pvramids in Figures 3 and t show
that Phavao population is ageing, a
result of combined low mortality and
birth rate. Children under 15. who rep
resented 25.6 per cent of the population
in 1988. represented only 22.1 per cent
of the population in 1996. In
,
before AIDS hit the province, the crude
death rate was 5.3 per 1000'. The crude
birth rate is stable at about 12./ per
of couples use
1000. Some 90 per cent
condoms).'
contraceptives (but not
1
i
5-59
0-54
5-59
0- 14
MALE
-69
-74
Source: Phavao Provincial Health Office
The inl'nistnicturc in I’hayao i.s gooilOver 99 per cent of the villages have
access to electnctty. The road system >s
excellent with ven- few villages situated
awav from a paved road. The province
has 313 schools. 3381 classrooms. 4803
teachers and 86.948 students/
People work hard in Phayao. A full 70
per cent of the 255,794 people consti
tuting the workforce work 50 hours and
more per week. Household income
however is low. with 28.7 per cent o
f CSS I = Baht 25.
< During the period eot ered by this report
varied considerably, currently being at CSS
M I = Baht 35-
fl
but subsequently the rate has
the rural population making less than
6000 baht per year1.
The main source of income is agricul
ture, which employs 44 per cent of the
workforce. The main crop is rice. Rice
producers get a yield of less than 600 kg
per rai, and about 18 baht per kg. No
wonder, then, that 33 per cent of hold
ers of less than five rai (who themselves
make up 32 per cent of all holders) rely
mainly on income from non-agricultural
sources. On average. Phayao house
holds (size 3-3 members) spent in 1994,
4340 baht per month, of which 193 baht
was on medical and personal care.2
large. A survey of 63 villages in Chun
District in 1991 revealed that 1692
women age 15-34 years, or 14.6 per
cent of the female population of that
age group, were working as sex work
ers. Of those workers. 245, or 14.5 per
cent, were working in other Asian and
European countries. Most women
leave “voluntarily”, as the result of
perceptions about their role in society.
They behave as their parents, their
community and themselves under
stand they should. Parents see their
daughters as the agent responsible for
family survival. Communities con
demn prostitute daughters less than
those who do not help their families.'
Daughters internalize that role, and
many women implement their dream:
help the family build a new house and
buy consumer goods, help the broth
ers through college, and come back to
get married. As we shall see AIDS is
changing this pattern.
To make ends meet, one option is to
migrate. In some villages, however, that
percentage is much higher. According to
a detailed survey of four villages in
1994.' almost 50 per cent of men and
women aged 17-21 had lived outside
the village for at least one month in the
previous year. About one quarter of the
migrants leave for education. The rest
leave to find short-term jobs, mostly
when there is a lack of local work in
agriculture. Men leave for blue-collar
jobs such as construction worker and
taxi driver. Typically they leave in
groups. Married men leave their waves
behind.
HTV spreads in Phayao
Province
HIX' has been spreading silently into
Phayao. probably since the late 1980s.
People then were paying little attention
to the virus:
For women, one frequent option is to
enter the commercial sex workforce.
The number of Phayao women enter
ing sex work is unknown. However
the numbers are thought to be quite
"We fearfamine, not AIDS"
was the answer to early information and
education efforts. By 1993 AIDS
17
i-iiv/Aiub in nnayao: me crisis
started showing its face in most com
munities. For many people, it was too
late. HIV prevalence levels among mil
HIV/AIDS in Phayao: the crisis
itary recruits and pregnant women had
already reached 20 and ten per cent,
respectively.
I
Province
Table 2: Reported HIV symptomatic and AIDS cases, by year,
AIDS cases
1989-1990
3
Chiang Mai
Total
HIV
symptomatic
cases
0
~
Male:Female
ratio at
national level
3
Male:Female
ratio in
Phayao
3:00
~
7
9
16
4.3:1
1992
79
212
456
1082
1256
3344
41
120
5:01
6.8:1
6.1:1
151
368
712
1498
1620
4671
4.7:1
6.6:1
1995
1996
Total
256
416
264
1327
Chiang Rai
Lampoon
3.7:1
5.5:1
3.0:1
4,7:1
2.7:1
4,0:1
3.1:1
4.8:1
2,633 (328)
361 (170)
Mae Hongsorn
i
io 2.“:I in 1996. with women relatively
more represented among AIDS cases
in Phayao than at the national level
(Table 2).
J
Phayao became the Province with the highest
rate of reported cases in Thailand. At 219 per
». M)0 populanon. the Northern Region of
Thatland has the highest rate of AIDS reported
!
I
yses. In the North, the Provinces constituting
Number of reported cases (per 100,000 population)
Northern
25,082 (212)____________________________________________
7738 (38)
’
’
North-eastern
I
I’lrtv'm 'LhT rCP°n ‘hC l,igl’CS' leVC,s' wit,‘
I
100 0 <
, P' reportinS 629 AIDS cases per
100,000 populatton front the outset of the epidemic until February 1997 (Table 4)
Figure 5: Reported AIDS cases and HIV
symptomatic cases by age and sex, 1989 - 1997
Table 3: Reported AIDS cases from 1984 through 1997 (February), by region.
Region______
-----------------------‘
Source: Phayao Provincial Health Office
Source: Phayao Provincial Health Office
The number of reported AIDS cases
increased steadily. HIV and AIDS
spread in both sexes, while the male to
female ratio evolved from 5:1 in 1992
-------- -----------------------------------------------------------------------------------------
~7,4O1 (477)
"5.771 (462)
~T,570 (388)
Lampang
11.0:1
1991
1993
1994
1
Phayao_______
Phayao Province, 1989 - 1997 (May)
Year
¥
|
Proportion %
i
58.9
Central_______
South________
Total
19,060 (101)____________________________________________
3564 (48)
55,443 (95)
60-i-------------50--
142.7
40- -
Male | | Female J
30.6
30 --
Source: Division of Epidemiology, Ministry of Public Health
20 4-
’O-S
ZB
10--'
19.5
12.2
12^
0.3 0.4
3.7
0 J*
0-4
5 - 14
15-24
25-34
“44
Age group (year)
3
45 - 54
2
0.7
55 - 64
0.5
0
>65
Source: Phayao Provincial Health Office
18
__
19
i
Hiv/AIDS /n Phayao: the crisis
HIV/AIDS in Phayao: the crisis
The morbidity rate seems to be higher
among those who gave agriculture as
their primary occupation (Figure 7).
Agriculture workers are most likely to
seek temporary work outside the
province when there is low demand for
their labour in Phayao.
- -than men.
Women with HIV/AIDS are younger
jority
of cases of each sex
but only slightly. The maj
group occur in the 25-34 age group (Figure a).
Figure 6: Distribution of AIDS and
HIV Symptomatic
A tremendous impact
on the people
Rate per 100.000 population
■ 1989 - 1993
□ 1994
11 1995
■ 1996
800
600
The crude death rate increased dramat
ically, from 5.3 per 1000 in 1986 to 6.8
in 1993 and 9.5 in 1996 (Figure 8). No
Year
0
I .LI
Chiang Mum
Ponq
K- Puaang___________________
Maa
Muang
Chung
Chiang Kum Ook Kamtai
Figure 8: Crude death rate, Phayao Province, per 1000 population
Source: Phayao Provincial Health Office
10
In all districts, people started to seek care for
I llV-related symptoms.
8,16 8,97
8
6
Figure 7: Occupation Specific
Morbidity Rate
5,29 5’53
-----
5,83
6,48 6,78
2
0
20
__
1986
15
t
6,62
5,32 5,63 5,82
_______ _—
►9,45
4
Rate per 100.000 population
10
other condition than HIV/AIDS can
explain this increase. By 1994, AIDS
had become the leading cause of mor
tality in the Province. It represented
11.3 per cent of all deaths, and 18.2 per
cent of all deaths if one includes those
cases where AIDS is the suspected
cause of death but was not medically
confirmed. The AIDS death rate in 1994
was 1.53 per thousand, hitting men 5.2
times more than women, at age 25-34
(55.3 per cent of the total). Some 40 per
cent of them were single.1
6,34
2,78
6
merchant
agriculture
Occupation
Source: Phayao Provincial Health Office
I
1988
1990
1992
1994
1996
!
Between 1986 and 1996. mortality
among men. aged 25-34. and among
women, aged 20-29. increased eight to
nine-fold.'
There is no accurate information about
the infant mortality rate in Phayao. The
rate of infant deaths to live births regis
tered in the province shows a dramatic
increase instead of further decreases as
expected (Figure 9).“
The population growth rate (Figure 10)
declined to reach almost zero. The
population in Phayao Province is now
expected to decrease, as the result of
increased mortality and decreased fer
tility among women with HIV.
21
I
I
I
Hiv/AIDS in Phayao: the crisis
HIV/AIDS in Phayao: the crisis
1’ Figure 9: Measured and projected infant
mortality rate (IMR) in Phayao,
1987 - 1994
AIDS made its economic impact deeply felt,
reatment costs of opportunistic infections are
very ugh. Costs of antiretroviral therapy are even
higher (See Tables 5 - 8).’
14
Tables: Cost of treating opportunistic infections
12
Measured IMR
J 10 -I 8 <r
I
according to National Guidelines*
(1 oooPbraht),SOde
6 --
1
Tuberculosis
32^
Cryptococcal meningitis
68>668
4
i
2
Candidiasis
Projected
[Cytomegalovirus infection
0
H-------- --------- 1-------- 1-------- 1-------Year 1987 1988 1989 1990 1991 1992 1993 1994
Table 6: Costs of antiretroviral
Drug
Figure 10: Population growth rate in
Phayao, 1986 - 1997
Didanosine (100 mg)
5 __
0
J—I—H w- ]
1988
1990
Indinavir (400 mg)
3.83
Ritonavir (10Q mg)
3.2
! ]—
H- 1—H
1994
1996
^Saquinavir (200 mg)
64,4
97.0'
99,0
83.3
50,0
54.4
0.43
1992
Year
Women who know they have HIV are less likely
to want to have a child. In addition, there seems
to be a biological reduction in fertility among
women with HR7.6'7
Table 7: Costs of double combination thera
py
^Double combination
_ Zidovudine/didanosine'
__j!dovud[ne /zalcitabine
—Zidovudine /lamivudine
_ Stavudine/didanosine
— Stavudine/lamivudine
__
22
r
(times) | Daily cost (baht)
=
~
72.0
3x2
2x2 _______ 181.9
193,1
1 x 3 _______ ~
194,0
1 x2 _______ ~
198,0
1 x2 ______ ~
2x3 ______
500,0
6x2 _____________ 600,0
3x3 __
490,0
45.5
Lamivudine (150 mg)
4.61
'5.82
1986
Stavudine (40 mg)
m____________________
"02
'•^8.09
X. 5.96
8.71 8.11 8.08
i
12,0
Zalcitabine (0,75 mg)
118
agents
Jjnit^ost (baht) I Daily
Zidovudine (100 mg)
Population growth per 1000
10
300
Average cost
Cost >er day (Baht)
Cost
er month (Baht)
253.9
~~
265.1
—~
7617.0
^7953.0
270,0
~~
~8100.0
375.9
~392.0
~~
~11277.0
~11760,0
~9341.4
377.4
23
'
I
1
HIV/AIDS ’ - Phayao: the crisis
HIV/AIDS in Phayao: the crisis
Table 8: Costs of triple combination therapy
Triple combination
-^UdireTdida^^
7j^~^e^ndjnaw_
Average cost________
Cost per day (bahtj_
Cost per month (baht)
753.9
853.9
743.9
770.0
870.0
760.0_____
792.0
1
22617.0
25617.0
22317.0
231000
261000
228000
23758.5
__
_
result, people lost their jobs
As a
..
not only related to
their employees, and their
Direct costs are
customers,
medicine. Having heard from
Children
were sunt
s—- away
western i —
suppli'-‘rs"that there is no
doctors and nurses
from day-care.
From Hov^ihon
X1HS-. people with HIV and
cure lor lerstand that modern medi
AIDS und
, <>f AIDS went far
cine has no cure lor them. They then
Ihc consequences
■
.'
economical
sphere. Once
of
treatto alternative sources
beyond the c^-...
turn i
to
spend
all
of
•alized
that
AIDS
had come m
people real...—
rnent. where they tend their assets or
community, people were so
their savings, selling
to their c
that they cut relationships
L result, people
frightened
going into debt. As a
—s commonly | with neighbours, and friends affectccl
with' some financial means
including refusing to
of thousands to hunby HIV/AIDS, i
spend from tens
attend their funerals or joining in tradi
of thousands of baht on
dreds c.
tional community ceremonies.
treatment' •
ln addition. MOS causes major income
loss as it mostly affects people age
Body bags
Not wanted at the wedding
At the early stages of the epidemic,
rejection of AIDS patients in the
community was partially caused by
hospital medical procedures related
to AIDS deaths. When a patient
died at the hospital, the body was
put into a plastic bag. Tloe family
was told not to perform traditional
bathing rites, but to go straight
ahead with cremation. Noting how
strictly the hospital dealt with the
corpse, villagers worried that the
virus could perhaps be transmitted
from the body in some way.
I burst into tears in front of all the
guests. I carried a boui of nee. but
they would not take it from me.
They said I didn t have to sen e and
should have let other people do it
instead.
Wan, serving at a wedding party.
She learned about her MIX’ infec
tion during her first pregnancy.
From Havanon "
No wound!
[My friends/ tell me not to go with
them when they seek for jobs any
more. Ibey are afraid I will eat and
drink with them. I told them that I
am all right. I don't have any
wound in my mouth.
Kampan’s husband died of AIDS. She
has to take care of her nine-year old
son by herself.
From Havanon “
(PWHA) and their families. That d
health personnel.
25
i
-4
Phayao peop'" make great progress
Phayao people make great
progress
P«;plc "^(ed no lime in responding to
I
I HI\. individually and collectively.
3
Figure 11: Prevalence of HIV among military con-
scripts, Phayao
HIV prevalence (per cent)
“ r-----------------------____
25 10
\
5
0__
1991
+
-I------- 1
-H--------- t-
-4------- t-
1992
H---------- +■
-4---------
1993
1994
1995
1996
Individuals adapt their
sexual behaviour
1
In June 1993. HI\' seroprevalence levels among
mihtao- conscripts from Phayao Province started
to decline (Figure 11). In 199’ thev have reached
a plateau at about seven per cent, or about
one
thud of the peak lex-els reached in June
1992 and
in January 1993. In principle, all young imen aged
21 are subject to military sen-ice but a :
sample is
recruited through a lottery- system All conscripts
r
are tested for HIV. A positive result does
—not
I exclude them from the military- sen-ice.
I
■
Phayao /:
>p/e make great progress
pnavao people make great progress
I
The hospital data from prenatal clinic records for
1993 1997 (Figure 13) show the same trend.
Testing is voluntary. More than 90 per cent of
pregnant women take the test.
nant woman, Phayao,
HIV prevalence (per cent)
Thailand Phayao
Phayao 2
Figure 14: HIV prevalence among pregnant women
by age group, Phayao, 1993 - 1997
12,-----------
101--------
HIV prevalence (per cent)
I 8’______
6'---------
14
•>-
I 4:__ a
15-19
12-
2:____
“3 Jun 94 Jun 95
0L->—• 77n905J^TrTn92 Jun 93
Dec 94 Jun 96
I Jun 89
Dec
92
Dec 93 L—
Dec 90 Dec 91
I
Dec 89
Month
10
20-24
8
25-29
6
30-34
4
)f II1V among pveg<
In June 199i. the prevalence Province
stalled to
nant women in 1’ltayao . 1 12, Ho/e.- //’U insults
decline as well (See Figure
include Pour District.
from Pbuyw 2 ll,ies
W°men
Phayao, iw
■&
■&
2u________ i________ i________ i________ i_______
Jul-Dec, 96
Jul-Dec, 93
Jul-Dec. 94
Jul-Dec, 95
Jan-Jul, 97
Jan-Jun, 94
Jan-Jun, 95
Jan-Jul, 96
Year
Source: Hospital Prenatal Record
j
HIV prevalence (per cent)
The same downward trend is observed when the
HIV prevalence data are disaggregated by age
(Figure 14). As expected, the decline is greatest
among younger women.
10
9
8'
6
5
Jul-Dec, 93
I
Jan-Jun, 94
Jul-Dec, 96
Jan-Jul. 97
Jan-Jun, 95
Year
Jan-Jul, 96
Source:
Primigravidae show also greatest decreases in
HIV prevalence (Figure 15). Premarital coun
selling started in Phayao in 1996 and cannot
explain the downward trend among primiparae.
which started in December 1993- Moreover, only
about five per cent of couples use premarital
counselling services. The slower decrease (if
any) among second pregnancies may reflect
transmission within married couples.
Hospital Prenatal Record
29
i
Phayao people make great progress
Phayao peopip
make great progress
Figure 15: HIV prevalence among pregnant women
by parity, Phayao, 1993 - 1997
potential donors "'ho suspect they might test
positive for HIV.
HIV prevalence (per cent)
16
14
parity 1
12
parity 2
10
parity 3
8
6
4
2
0
Jul-Dec, 93
Jul-Dec, 94
Jul-Dec, 95
Jul-Dec, 96
Jan-Jun, 94
Jan-Jun, 95
Jan-Jul, 96
Jan-Jul, 97
In the past. Phayao
Young men approved of
People viewed
I
lle? hnving sex as normal.
Almost the practice of
commercial sex in 1994...
every unmarr|ed man used to
frequent
nyrried men would
sne'k^ 'V(,''kCrS Many
It is something u hich people
sneak
•'''though perhaps not as '
’<'
brothels.
see all thc time.
;i.s when■ ) they
were single. For
"lcn
work in
other
provinces, lisitjng
workers |ur iron,
nsed
to
be
considered
home
men to thef)l /a>c a
” ;is :l
enhancin'.U expe^net. it really influences
men "ormally had their
■Se-Xll;|l experience with a
(>>ie s mind.
Prostitute.
SX;’’T™*- >■».«
Year
"
tbillfi to
Source: Hospital Prenatal Record
Figure 16: HIV sentinel serosurveillance among
blood donors, 1989-1996
Young ”>en from Chiang
Kham on
pre-marital com
mercial sex in 199q
Source: Pramualratana el al‘-
per cent
hl
10
8
6
4
2
0
Month Jun8e D«c00 Jin00 Dec80
Previous 12 months
91 D«#l An82 Dec92 JunS3Dac83 Jin 94 Oc 94 Jun95 DecBJ
(per cent)
Phayao
Thailand
80
60
Source: Division of Epidemiology
401
HIV infection among blood donors shows a sim
ilar downward trend (Figure 16). That trend
might, however, result from self-exclusion of
20
30
64,8
■|41,9
■__ 40,2
°tMilitary conscripts
25,0
IjiTigosi
27,0
□ 1996
22,0
2,2 3,6
male labourers
male secondary
school students
j
Phayao p'^ple make great progress
I
pnayao people make great progress
,
r„me to understand that
But as villagers have co^
transffiission
AIDS is a killer an
community s
through sexual 'nte^ve changed significantly,
norms on seXUll^JTorkXnmt>chhess than
Now. men visi - ■
of young mens
before (Figure 17). T“e p,
clKmged also. Now
initial sexual relationsl 0 . ,
th.it hjving
the majority ol young I '
M;de teenagers
decrease is, however, compensated to some
extent by an increase of sex workers at restau
rants and karaoke bars, where men pick up
women for sex outside. The number of knowm
indirect sex workers to the province increased
from 16 in 1994 to 88 in 1996 (Figure 19). They
tend to sell their services much less often than
direct sex workers do u. We shall discuss the sig
nificance of that phenomenon.
| find a girl friend."
surveillance data tend to> indi- I
sex work- I
Sexual behaviour
visit commercial
’ - cent ol mil" I
cate that young men ’
per
to have I
ers less frequently. In, 1997. oH).3declared
from
Phayao
.
jury conscripts I
worker over the past I
visited a coniine rcial sex r.... cent in 199V ' In
about 66 per
year down Ironi
cent ot male sec- I
but now brothels have
1'7'and 1996. under four per
closed for lack of
199'.
.......... 1
customers I ondary
| sex establishment
phayao Province
Uell i„ Ibe rillane
' M‘
before that
behaviour surve ilia nee s\ s c
^uorke^nearlbeiilki.^cannot
Tbev clicln l Ixuv to
to
« h ix-ii* «■ s" ■" “pbv
year. L
town. AH men. from teenager
to middle aited. mstted sca
morkets. Orer sis or seren
vetns. since.WSr.rriret.
those sex establishments didn
make enouffr money to no on
cial sex establishments.
operating. Ihe brothels had
Zen. and they had to pay
,ltof these chants >n ^-unbroth^
---;
icitboiit
ciuy
As
a
resu
all the expenses
close, in 1990. there were
els had to
customers, so ibev
I . bcid to close
1996 there
doom.
mercial sex
with 449 commercial
. . seK establishments and
were 12 comi“
— ”X «
A village headman
181 *
commercial sex
.. „e ,r„a i«k
Source: Havation
Figure 18: Evolution of sex work
establishment Phayao Province
100
Direct
<7"^
50 -
A Indirect
Total
------- ■------- •------ ------------------ 1-------- 1-------- L_
0
1990 1991 1992 1993 1994 1995 1996 1997
Figure 19: Evolution in number of sex
workers (SW),Phayao Province,
1990 - 1996
* JX,f
500
0
*
1990
1993
1996
Source: Phayao Behavioural Surveillance System
33
”
Phayao people make great progress
"
'
■
■■
Phayao people nake great progress
I
When they do visit sex workers, an increasing
number of men use condoms consistently. Ten
years ago. condoms use with sex workers was at
best erratic. But in 1996. 66 per cent of Phayao
conscripts report consistent condom use with sex
workers and 56 per cent in 1997. up from 48 per
cent in 1995 (Figure 20).'"
Consistent condom use among male labour visit
ing sex workers was 66 per cent in 1997. up from
36 per cent in 1995. A large majority of the few
students who went to the brothel used condoms
consistently. Condom distribution by the Phayao
Provincial Health Office shot up from 16-1.548
units in 1990 to 942,874 in 1997.
eir fannhes. ,n particular from the blood rela
te es (parents, brothers and sisters). Moreover n
one study, awareness by the husband htt h s
SZa^ “ — — -
Figure 20: Proportion of reported consistent condom
use with commercial sex workers in past 12 months
(per cent)
80
60
40
80,0
r
67,6
58,9
48,3l
61,7^
I 35,7|
20
.f 667 □1995
1
I
□1996
It S good to
-nonfood,
Il 997
0
Military conscripts male labourers male secondary
school students
A person with HIV/AIDS helps out at a
social event
Communities respond
In fact, people with HIV/AIDS often are anree
by ““ I“pp“
First inspired by fear, community attitudes
towards people living with HIV/AIDS (PWHA)
started to change. They are now increasingly
inspired by compassion. In focus group inter
views, most PWHA report loving attitudes from
34
Communities have adanrRd
make it possible for PWHA to live in
I
i
midsT
SbXwc
h^dition focus on food and
,tS’ WhlCh have great importance in Thai soci
Rn
!l
li
'JWMALllI
Phayao ?ople make great progress
Phayao people make great progress
I
ety. Traditionally families in the north
sit in circle with the dishes in the mid
dle using their fingers to roll chunks ot
sticky rice into balls and dabbing them
into 'flavoured dishes. At first families
would reject people with HIV from the
meal. Now some families keep their
traditional practice, realising that HIV
cannot be transmitted through commu
nal eating HIV-positive people." Other
families are introducing the use ot a
helping spoon to serve the condiments
on separate dishes for each participant
to (he meal.
I
explicit policies of keeping children with
HIV at school.16
People with HIV/AIDS are: also better
at large.
accepted in (he
t.— community
—
People with HIV/AIDS arej now invited
to participate in
i.. social
------ events, and to
- t food-related
help in chores that are not
(Figure 21). The
— Phayao AIDS Action
interviewed
81 businesses
Centre
employing more than ten workers ( M
per cent of the total in the province). 131
chief monks (30 per cent of the total). 92
school principals (30 per cent ot the
total), and 89 day-care centres (30 per
cent of the total). Eighty-eight per cent o
the businesses have the explicit policy of
keeping people with HIV at work. Over
two in three (67 per cent) of tire chief
monks allow PWHA to organize activi
ties in the temple - although 98 per cent
of them will not accept people with HIV
as monks, and candidates are required
to take a blood test. Among schools and
day care centres interviewed, 92 per cent
and 83 per cent respectively have
I
-------- are? building
People with HIV/AIDS
communities of their own (Figure 22).
Irrespective of the psychological support
they get from their families, they hnd
great comfort in the solidarity of people
with whom they can share their experi
ence. There are 24 groups of people
with HIV/AIDS in Phayao, with 1609
people participating. That number is ris
ing rapidly.
Communities have started to deal with
the causes of their vulnerability to HIV.
According to a community survey done
by village health workers of one district,
the number of women (age 15-35) leav
ing the district to work as sex workers
decreased from 1692 in 1991 to 2W in
1996. Rather (han sending their daughtors to town "to make some money .
thev now tend to keep them in school, a
I result of an active effort from the
Ministry of Education partly motivated
by HIV AIDS.'"
Government and
NGOs respond
From 1984 to 1992: Focus on sex
workers
When HIV was first detected in
Thailand, the Government appointed the
sexually transmitted diseases (STD) clinr
-AlkNOVNlFCW.
<*• adapt To
Mrl.KMexift TRACXiNnS To AoeCPy
diswuaimatw* ,
ptATHs
Figure 22: People with HIV/AIDS organize self-help
groups
ics as the main agencies to deal with this new dis
ease. They were put in charge of a prevention
campaign focused on “risk groups’, mainly sex
workers and their clients. In 1991, the Government
created the National AIDS Prevention and Control
Committee (NAPCC) chaired by the Prime Minister.
The end of that year the NAPCC announced the
“100 per cent condom use campaign” for commer
cial sex establishments. The goal of that continuing
campaign is to ensure that each sex act in com
mercial sex establishments be protected by a con
dom. The Government has provided strong media
support for the campaign and also organizes con
dom distribution.
37
Phayao people make great progress
Phayao people take great progress
1
caution policies. Soon, the
prox'incial
leadership realized that "care, not scare"
had to be at the centre of their action.
Figure 23: Condom distribution in
1990-1997
1,000,000 ---------- -------------900,000 B
■
800’000 700,000 -
Is
With AIDS also came the realization
that everyone was at risk. The problem
I
■ ■
■ ■
600,000 _ I ■ H ■ ■
500,000 ■
? I | |
E 1, I
400,000 | I [ I ■ | I I j 11
300,000 H H ■ ■ ■ j | |
200,000.
H H H I J ■
100,000 .■■■■■■■■
o I■'■'M;
!B.M M
was not htnited to sex workers and
their clients. Sex work is a job. not a
gies. approves operational plans and
oversees monitoring and evaluation.
status. Sex workers become houseWives. Then- clients are husbands and
lovers. HIV is
not only tmnsmiued in
commercial sex establishments. It is
also Uansmitted at home between married partners.
1990 1991 199219931994 1995 1996 1997
Source: Phayao Province STD Clinic
also emerged that something deeper
than risk was involved. The province
had to deal with the specific factors of
Inerabihty . the propensity of neo-
In Phayao as in other Provinces, staff from the
STD clinic took charge of implementing the 100
per cent condom-use campaign. They visited
commercial sex establishments and taught sex
workers, rallying support from the establish
ments’ owners. Condom distribution picked up
dramatically (Figure 23).
p e to put themselves in situations of
.
Thls mc:,nI I:1^iing social norms
meant promoting girls' education It
meant creatmg economic opportunity’
^P^tally in those communities most
affected by HIV/AIDS. It meant
The STD unit also collaborated with other sec
tors. However, at first it was difficult to imagine
what role the other sectors might play, beyond
participating in information campaigns in sup
port of AIDS prevention.
expanding care for AIDS patients
beyond simple medical care. It meant
mg holistic, bringing in the contribu-
lab™
u°nkS’ S°Cial w°ri<ers,
abour and other sectors.
Expanding the response
But in 1993 AIDS became more and more appar
ent. And with AIDS came discrimination, partly
fuelled by the earlier AIDS campaigns - which
were based on fear - and also by overly cautious
health personnel, misinterpreting universal pre-
Control was created, followed by the
creation in 1994 of the Phavao AIDS
Action Centre. The Governor of Phavao
leads the action on HIT AIDS He
chairs the Provincial AIDS Committee
whtch sets policies, goals and strate
Clearly officials c'
°f ±e Ministry of
Public Health alone
could not do this
job. The province as
a whole had to be
mobilized. IIn 1989 the Provincial
Committee for
~ AIDS Prevention and |
i
The Provincial AIDS Action Centre for
mulates the policies, goals and strate
gies for approval by the Pmvincial
Comnuttee. links up with ti,e nK.dj;,
coordmates
implementation
of'
f IV/AIDS-related activities, and assists
(PPHO)'ya<; !,nn'inci:,l ,k'll'l> <^ffce
(U HO vvtth fundraising and allocatton
of funds to HIV/A^S projects. The
Centre consists of the following secu°ns: mformation, planning' and
budget, technical and training, research
tS
3nd ^''’’Inistrauon.
A I3S Acll0n Centre hosts the rep
resentative of the nongovernmental
organization (NGO) CARE Thailand.
which liaises with other NG Os active
on HIV/AIDS in the
the province.
Moreover, in five districts-’,
, local AIDS
action centres are :active, extending the
work of the Phayao AIDS
Action
Centre. The Centre keeps the institunonal memory of the province on
A DS. Its entire staff participated in this
Each year, in accordance with the budget
1 Chiang Kam, Dokkamtai, Chun. Pusang.
Muang
38
39
I
ll
Ptiayao ^?ople make great progress
Phayao people make great progress
cycle, the PPHO - assisted by the AIDS
Action Centre - submits to the
Provincial Committee a set of guidelines
for project development.1' In line with
the National Plan 1997-2001,18 these
guidelines recommend a set of strate
gies which various sectors should adopt
in the development of their projects.
The Response in 1996: a
brief overview
An intense level of activity
From 1993 io 1996. the response to
HIV/AIDS by Phayao institutions
steadily increased in intensity. In 1996.
public and private institutions in the
province implemented
5 projects,
with a budget ol 30 million baht, or a
little more than 2 I SS <at the then rate
of exchange) per capita.
Project resources directly support
the private response to HIV/AIDS
Around the world, it is too often the
case that HIV/AIDS project resources
remain confined to the organization of
meetings and seminars, targeted at
staff of organizations supposed to be
involved in the response to HIV/AIDS.
But in the first instance, it is ordinary'
men and women who respond to Hl\
and AIDS. In Phayao. this point was
recognized, and 41 projects (55 per
cent of the total, representing 76 per
cent of 1996 project resources) aimed
at supporting the "private response
to HIV/AIDS - relating to how people
respond to AIDS in their private lives.
Furthermore. Phayao province recog
nized that people do not only
respond as private individuals, but
also as members of families and com
munities. So out ol the total resources
allocated to the private response. 39
per cent aimed at individuals, five per
cent at families, and 11 per cent at
communities.
The scope of these projects was broad,
as they aimed at reducing risk as well
as building capacity. They directly ben
efited many categories of people in the
province. And many sectors were
involved in implementing them, partic
Support to the private response:
ularly at district level. Project, funding | focus on various target groups
came from various sources, but mainly
from the Ministry’ of Public Health. . Members of most groups relevant to
Annex 2 describes the framework used
the epidemic
received support
to carry out the review described in the
through one or more projects. As
following paragraphs.
Figures 24 and 25 illustrate, projects
focused on people with HIV, AIDS
and their families, as well as on
Pl
Figure 24: Distribution of project
targeting the private
response, 1996
Figure 25: Distribution of project
resources targeting the private
response, 1996
■ Students
5%
12%
(per cent)
12%
7%
5% 7%
8
□ Youth
■ Soldier/police 4 family
■ Soldier/police 4 family
■ General population
39%
■ Students
20o
0 1 3
□ Youth
I
■ Risk groups
19
■ General population
■ Risk groups
■ AIDS volunteers
■ AIDS volunteers
□ PWHA and family
□ PWHA and family
■ Health adm. staff
■ Hearth adm. staff
school and out-of-school youth. Other
targets include sex workers and their
clients, the general population.
Project resources in support of the
private response have been targeted
mostly to people with HIV/AIDS.
While projects in support of the insti
tutional response have targeted the
health sector they did reach out at
other institutions, such as coordinat
ing committees, monks and teachers
(Figures 26 and 27).
Figure 26: distribution of projects
supporting the institutional
response, by target groups, 1996
Figure 27: distribution of projects
supporting the institutional
response, by target groups, 1996
■ Health Personnel
3
2
0%
■ Counsellors
18
□ Monks
■ Counsellors
12%
■ Religious leaders
5
■ Hearth Personnel
(per cent)
□ Monks
■ Religious leaders
H Provincial AIDS Committee
■ Provincial AIDS Committee
■ District AIDS Committee
■ District AIDS Committee
□ District AIDS Working Team
□ District AIDS Working Team
^^^^79%
■ Teachers
41
■ Teachers
^ridydo people make great progress
Ptiayao people make great progress
In aggregate, the scope of projects is
comprehensive
r
Figure 28: Distribution of projects
in support of the private response
Figure 29: Distribution of project
resources in support of the
private response, 1996
sive projects, they develop approaches
that are dren later adopted in the public
health system. For instance, NGOs are
playing an important role in the further
definition of the comprehensive support
package to people with HIV/AIDS.
Substantial financial resources were
mobilized from various sources
Figure 33: Origin of project
funding, by sector (1996)
10%
■ Geared at the virus
40%
Capacity building
■ Geared at the virus
■ Both
»
50%
used
to
cover
administrative
6
(Figure 30).
Figure 30: Distribution of project
resources by type, 1996
4%
23%
■ Curatnre and care
■ Supporting and welfare
I ■ Labour and social Welfare
Defence
I
lleahh.thePPHOtookthcleadinfundon k,h:llr of ull its pannes (see
Figure .33) The Provincial Committee
then allocated those resources to projects
.submitted by institutions from various
sectors (see Figures 31 and 32). This col■ lective effort of the Province led to the
mobilization of considerable funds fronl
■ Public health
bUdSet- The 1996 budS« for
HIV/AIDS amounted to 30 million baht
25%
■ Educational
(then USS 1.2 million/ or 60 baht per
61% ■ Labour and social Welfare
capita (then USS 2.4). This budget repre
Defence
sented 23 per cent of the public health
budget of the province (127,635,580
baht), or 14 per cent of 206.3/3.980 baht
if we include private payments to the
Public system) and 2.5 per cent of tire
, n
provincial budget (1.2 billion baht)
During the period covered by this report USS 7 = Rnlo
/
varied considerably, currently being at USS1 - Bah 3-’
S’‘bSe‘JUe,!"'' ,he
has
Interior
5 CARE. FARM, World Vision, ACT, the Sisters of Charity, DISAC Phayao, the Church of Christ
42
raiser lor all seciors. As most of the pu|,.
1-e resources for HIV/AIDS come from
'he budget ol the .M,n,stn of Public
O Intenor
2%
A total 29 out of 75 projects were imple
mented outside the health sector, to
which the latter 61 per cent of’the
resources were allocated. Some of die
Projects are implemented by NGOs3.
NGOs play a very important, comple
mentary role. In die more labour-inten-
Using more traditional criteria, 46 per
cent of the project resources were allo
cated to cure and care; 28 per cent to
prevention and promotion; 23 per cent
to support and welfare. Less than four
per cent of project resources were
Unknown
■ JICA
I ■ Educational
12%
■ Adminietration
28%
I
I lie PPI IO was designaled io aci as fund
resources, by implementing
sector, 1996
Prevention and promotion
^^^^^75%
■ Public health
Figure 32: Distribution of project
45%
Defence
■ WHO
3
9
costs
i D Educational
Figure 31: Distribution of
projects, by implementing
sector, 1996
■ Both
As projects tackle various factors of vul
nerability and risk, their scope, on
aggregate, is quite comprehensive
(Figures 28 and 29). Projects addressing
risk factors include condom distribution
and information campaigns. Capacity
building activities include life-skills
development in young boys and girls;
financial support for low income fami
lies with a person with HIV/AIDS; and
the development of local action plans,
using the Participatory Rural Appraisal
(PRA) method which was used by all
sub-districts in Phayao province.
O Intenor
■ Labour and social Welfare
>
Capacity building
■ Public health
O%20/ 9%
Many partners from public and
private sector implement projects
if-
n
Turning
sis into opportunity
Turning crisis into opportunity
Mainstreaming AIDS
v
HUSH
*0 wq
P
M
2541
S
V- I
I
I
A t the beginning of 1997, the
jLjJ’hayao Provincial Health
Office (PPHO) found itself at a strategic
crossroad". Much had been achieved,
but much remained to be done. It
began to be felt that continuing to
tackle AIDS as a "special problem”
through "special projects" might be
counterproductive.
Mainstreaming
might be required from now on: the
inclusion of 11IV AIDS as a new dimen
sion of the core business of all relevant
sectors.
success on HIV/AIDS, and shape
Phayao’s health-care system to enable
effective implementation of that
strategy.
Study design
This study belongs to the PPHO. which
has been in the driver s seat throughout
the study. The office set up a study
team, composed of members of the
Phayao AIDS Action Centre and staff
from various branches of the PPHO.
including those working on health-care
reform, to undertake the study. The
team was organized into groups work
ing on epidemiology, social science
and economics. The study team mobi
As the province was to embark on
lized support from Thai experts in
these fields from the Ministry of Public
Health,
and
universities
namely.
Chulalongkorn and Srinakarin. The pri
health-care reform, it had the opportu
nity to explore what this mainstreaming
meant lor the health sector. For that
purpose, the I’PHO needed an articula
tion ol the lessons it had learned while
responding to 11I\ AIDS over the past
ten vears.
mary' audience of the report is the
PPHO itself and its constituents. The
main product of the study consists in
eventual follow-up actions in Phayao
and elsewhere, and in their impact on
The HIV and HealthCare Reform Study
health-care.
Stock taking, not research
a
'Wl
Hence, through the "HIV and HealthCare Reform Study", the PPHO
attempted to articulate what it had
learned
from
the response
to
HIV/AIDS. The objectives were to:
The team took stock of experience by
reflecting on its own experience with
HIV/AIDS over the past ten years, and
by using existing data in support of that
reflection. The team held several ses
sions to reflect on what might be the
key factors in an effective response to
Adopt a strategy whereby Phayao's
people could move from progress to
45
Turning crisis into opportunity
I
i
1
I
I
AIDS, and to what extent these "secrets’'
have been at work so far. At the same
time, the team exploited existing data to
review progress and support their
reflection. No additional research work
was carried out, with the exception of
locus group discussions with key par
ticipants to the response to HIV.
An attempt at a
comprehensive review
The secrets of an
‘integrative under
standing’ of HIV/AIDS
46
What is an integrative un^rstan^
-------------- --------- ---------
People and institutions looking at the HP/Aint , ■ /
hence resend difjerently. detunes in cZLZ?"'
^emU
md
focus on 'he tints and took for teclnu.loeicalu^ ?
B",IWclical xientids
ologicallMy^caivf(K.lls oll
'-“ 'f"- Mets taking, socimend social re■^nfiineerinti. Such riettscan hehdnll.^
a"d recoma common.
By articulating its experience, the
Phayao Study Team attempted to
develop an integrative understanding’
of HIV/AIDS. That understanding is
essential, to create a common vision
of progress and success among the
many partners who must collaborate
to make action effective (see box).
Because the PPHO is responsible for
mobilizing the overall response to
HIV/AIDS in the province, the scope
of the study is deliberately compre
From the understanding of the epi
hensive. HIV/AIDS is challenging
demic and the response to it, key fac
ewer}- aspect of society, and reviewing
tors of progress - “secrets” - emerge.
the response to HIV/AIDS lends to
Once recognized, these secrets can
become an overwhelming task.
serve as criteria for designing more
Hence, reviews are often limited to
effective responses to AIDS.
•smaller geographical entities (a disIrict, a community), a set of activities
Moreover, HIV/AIDS is typical of the
(condom distribution, care, etc.) or a
several socio-behavioural problems to
“target" group (people with HIV/AIDS,
which health systems need to adapt
children). As a result, reviews seldom
Better understanding the response to
address systemic characteristics that
AIDS amounts to better understanding
can only be explored by looking at the
of how people maintain and enhance
response to HIV/AIDS as a whole.—
their health. Hence, a health-care
Therefore, the team resisted the temp
reform that would benefit from the
tation to limit the scope of the study
integrative
understanding
of
as the review had to inspire the over
HIV/AIDS and of the response to it
all strategic direction in Phayao.
would be better able to deal with the
Rather, through its reflection on its
socio-behavioural problems of the
understanding of HIV/AIDS, the team
next century.
attempted at identifying the systemic
implications for an effective response
to AIDS.
Turning err- into opportunity
"niolues
"^denttattdi,.,. and solidarity
some proponents of the mainstream apptoac
‘'7
///IZ-|7/W- ^hile
spectme in tomn. it is onepersttectire tn , „
Z '“
'7 Z< 'hc (’"'y l>erexistinK pathmays to a ran^e of possible 7 "7":' '''cl'’l,,,"'/e‘/.Vbip this widens the
'here ha need for an intepratire i<ndelsta7dbw7i'rl''7S ‘"“l IVS,‘,‘"SCS 1,1
and more synergistic connections hetmeen ///| xn^ ’" '‘/>C"S "’C
,,lder
ohrtotts/y related intetremions mben the it dpi'.
"'her less
^cn>e been broken doirn. ■'here
'.'^7777' ,hc
""heoty I
tnechantcal. connections or intepratit 'n.
7
' J
r‘"bcr
The first fundamental secretthe community’s own
response determines
progress
These ;are dealt
' ’ with in
more detail
below. But there V
. ------ ' was a more fundamental lesson that Phayao Province
learned over the past ten years.
I
II
JI;.' ;
This was that the outcome of the batt!
le
against AIDS is decided within the com
munity. People, not institutions, ulti
mately decide whether to adapt their
^exual, economic, social behaviour to
the advent of HIV/AIDS. Governmental
und n„ng
menl;i) org;lni2;iljons
• n only mfluence. constrain or faciii.
‘
responses to HIV and
haor
" * n,OSt imPortant
o ,of progress lies within cotnmuni-
ow AinrT°f
ple tO
Pe°lives, to “
how AJDS affects their
act if
Sun^'and tO leam fr°m their acti°ns.
Supporting individuals, families and
communities in such a process repre
sents both a key role and a major chal
lenge to institutions involved.
I*’
‘ I
Phayao peOp]e demonstrated
demonstrated their
apactty to adapt to the reality of HIV
Once informed about the emergence of a
new and deadly sexually transmitted dis-
42
lll
fl*—®5
.
...
■
sapM^na
JU’
Turning -isis into opportunity
Turning crisis into opportunity
I
I
I
Figure 34: HIV seroprevalence among conscripts
and number of reported HIV/AIDS cases
Seroprevalence (per cent)
Number of reported cases
-r 18
1800 -r1600 -1400 1200 -1000 ..
800 -600 -400 ..
200
0
1991
1992
1993
1994
1995
-16
-14
- 12
-10
-8
-6
-.4
-2
0
1996
ease in their midst, they adapted their sexual
lx*haviour. even before communities started expe
riencing AIDS cases and death from AIDS. As
Figure 34 shows. HIV prevalence among young
men decreased significantly in 1994, a reflection of
Ixhavioural change prior to 1994. when many
young men reacted to the initial information cam
paigns. That was also the year when the number of
HIV ■AIDS increased dramatically. Men had already
changed their sexual behaviour, even Ixfore they
knew someone living with AIDS.
By contrast, it appeared that with the exception of
the 100 per cent condom promotion campaign, few
projects were likely to make a significant contribu
tion — because they have yet to reach a sufficient
proportion of people in need. Secondary school
children in only two out of eight districts benefit
from intensive sexual health and life-skills training.
About five per cent of couples use premarital coun
selling services. Some key groups, such as depart-
48
ing and returning migrants, injecting drug users and
men having sex with men have yet to benefit from
project resources. And in the final analysis, what
people do with whatever information and support
institutions might provide is their decision. What
they decide depends on their capacity, real and
perceived, to take charge of their lives.
The second fundamental secret:
people’s own capacity to observe,
understand and act determines their
response
Economic opportunity in Baan Tom
One day in Z993. Khun S. was visiting Tom Dong, a village
bordering the forest in Muang District. That village was hav
ing more than its share of AIDS-related deaths. Young
women who had left the village to enter the commercial sex
industry were coming hack with HIV and eventually dying
from AIDS. There he met Khun Z. a young lady who came
from Bangkok to visit her mother.
are you doing in Bangkok?” asked Khun S.
I work in an artificial flowerfactory”, she responded.
“You represent human capital'for this village”, said Khun S.,
"why don t you talk to your boss, and propose to open a fac
tory' right here?''
"OK " she said.
The factory was opened some years later. Women work at
home, and sell components for artificial flowers to the fac
tory, which now injects 200,000 baht per month in the local
economy.
Suwat Lertchayantee
49
my
rummg crisis into opportunity
According to the Study Team, the
capacity for people to assess their own
./actors of vulnerability and of risk
explained progress achieved so far.
Hus held for individuals, families and
communities, whether villages or selfhelp groups.
Phayao people have made progress
because they went beyond their first
reaction ol fear to assess their own sit
uation with respect to HIV/AIDS
They saw that they were vulnerable to
ID. were able to predict what would
happen il they did not do anything,
and refused that eventuality by acting
on their major factors of vulnerability
and risk. Their capacity to adapt to
the advent of AIDS was critical in
achieving progress. Making further
progress will hinge on developing
that capacity even more. Hence, in
the eyes of the people of Phayao.
Jacihtatnig community level responses
constitutes the key role for institutions
involved in the response to HIV/AIDS.
So what should the
institutions do?
Given these two fundamental secrets
that the community's response
determines progress, and that their
capacity to observe, understand and
act determines their response - what
’-nen are key ingredients of an effec
tive institutional response? It must be
o support these two fundamental
50
insights. In practice, the Phayao StudyTeam identified several key factors of
institutional progress, or “secrets” of
successful HIV/AIDS control.
The AIDS Action Centre concluded
that, the following institutional factors
might have contributed
-------------- to progress
over the past ten years:
combination of short-term action
to reduce risk and longer term
action to reduce vulnerability;
establishment of multi-sector part
nerships whereby planning, deci
sion making and resources are
shared;
dynamic, continuous adaptation of
strategy as the province was learn
ing how to deal with AIDS, and
human development strategy
emphasizing not only technical
skills but compassionate, clientoriented attitudes as well.
First institutional secret
combine short-term action to
reduce risk with longer-term
action to reduce vulnerability
Over the past ten years, Phayao
province has learned the limitations of
targeting only situations of risk
(immediate danger of HIV transmis
sion) and has progressively evolved to
address factors of vulnerability
(conditioi»ns leading people to
place themselves
in danger) as well.
X*"
rs "”r“'
PH
a short-term action Even ff ''h,S tould oniy He
carted using condoms
reduced their visits n
“’"ststently, and
HIV would eventuallv snre'T^'1
'V°rkerS'
hity, and rhe next lin inI° lhc C()ninHiwould be the use line
o/ of
<>f battle
e ;•:lg:linsl "w virus
of
condoms
by
'hey discover th-v
by c<n,P'" "her
ihey have Hl\\
' I
While this approach needs
undertaken, it
<'oes have obvious linti.atio:l()
ins- Which couples'
be
for HIV? At tvhal frequency?
r1...*
o-a- ..
.
> •trategics leading people
I (whether
infected
Wi
hin'h’
"r nO,) tO :,void
I risk situations.
Wtthm households, this involves
| improving
communications.
providing
enhanced economic c—
opportunity (see box:
Economic opportunity- in
Baan Tom)'
— prolongmg education, and ,
training in life-skills. Within
communities, this
norms,
ing the
parents
cial sex work.
to conmier-
Second institutional s;
secret:
multisectoral collabor;
-ation
As soon as tthe factors of societal and individual
vulnerability
are recognized, the need for effec
I
8
ttaas::?;. siinfa
Turning crisis into opportunity
aaawaiMaiMWif- nil r>fiii
ejsl'
Turning ^isis into opportunity
I
“Formerly we did not recog
nize the importance of collab
oration. We thought that we
could work by ourselves.
When AIDS came, we realized
that it is impossible to work
alone. ”
Dr Aree Tanbanjong, Phayao
Provincial Health Office
“You need to let each sector do
their thing, not be redundant.
Not every' sector doing an edu
cation program. During these
3 years we had a lump sum
budget in addition to the nor
mal budget. It catalysed a
dialogue on how to use it and
created good collaboration."
Dr. Petchsri Sirinirund, Chief
Medical Officer, Phayao
Provincial Health Office
Source: Interviews by Dr. Heidi
Larson -■
tive multisectoral collaboration to reduce that
vulnerability becomes obvious.
Fourth institutional secret:
the need for compassion
promoting condom use as a contra
ceptive as well.
Intervention to reduce HIV/AIDS affects the
core business of every sector. For instance, agri
cultural extension workers can give priority to
villages where land ownership is low, to pro
mote job opportunities to landless villagers who
would otherwise migrate out of the Province.
For instance again, the Phayao Provincial Health
Office is now advocating an AIDS-sensitive
poverty-reduction strategy: the economic sec
tors of the province need to take the advent of
AIDS into account in their plans, by targeting
those villages that are most vulnerable to HIV
with economic development projects.
Facilitation requires compassion or
empathy, the process of putting one
self without prejudice in someone
else’s situation. Compassion is a
rational attitude, and should not be
confused with sentiments such as
pity, or commiseration. Given that
people will decide the outcome of the
epidemic, and compassion is needed
to understand and influence their sit
uation, the alternative to compassion
is failure. Only compassion can lead
the health worker and other front-line
workers to put their health advice in
the proper context. Health-care work
ers who promote condom use by mar
ried couples for safer sex and fail to
understand the perspective of house
wives might hurt their feelings, as
they see the condom as the mark of
dishonesty. If they understood the
housewives' perspectives, they might
find common ground, for instance by
A kaleidoscope of anecdotes and
impressions (see box page 53) illus
trates many facets of compassion. The
challenge, however, is to put in place
systemic incentives to compassion, so
that this attitude is not just the feature
of a few exceptional actors, but
becomes a key characteristic of all
institutions addressing the HIV/AIDS
issue.
Third institutional secret: dynamic
adaptation of strategic planning
To play their facilitating role, institutions in the
province had to adapt their action as their
understanding of the epidemic was improving.
For example, at first, youth health education
began in the form of biology classes focusing
on the virus and its transmission. Now, the
focus is moving away from the virus and even
from AIDS per se towards life-skills education.
Before, the training was done in separate
classes given by health workers; now the strat
egy is to incorporate the work into the school
curriculum and have the classes given by the
regular teachers. The same process is at work
in health education given in health facilities:
before, HIV was the focus of the teaching given
to individuals, now the strategy is to focus on
communication about life and sexual matters
within the household.
52
The Phayao Provincial Health Office
has done much to foster compassion.
Health workers have been trained in
meditation techniques, as one has to be
at peace with oneself to reach out to
others. They are encouraged to think,
analyse and act on their own to adapt
to the situation of the people they are
to serve. Beyond the health sector,
compassion has replaced fear as guid
ing principle for setting HIV AIDSrelated policy’ in the province.
A kaleidoscope of compassion
‘When my brother died ofAIDS', says Kaeiv, a nurse in a health centre. I gave him
the ritual bath before his funeral. Before that day, no one would bathe people who
died ofAIDS. Maybe that gesture did contribute to the reduction of discrimination I
observe in the sub-district?"
'During home visits, families affected by HIVjust look at how you hold their baby,
saidJiab. Ifyou don t hold the child or show that you are scared, they will write you
oJT’.
->
53
Turning crisis into opportunity
"There is not much I can do in that village, ’’says Sister X, who assists self-help groups
ofpeople with HIV. “There, people with HP7AIDS hate a difficult time getting organ
ized. because local health centre staff don't welcome them. Hoey miss a place to stait
from
"U'e hate reflected on thefactors involved in ourpsychological recovety after we had
learned that we had HIV, "said a leader of a self-help group. "In each of our experi
ences. meeting a caring person is the key to our accepting our situation, and our
moving on with our lives."
W hen Ying was asked what role she thought Buddhism was playing in Phayao s
response to HIV/AIDS, she responded: "It is always on our minds."
People in Phayao
Of course, none of those factors is fully
implemented in Phayao. The next sec
tion discusses what strategic shifts the
province is considering as a result of
the study. Implementing such strategic
shifts would entail major changes in the
health sector. They are discussed in
Annex 1, "Health-care Reform in
Phayao".
CA
55
W
■■
"l
Ki
I
Progress in Phayao may be
stalling
A fter a rapid decrease in the early
HIV prevalence levels among
pregnant women and among conscripts have lev
elled off at seven and five per cent respectively
(see Figure 35) since early 1995.
jlX-1990s,
These prevalence rates are still among the high
est in Thailand and in Asia. They translate into
unacceptable levels of morbidity, mortality and
suffering. Clearly, there is no room here for com
placency. The current dynamics of HIV transmis
sion might explain lack of recent progress and
provide strategic clues for the way forward.
IH I■
i-
Figure 35: Prevalence of HIV among military con
scripts, Phayao, 1991 -1996
%
257
20.1
20-
20.2
17.8
15- -
15.2
15.4
14.6
11.2
10--/
► 8.1
5----- '----- H------- 1
7.74
7.5
I
I------ +------ 1
3:6
I----
+-.. -f—^--1
1/91 6/91 1/92 6/92 1/91 6/93 1/94 6/94 1/95 6/95 1/96 6/96
0
L
.....
Source: Hospital Prenatal Record
Progress in Phayao may be stalling
Changes in the
dynamics of HIV
transmission
The dynamics of HIX’ transmission are
changing in Phayao. as the epidemic
matures and patterns .of sexual net
working change. Here we shall
describe the most likely scenario of
HIX transmission, based on a mix of
data and of qualitative information.
This scenario is serving as the basis
lor further planning, while it is being
confirmed and refined as knowledge
and understanding of the epidemic in
1 hayao and elsewhere improves.
HIX infections still occur to a large
extent among people who migrated
outside the province. The first waves
of HIX AIDS patients were men who
returned from blue-collar work out
side the Province. Then, an increas
ing number of sex workers came
back with AIDS. Given the incubation
period of HIX’, that pattern depicts
infections acquired five to ten years
ago. and current infections may fol
low a different path.- However, the
pattern is likely to remain highly rel
evant, as men continue to migrate for
work, still go to commercial sex
establishments and do not use con
doms consistently with commercial
sex workers. Still 40 per cent of 1997
military conscripts had visited a com-
Progress in P ?yao may be stalling
mercial sex worker over the past 12
months. Among them. 41 per cent
had not used a condom consistently.
The comparable figures for male
labourers are 22 and 34 per cent,
respectively. Moreover, significant
numbers of men report having had
sex with men (Figure 36). and that
most of that sexual intercourse was
unprotected (Figure 3"’). Consistent
condom use by men having sex with
men was 38 per cent among male
labourers (five per cent of these men
reported sex with men over the past
12 months). The corresponding fig
ures for conscripts were 2 i and six
per cent.
hardly comes as
Figure 36: Proportion of men reporting having had
a surprise, as the
100 per cent con
sex with men in previous 12 months
dom policy is not
implemented at
(per cent)
100 per cent,
25_____
22.9
with the result
20
that, while the
□ 1995
15 —
client who uses
0 1996
9.9 10-6
10
condoms is pro
6.9
■ 1997
5
tected. the sex
2.6
0
worker is still at
military conscripts
risk from those
labourers
secondary school
clients who do
students
not use condoms.
(Given the high mobility of commer
difficult to remain abreast of dlc
cial sex workers, they may have
new
‘spots". However, while the -indirect"
acquired the infection in another
commercial sex activity is a source of
province).
real concern,
turnover is
concern. customer
.
bkely
to
he
much
lower
than
in com
be
In addition to commercial sex estabmercial
sex
establishments,
leading
to
lishments, sex workers
• increasingly
relatively
le‘ss new infections.
offer their sendees in ;
some restaurants,
karaoke
bars, traditional
massage parlours
use by men when having
and motels. The
12 months
province has no
known commer
(per cent)
cial sex establish
100~i--------ments
offering
100
□ 1995
sendees by malesT
50-41-2
Men would pick
37.5
D
1996
29.4
37.5
up young men in
■ 1997
karaoke bars and
0-L
restaurants. This
military conscripts
is a changing
labourers
secondary school
students
scene and it is
-no6-9
LJdBL
Some women haw rectal STDs, an
indication that anal sex is practised
w ith women as well. Women w ho left
the province for commercial sex w'ork
continue to return with HIV from
other provinces and from other coun
tries. When asked about their previ
ous occupation. 14 per cent of preg
nant women delected with HIV infec
tion in 1996, responded they had
worked in the commercial sex indus
try.
Not all people have been infected
with HIV outside Phayao. Many get
infected within the province, through
sex both outside and within marriage.
Commercial sex activity still exists.
The HIXr prevalence among commer
cial sex workers in Phayao is about
60 per cent (Figure 38). This high rate
4
58
I Tri
• .
is
Progress in Phayao may be stalling
Progress
Phayao may be stalling
t
Figure 38: Proportion of male respondents reporting
casual sex in previous 12 months
II
per cent)
60
In Phayao, most new infections may now be
acquired within marriage.
I
Figure 39: Proportion of consistent condom use
among men when having casual sex in previous
12 months
57.1 52.2
□ 1995
(per cent)
40--
■ 1996
25.0,
I
20-0u
military conscripts
18.2
I
labourers
4.6
1997
62,5
80
3.1
60
secondary school
students
44,1
38,6
33,3r_M
37,5 36,7
40
■ 26,2
□ 1995
28,6
■ 1997
20
Injecting drug use exists in Phayao Province (and
is reported principally in Pong and Chiang Kam
districts). A few HIV infections are attributed to
injecting drug use since the outset of the epi
demic in Phayao. Over the last quarter of 1997,
45 heroin addicts were treated at one of the drug
rehabilitation clinics. There are no community
based data on the prevalence of injecting drug
use. Use of non-injectable drugs such as amphet
amines appears to be widespread, leading to
concern that some users might shift to injecting
drugs.
Some infections are acquired through casual sex,
as significant proportions of both male and
female respondents in the Phayao behavioural
surveys report having been in that risk situation
over the past year. Contrary to the speculation
that men would turn more to casual partners
after giving up visits to commercial sex workers,
Phayao behavioural surveys do not indicate that
casual sex is on the increase - rather the oppo
site (Figure 38). Condom use in those structures
remains low (see Figure 39).
o>—---
military conscripts
|
■ 1996
labourers
1
secondary school
students
There is limited evidence that about 20 per
cent of the partners of women with HIV are
not infected. Assuming that 50 per cent of the
2500 women aged 25-35 (10 per cent of the
population. HIV prevalence five per cent) liv
ing with HIV are married, this would translate
into 250 men living with an HIV-positive wife.
The same assumptions about marriage ratio
and ratio of discordance would translate into
500 uninfected wives of men. aged 25-35 liv
ing with HIV. Some 750 spouses would live
with a person with HIV in that age category
alone.1
In addition, approximately 280 HIV-positive
women in Phayao (or five per cent of the popu
lation of pregnant women) gave birth to an esti
mated 70 infected children (1997).-
61
in rudyao may De stalling
Progress in Phayao may be stalling
fib
fj
Much remains to be
done on the social
front
More progress is needed on the social
front as well. People with HIX' AIDS
observe that unaffected families still
look down on them. They find it diffi
cult to have access to credit and to
insurance. They are unable to become
monks even for short periods: only 1]
per cent of the chief monks inter
viewed allow people with HIX' to
become monks. Still JO per cent of the
businesses interviewed use HIX' status
as a recruitment criterion. Parents
known to have HIV still have a hard
lime sending their children to pre
school.
Fundamental causes of vulnerability
persist.
The first source of vulnerability is the
lack of information about one's HIV
status. Most people know only too late
that they have HIV: when symptoms
of HIV lead doctors to perform an HIV
test. By then, they may have unknow
ingly transmitted HIV to a person they
love. Only couples attending premari
tal counselling, pregnant women, and
people applying for overseas work get
a test early on. Similarly, communities
are only informed of the occurrence of
HIV when people are sick or die. They
■
.
-•
A second source of vulnerability is
silence about sexual matters. “We do
it: we don't talk about it!" Here, as in
so many other pans of the world, men
and women have not learned how to
discussmatters pertaining to sexuality.
In a way, everyone lives in a make
believe world. Fathers pretend that
their daughters work as maids and
entertainers, but not as sex workers.
Wives want to believe that their hus
band is different and does not cheat
-on them. Giris, who declare in an
interview they would never engage in
sex work, will say a few minutes later
that they performed such work before.
The issue is how to break the barrier
of silence without breaking relation
ships, how to face reality without
being overwhelmed by it.
villages may be more vulnerable to
HIX than others depending on
whether villagers own the land or not.
of the couples use a contraceptive
method, condoms are not used for
contraceptive purposes. A partner pro
posing to use a condom will immedi
ately be suspected of promiscuity.
Women will tell their partner: “What?
Do you think I am a prostitute?"
A fifth source of vulnerability comes
from ill-adapted social norms, both
old and recent. For example, girls
engage in commercial sex work not
necessarily out of sheer poverty, but
out of a deep desire to help their fam
ilies. In today's materialistic lifestyle,
their desire translates into building a
new house and/or purchasing con
Now comes the hard part. As we saw
sumer appliances. Tradition values
in
the section on Turning Crisis into
girls who support their families effec
Opportunity (page 45). those who
tively. In such a context, usual pre
would adapt to HIV and AIDS on their
scriptions. such as increasing female
own have done so. For many people,
literacy - may not work as effectively
however, whether individuals or com
as modifying their attitudes. “We love
munities. general information about
to come to school, and to learn
AIDS and mass distribution of con
English: that way, w'e will become
doms is not what they need. They
super stars, and earn more money”,
either need personal information about
answers a girl to a scholar studying the
their own status, need general infor
link between sex work and school
mation
of a different kind, or resist to
education. Only when society stops
behavioural change altogether.
expecting that girls materially help
their parents will the pressure on them
Most people living with HIV are not
be released.
responding to their concrete situation
because they are unaware of their sta
New’ social norms may be ill adapted
tus.
What they need is access to early
as well. The 100 per cent condom pol
testing
and to counselling, to help
icy in commercial sex establishments
them
in
assessing and acting on their
has portrayed the image that condoms
own
factors
of vulnerability that put
are only good for use in those circum
themselves and others at risk.
stances. As a result, people associate
condoms wdth commercial sex, and
Some people might not consider
perceive them as unacceptable in a
themselves
: risk:
' ’ for instance they
at
loving partnership. While 90 per cent
might be unaware of casual
------- 1 sex or
Now comes the
hard part
-
»
A third source of vulnerability is the
use of drugs, in particular alcohol.
While there are no data on alcohol use
in Phayao Province, alcohol is con
sumed on a large scale.
A fourth source of vulnerability is lack
of land ownership and migration. In
focus-group interviews people make a
clear link between lack of land own
ership, migration and HIV/AIDS. Some
62
•/
only see “the tip of the iceberg" and
might take more forceful steps to
respond to HIV if they were appraised
of the full extent of HIV infection in
their midst.
M.
rfsfefcags
63
-
r
Progress in Phayao may be stalling
anal sex as situations of risk for HIV
transmission.
Others are “late acceptors" or “resis
tors” to behaviour change whb have
yet to face the implications of the
advent of AIDS in their lives23.
Injecting drug users and men who
persist to have unprotected sex in
commercial sex establishments fall in
that category. More radio shows and
more mass information will not help
such people. To help people face their
reality and deal with it. personal and
peer-based, rather than media-based
approaches will be needed, combin
ing interventions from various sectors,
mixing information, senices and
changes in social norms.
From progress to success: a
triple strategy
Despite evident progress on HIV/AIDS
in Phayao. that progress has been
stalling in recent years. To turn
progress into success, a triple shift is
required:
focus on people, including people
with HIV AIDS as key participants to
the response to HIV/AIDS:
generalize early testing and coun
selling. to allow more people to adapt
to their own situation;
create packages to combine the sup
port from various sectors to key par
ticipants to the response to AIDS.
Focus on people: who might make a
difference?
From the scenario described in the pre
vious chapter, key participants to the
response to AIDS can be identified. For
the immediate future, it is clear that the
following people could contribute most
to further progress on HIV/AIDS:
•
people with HIV/AIDS, including
pregnant women-,
•
departing and returning migrants,
both male and female:
•
youth;
•
men who have unprotected sex in
commercial sex establishments;
•
men who have sex with men;
•.
injecting drug users.
w
Progress fn Phayao may be stalling
Pregnant women with HIV now have
the chance of preventing transmission
of HIV to their babies. For that pur
pose, the Phayao Provincial Health
Office has organized support to preg
nant women with HIV with encourag
ing results. From October to December
1997, almost 100 per cent of the 1177
pregnant women attending antenatal
clinics in Phayao Province accepted to
be tested for HIV. Some 62 per cent of
those women found to have HIV
received
zidovudine
prophylaxis,
(hereby preventing an estimated six
cases of pediatric AIDS in a four-month
period. Preventing 24 cases of pediatric
AIDS per year has to be done. This
intervention will, however, have no
impact on HIV incidence, estimated at
99 new infections in Phayao in 1997.
young people, both young men and
women, whether at school or out-ofschool. Only by keeping the new
cohorts of young men and women
free of HIV will Phayao sustain
progress. Both young men and young
women need to be considered. Even
if in Phayao Province many young
girls engage in sex work, more young
men are infected with HIV than young
women. Young people of both gen
ders will have to look at their specific
factors of vulnerability (which will no
doubt include drug use), and act on
them.
Men insisting on unprotected sex
Commercial sex workers have been
and are playing a major role in the
progress observed to date. They are
not the problem. They are part of the
solution, as they attempt at protecting
themselves, their future children, and
their customers. Direct sex workers-'1
can make the greatest contribution to
progress, because on average, they
serve a greater numbers of clients
than indirect sex workers.
The issue is to reach core resistors to
condom use among their clients: men
who despite years of information and
despite their experience of AIDS in
the community continue to have
unprotected sex in brothels. It is even
more coiftplicated by the fact that
most visits for commercial sex take
place outside the province.
Departing and returning migrants
People irith 11IV and AIDS
People with HIV are not the problem;
they can play a great part in the solu
tion.21 We know that given appropriate
testing and counselling, people with
HIV AIDS will prevent transmission of
the virus to the ones they love: their
sexual partners, and for pregnant
women, to their future children.2"
The more people will know their sta
tus. the more effectively will they
respond to HIV. This however sup
poses that, through its various institu
tions, society holds to its part of the
deal.
64
y-
The greatest antidote against HIV in
Phayao might be AIDS-sensitive eco
nomic development, which would cre
ate economic opportunity within the
province. Migration, however, is not
likely to end any time soon. The issue,
therefore, is to reach migrants before
they depart and after they return, to
encourage them to protect themselves,
their loved ones, and society at large.
Young people
The future of the epidemic is of
course determined by the response of
65
- '•
Progress in Phayao may be stalling
Men who have sex with men
Meanwhile, the specific needs of men
who have sex with men will need to
be addressed. Furthermore, the prac
tice of anal sex with women must be
assessed and eventually addressed.
Injecting chug users
Currently, Phayao has no information
about the extent to which injecting
drug use contributes to the epidemic in
the province. This practice needs to be
ascertained and harm-reduction pro
grammes need to be put in place.r
Generalize early testing and coun
selling
to individuals and couples
•
to the community
result, a very substantial proportion of
new infections in the province proba
bly takes place within marriage.
Yet, a significant proportion of such
“discordant” couples will use condoms
if they know their situation. Discordant
couples who don't know their situation
won’t, unless all couples change their
attitudes towards condom use. A
change in attitude among all couples is
unlikely to happen at a sufficient scale
any lime soon.*
Discordant couples have a strong
incentive to override current negative
perceptions against the condom.
*
i
The detection and counselling of dis
cordant couples could be carried out at
least on four occasions:
Early testing and counselling can be
applied in two ways:
•
♦
Early testing and counselling of
individuals and couples
Currently, most testing and counselling
is done for people who have HIV.
Hence they are tested many years after
the outset of the infection, and the
probability is great that they have trans
mitted the infection to people they
love, simply because they did not
know that they were infected. As a
Progress in Phayao may be stalling
Such pressure does not seem to exist
for remarriages. Most widowers and
widows (many of them ha\ ing lost their
spouse from AIDS) remarry without
checking their HIV status or that of their
partner. Overall, premarital testing and
counselling cover only a small propor
tion of the total number of marriages.
As data are kept individually, and not
per couple, it is difficult to assess either
the proportion of discordant couples
among clients, or their decisions regard
ing marriage once they are appraised of
the test results. Most discordant cou
ples, however, decide not to go ahead
with their plans to marry.
The advantages of early counselling
would not be limited to the couples.
Indeed, the process of counselling
applies to communities as well, and
would produce great benefits.
This raises a major public health issue.
If premarital testing and counselling
were covering all marriages and would
systematically result in discordant cou
ples not marrying, people with HIV
would then never find a stable sexual
partner until they find a person who
has HIV as well. This is already taking
place to some extent, as some people
with HIV find a partner in self-help
groups. Social pressure for discordant
marriage candidates not to marry
should be addressed; measures for facil
itating marriages among people living
with the virus should be considered.29
Premarital testing and counselling
Family planning consultation
There is growing social pressure in
Phayao for young people to test for HIV
before they marry for the first time.
• With a contraceptive prevalence rate of
more than 90 per cent, family planning
clinics represent a major entry point for
•
premarital testing and counselling
•
family planning consultation;
•
the ante- and post-natal clinic;
•
on first detection of HIV infection.
While women typically refuse to share
with their partner the news of their
infection at the time they learn about it.
it might be possible to convince women
after delivery to do so. before the)- are
likely to resume sexual relations.
On first detection of HIV infection
The diagnosis of HIV represents
another opportunity for detecting dis
cordant couples. This may have impor
tant benefits, as the infection of people
with HIV is likely to increase when
viral load increases. Other opportuni
ties include blood testing at anony
mous clinics.
Community counselling can be consid
ered in three contexts:
67
■
Ante- and post-natal clinic
Community counselling
ft
66
detecting discordant couples. Providers
of family planning consultations could
promote counselling and testing for
HIV as a matter of course. The problem,
however, is that women come alone to
family planning clinics. The first step
towards implementing this strategy
would consist in insisting on the joint
responsibility of couples for their repro
ductive health, and therefore in system
atically inviting men to join their partner
for family planning consultations.
%*
■Ml
Progress in Phayao may be stalling
•
villages and neighbourhoods:
•
among peer groups;
•
at the tambon level.
Vilkiges and neighbourhoods
In addition to early counselling of cou
ples and individuals, communities could
be further empowered for action. That
empowerment starts with information
on the level of HIV prevalence.
Communities are only aware of the ’tip
of the iceberg": (hey typically know who
in the village has AIDS, but have no
knowledge of the prevalence of HIV. At
this stage of the epidemic. AIDS cases
represent only alxiut ten per cent of the
prevalence of HIV (sec Epimodel
Projection in Annex .3). Communities
could be given that information, on the
basis of the average prevalence in the
district. However, communities would
be further empowered if health-care sys
tem providers were to inform them of
the actual prevalence of HIV (obviously,
without disclosing the identity of those
who have HIV). This may be important,
as there is strong suspicion that commu
nities are not equally vulnerable to the
epidemic. This information would stim
ulate communin’ members to analyse
their specific factors of vulnerability and
of risk, and to act on them.
HIV/AIDS who participate in self-help
groups. The province could provide
support to the development of more
and stronger self-help groups of people
with HIV/AIDS, as more and more peo
ple would be aware of their status. At
the same time, the province could
reach out to, and build on existing net
works of sex workers, men who have
sex with men and injecting drug users
to assist in the joint analysis of risk and
vulnerability, and stimulate action to
tackle tb^se factors.
This supposes that sulxlistrict level staff,
in health centres and in other sectors
have the skills and attitudes to facilitate
(and not control) such joint analysis (see
next section). Further, (he empowerment
assumes that communities and sell-help
groups can wield sufficient Financial
resources and services in support of their
response to HIX’ AIDS.
Joint assessment, analysis and action
at Tam ho n (suh-districl) level
Health centre staff would play a pivotal
role in this process, as they have privi
leged access to HIX’ AIDS-related infor
mation. Communities would look at
general factors of vulnerability and risk,
while existing groups of people with
HIV/AIDS and of young people would
analyse the specifics of their situation,
and their specific support needs they
require for effective action. The synthe
sis would take place at the level of the
Peer group counselling
Peer group counselling is already being
carried .out among people with
68
I
Progress in Phayao may be stalling
local
Tambon
Administrative
Organizations, where action plans of
communities and of specific groups
would be reviewed and assessed.
Representatives of the various sectors
and members of the community would
make specific commitments in support
of the action plans of the various key
participants in the response to HIV and
AIDS. The Tambon Administrative
Organization would not control the
process, but rather ensure that each
party delivers according to its commit
ment. Health centre staff, community
leaders and incmlxrs of the self-help
groups would assist the Tambon in
monitoring effective implementation of
the plan.
the response to HIV/AIDS, and would
receive an indicative list of possible
additional commitments from various
sectors, with the costs to the Tambon
of the commitments.
How would such a difference
be made? Combining multi
sectoral support into packages •
That is where Phayao institutions can
make most progress. Seen from above,
projects cover on aggregate the whole
spectrum of activities characteristic of a
holistic response. However, the sup
port people receive from institutions is
still fragmented.
Whatever support people get depends
on the ability of local institutions to
formulate projects, and to submit them
to the Provincial AIDS Committee. As a
result, people with HIV AIDS have
access to a day-care centre only in two
districts. Projects to reduce the vulnera
bility of young girls still reach only a
minority of them. A few health centres
offer counselling and testing services;
most do not. Building on ten years of
experience. Phayao Province can now
define packages of interventions in
support of key participants to the
response to HIV AIDS, and strengthen
local management to ensure their com
bined delivery.
The proposed process of community
counselling would work best if institu
tions from various sectors effectively
supported community action to reduce
factors of vulnerability and of risk.
Rather than continuing to develop sec
toral projects, institutions would need
to focus on combining their support for
key actors in specific communities, in
their response to HIX’ and AIDS.
To tailor the action plans to local
needs,
Tambon
Administrative
Organizations would use their own
budget, for which they are acquiring
increased autonomy. They would be
informed of the existing commitments
made by the various sectors in the
province to the various key partners in
»* *
Given the particular contribution of
people with HIV/AIDS to further
69
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o s 3
S-
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rS
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-
■2 °
2 3- c
EH
5>n> O
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Table 9. Example of a package (multisectoral support to people with HIV/AIDS)
Level
District
I Health Care
Education
Religion
Labour
IPD* and OPD’ Testing and
________
Secondarz
counselling Referral care Day-care children of people with
Social welfare
District office Target job
District office Approve funding
opportunities to most vulnerable for poor families affected by
communities Inspect non
HIV/AIDS
discrimination at the work place
Centre Palliative care and referral HIV/AIDS
care Croup therapy Meditation
practice Referral to other sectors
Support to self-help groups
Sub-district
Health centre Testing and
Primary Admit children of
Tambon agent Job training Education
people with HIV/AIDS Temple grants Small grant for capital
Of Counselling of self-help
allow people with HIV/AIDS as investments
groups Referral of issues to TAO' monks Welcome self help"
counselling Palliative care and
and other sectors Supervises
home-based care
Village social welfare Assist in
application for funding Provide
monthly subsidy
groups for activities in the
temple Support basic needs
such as shelter and food
Traditional therapy,
counselling, meditation
Community
VHW* and home nursing Follow Nursing Schools Admit
up on therapy Psychological
Children of people with
support Help in daily activities Sell HIV/AIDS
help groups Information on care
Encourage members to comply
Families Invite people with HIV/AIDS
I amities Recruit people with
in ceremonies and solicit their playing
a role
Village Leader Encourage self
HIV/AIDS in family businesses
Purchase goods and services
from people with HIV/AIDS
job creation Detect and report
with standards Participation in
help group activities Supports
exploitation-of people with
HIV/AIDS by crooks and
charlatans Families Support
community counselling
basic needs: such as shelter
and food
• IPD: In-patient department
OPD: Outpatient department
Ol: Opportunistic infections
TAO Tambon Administrative Organization
VHW Village Health Workers
t
.•
.
■■
_
..
-
*
Progress in Phayao may be stalling
Getting the most bang for the
baht
Moreover, the importance of achieving
strategic specificity is enlianced by the
current financial crisis. In 1997, the
provinces budget for HIV/AIDS was
reduced. Most of the public resources
were coming from the HIV/AIDS budget
of the Ministry of Public Health. That
budget will likely lx? reduced further in
the following years. At the same time,
other ministries arc going to lx? cut even
more, so that there is little hope for these
ministries to shoulder a greater propor
tion ot the HIV AIDS budget. Hence, the
need for a cost-effective strategy lx?comes
even more apparent. The direct involve
ment of the community, as descrilx?d
abo\ c, could lx? highly cost-effective.
On our path towards success, we pro
pose objectives to the people of the
Phayao. These objectives are ambitious,
but we believe that together, we can
achieve them:
• within five years, young people
would prevent themselves from
acquiring HIV7, as demonstrated by
HIV prevalence levels among con
scripts and primigravidae below one
per cent;
•
the incidence of pediatric AIDS will
decline by 50 per cent;
•
more than 80 per cent of people
with HIV/AIDS would lx? satisfied
with the quality of their lives;
•
more than 80 per cent of communi
ties in Phayao Province would rou
tinely assess and act on local causes
of vulnerability and risk.
I
Daring to aim at success
I'hcrc is a need to generate a vision of
success, which would mobilize people
in their private and public lives. That
vision might lx?:
One day in Phayao, HIV AIDS ivill
become a minorproblem, because tie all.
in our private and our public lives, ivill
have learned the lessons of the epidemic.
Then, whether injected or not. ive will be
able to live with HIX ' and AIDS.
To transform this vision into reality, we
need to implement the above strategy
effectively. Much will depend on the
capacity of the health sector, particularly
at the local level. In the next section, we
will scrutinize the health-care reform
now being undertaken in Phayao. and
propose specific measures for ensuring
that the reformed health-care system
passes the HIV test.
73
'
1
t-
Passing the HIV test
Linking HIV with
health-care reform
/T,o enable further progress on
-L HIV/AIDS. profound health
■
L
’
■
•' «\ J
-. ■
F----
■
■ 'x >
■
1^ -
i
Ry- d
care reforms are needed. The advent
of AIDS is challenging the health sec
tor at the level of purpose and roles.
AIDS reminds us that the purpose of
the health sector is not just to achie\ e
better health outcomes through the
delivery of health-care packages.
Society docs not only expect the
health sector to provide care. The
health sector has to counsel indi\iduals .and communities, and catalyse
other sectors towards action for
health. These latter roles have been
advocated since Alma Ata. Now. how
ever. it is a matter of life and death
that ‘health" effectively plays those
roles: no other sector will jump in.
Il will not be an easy task. First.
counselling individuals and commu
nities
throughout
the
province
requires major changes in structure
and process of a system used to con
trol disease rather than influence
other peoples behaviour. Secondly.
reaching out to authorities and col
leagues from other sectors constitutes
a hard task for health workers who
are easily fitting in vertical chains of
command. Thirdly, the incorporation
of HIV/AIDS-related procedures into
“the core health service”, the stan-
7S
dards for health-care system output in
Phayao. remains a challenge. The
entry point for this triple adaptation
of the health sector has to be the
health centre. At the interface with
communities and close to the
Tambon. the health centre is ideally
placed to cllectixely implement the
required changes. To develop excel
lent. AlDS.-compclcnt health centres.
Phayao will need to make profound
changes in its management structure
and further develop its human
resource strategy.
I he health-care reform now under
way in Phayao is described in more
detail in Annex 1.
(aiteria lor the overall success of
hcahh-carc reform in Thailand and in
Phayao arc being dcxcloped. Por the
Phayao Provincial Health Office,
however, one criterion of success is
clear: the reformed health-care sys
tem has to pass the HIX’ test". It must
be more competent to deal with HIV
and AIDS, for two reasons. First, the
system has to be competent to
respond to AIDS, the first cause of
mortality in the province. Secondly,
AIDS is typical of the socio-behavioural problems that the system has to
address more effectively through its
reform. The response to HIV/AIDS
over the past ten years may harbour
many lessons that apply to health in
general.
Passing the HIV test
Passing the HIV test
r-
How IIIV/AIDS
challenges health
care reform
AIDS forces health reformers to re
examine both the purpose and the
roles they typically ascribe to the
health sector.
The purpose of health-care
systems
Faced with the AIDS crisis. Phayao
Province did not aim solely at health
status improvement. Yes, the preven
tion of HIV transmission and the
.related reduction of disease and mor
tality due to HIV were fundamental
objectives. But the PPHO saw as
equally important the improvement of
the quality of the lives of people with
HIV AIDS and their families, and build
ing the capacity of individuals, families
and communities to deal on their own
with HIV and its consequences.
AIDS is modifying Phayao s vision of
health. Prolonging life and reducing
morbidity are not the only purpose of
health care systems, and of health-care
reform. Producing health-care proce
dures, “interventions", is not its only
output. Health-care reform has to aim
at more than good health status. As
soon as one accepts that people, not
health-care systems produce health.
then one realises that relief from suf
fering, irrespective of health out
comes, and autonomy, the capacity of
people to maintain their health on
their own, become equally important
purposes of the health-care system.
*
If autonomy and relief from suffering
are equally important goals assigned
to the health sector, then its capacity
to counsel individuals and communi
ties, and to mobilize other sectors
becomes even more important.
Source: Zeldin-'9
AIDS is not just challenging the pri
vate behaviour of individuals. It is
challenging professional behaviour of
health workers as well. From tradi
tional training, nurses and doctors
have been led to think that they were
in control. AIDS is telling us that they
are not, but that people themselves
are in control. We thought we were
powerful. We now realize our limita
tions a little more. Health workers are
used to ask people to participate in
their health programmes. Now, health
workers have to realize that they
have to try to play a small part in
people's lives, and to play it well.
There is no easy way for achieving
this transformation.
Develop a new and shared understanding of
health, and modify the mode of interaction with
individuals and communities. These seem to'be
the two avenues for effectively achieving this
transformation. On the basis of the experience in
Phayao, here are a few lessons learned for
achieving the required shift in health workers’
attitudes and behaviour. Training will not suffice
to obtain the required attitude changes through
out the system. Constraints in strictures and
processes have to be addressed as well.
•
The role of health-care
systems
Communities, individuals and
counselling
‘Give me a place to stand
on'. [Archimedes] said, and I
could move the earth
Intermediariesfolloic that
principle: the tcayfor the
weak to move the strong is
not by force but by modifying
their relationship, changing
the angle of approach.
Il needs to be written in job
descriptions.19
f
Ms Saowanee, Chief of the
AiDS/STD section in Phayao
Provincial Health Office
Train staff to think by them
selves. assess situations and
design responses. Rather than
being told what to do.'6
Dr Petchsri Sirinirund, Phayao
AIDS Action Centre
Formally recognize that individual and group
counselling is a legitimate use of staff.
Traditionally, counselling (and before, health
education) was seen as "soft". The ‘real work"
would involve interventions, involving consump
tion of material inputs, with some measurable
output: a Cesarean section, an immunization, for
instance. Now. we have to recognize that the
process of counselling itself is the output, to give
time and ample space for that activity, and rec
ognize best performers.
•
Give staff the necessary autonomy.
Empower staff with the responsibility, the related
authority and the skills to integrate all information
regarding a particular patient, and put it in the
context of his/her family and community.
Empower staff to participate in community assess
ment of health problems including HIV/AIDS.
•
Trust a priori.
If health workers have to let go of their control,
and accept that their clients will decide what to
>7
Passing the HIV test
f
Passing the HIV test
*
»
do, then their superx isors too have to let
go. Their trust in their staff is the main
fuel for their staff self-confidence. Self
confidence is critical to the performance
of their new role as facilitators in per
sonal and community decisions. That
trust, however, should not be under
stood as a “free for all" attitude. Trust
should be accompanied xvith a clear
understanding of tasks to be performed,
and support to the resolution of prob
lems encountered in the implementation
of those tasks.
•
•
Foster happiness co learn.
socially recognized commercial sex workers to
consult. Make sure that curative consultations in
health centres and outpatient departments allow
for a private discussion. Now those consultations
are sometimes done in the presence of others, or
behind a simple partition. This is perhaps accept
able if the health centre cares for babies xvith
measles, but not to give the chance to the mother
to share her anxiety that her husband might be
transmitting HIX’ to her. Similarly, make sure that
patient loads alloxx for a prixate discussion.
Currently, in Phayao outpatient departments, staff
hardly have the time to address the patient s main
complaint. How can they possibly take the time to
pul that complaint into a more holistic context?
Maybe the key is tc change staff atti
tudes towards learning - to make staff
understand that there is much wisdom
out there in the conmuiniry-. that they
can grow personally c they are eager to
learn at the contact wnh the people they
are serving.
Training is not the or_s avenue towards
staff development. Constraints in struc
ture and processes need to be elimi
nated if they are to p-iy their new role
effectively.
Training in understanding self.
Beyond technical skills, training has to
encompass key aspects of human devel
opment. This includes training in core
management functions, but also in key
spiritual values and skills. To be able to
counsel others, one has to be at peace
xvith oneself. To understand others, one
should start with understanding oneself.
•
Organize patient flow to encourage
privacy and confidentiality.
•
For example, open STD clinics in places
and at limes that are convenient for the
clients. Now, the STD clinic is located in
the Phayao Provincial Health Office,
making it difficult for anyone but
At first, around 1992, the role of the counselling clinic was unclear. Counsellors
would tend to rebuff people with a positive HIV test, because ue lacked the self
confidence to provide counselling to them. As numbers increased greatly, we
would have to deal with 50patients a day. Eventually; we became depressed, and
burned out. In 1994. I was saddled with stress, anger and ueakness. I would
argue with my husband for no reason, and started drinking. In 1995. I told my
boss I wanted to quit. My case was not the only one. So, the Phayao Provincial
Health Office set up a special coursefor us. We received training in self- andfam
ily psychology. Now 1 feel that I am a new person. Now that 1 know how to help
myself I think I know better how to help others.^'
Khun Nongkrem Meesub, Technical Nurse at the Dokkamtai Community Hospital.
78
Include the clients' perspcctixc in the review
of staff performance.
Develop an objective and transparent xvay for
clients, including people xvith HIX' and AIDS, to
give feedback on staff performance and attitudes.
Link this assessment with stuff promotion.
We see that the Tambon is
ver)' busy building roads. 1
wonder who will travel on
those roads, if they don t do
anything to help us stop
AIDS? 9
A person with AIDS during a
focus group interview
Catalysing other sectors
To respond to HIX’ AIDS effectively, people need
the combined support from many sectors. Health,
howexer. has a specific role to play. With support
of the co-ordinating authority, the health sector is
uniquely placed to catalyse other sectors: to reach
out and make them respond to the challenge
AIDS places on their own core business. In a first
phase, other sectors typically respond to AIDS by
replicating activities that are usually done by the
health sector. For instance, agricultural extension
workers would once in a while include an “AIDS
talk” in their discussions with farmers. While
79
■
...
JBL
Passing the HIV test
worthwhile in itself, this does little to
bring the support people would need
from the agriculture sector. This
requires that each sector adapt its core
business to the advent of AIDS. For
instance, an agricultural extension
worker would discuss what labourintensive crop the same farmers could
introduce to keep more young people
in the village, or how severely affected
families could adapt their farming
activities to the presence of people
with HIV AIDS in their midst or to loss
of their main breadwinner, rime is ripe
to try (his approach in Thailand, and
more specifically in Phayao.
Eliyl, the i-ighth National Social anil
l-conomic Development Plan puts peo
ple at (he centre ol all dcxelopmeni
activities. When advocating that each
sector review how AIDS affects its core
business, (he Phayao Provincial Health
Centre can count on the support of top
authorities.
Secondly, the 199’ Constitution calls
for the strengthening of the Tambon
(sub-district) level ot the administra
tion. through the creation of the
Tambon Administrative Organization
(TAO). Formerly, the Tambon was in
charge mainly of implementing infra
structure projects, such as building
roads. Now, the TAO will be in charge
of supporting all aspects of develop
ment. and will be authorized to retain
and spend some tax revenue.
Passing the HIV test
Thirdly. Phayao has learned how to
collaborate among sectors at the
provincial level (see Turning crisis
into opportunity). This is a major asset
when it comes to encourage local level
collaboration.
Instruction from the top to collaborate
at the local level will not suffice.
Somebody has to catalyse sectors
locally. Given the necessary authority
and skills, health centre staff are best
placed to play (hat catalytic role. Once
(hey play (heir counselling role effec
tively, they will combine technical and
local knowledge in a unique fashion.
Health-care reform represents a unique
opportunity to recognize the potential
ot local health staff to play a catalyticrole in the response to health prob
lems including HIV/AIDS. and to
explore effective implementation of
that role.
Providing HIV/AIDS-related care
To be able to counsel communities
and catalyse sectors in response to
HIV/AIDS. health staff have to be rec
ognized as competent care providers.
Two issues need to be resolved in that
respect: the inclusion of prex-entive
and curative care for HIV in the core
health service, and the organization of
continuity of care throughout the
health-care system.
Core health service: from minimum
to optimum
♦
With the help of the Phayao health-care
reform team, the Phayao Provincial
Health Office intends to guarantee to
its constituents access and quality of a
specific set of health-care procedures,
called, the core health service. The
province faces a choice: either continue
the work it has undertaken following a
normative path, or go along a positive
path instead. By following the norma
tive path, the health-care reform team
would fully det inc in theory' the core
health service, including its costs and
financing before it is implemented.
Alternatively, it is considering adopting
a positive path, whereby it would
define content, costs and financing of
the core health service in the process of
its implementation.
So far. a list of activities to deal with
the top ten health problems has been
developed. The specific tasks (or stan
dards of work) constituting each activ
ity are now being identified. For the
inclusion of HIV/AIDS-related activities
in the core health service several con
cerns will need to be addressed.
Elfst, costs of care for HIV/AIDS could
easily correspond to the total health
care budget. As a result, the Phayao
Provincial Health Office would not be
able to ensure access to the core
health service. In selecting HIV/AIDS-
related procedures in the core health
service, the Phayao Provincial Health
Office needs to know with what ele
ment of the core health service those
procedures are competing. This is not
possible if the core health senice
addresses only the top ten priorities.
To address that issue, the health-care
reform team would need to develop
the full list of procedures included in
the core health service, and not just
those related to the top ten health
problems. The next step would then
consist in defining the costs of per
forming each task. Finally, the health
care reform team would fine-tune the
core health sen’ice to ensure that the
constituents of the province can afford
it through a mix of public and private
financing.
Secondly, the health-care reform team
would need a method for selecting
procedures that would consider their
impact on people’s quality of life and
autonomy. On the basis of reduction of
morbidity and mortality as the only cri
terion, very little palliative care and
treatment of opportunistic infections
would be included in the core health
service. In that case, health-care
resources would be better allocated to
other procedures with a greater effect
on mortality and morbidity. How then
could the health-care reform team pro
ceed with the definition of the Phayao
core health service?
I
passing the HIV test
JL
mifitfihr im'------ -Trr --,,.
Passing the Hiv test
?■
I
Figure 40: Defining the budget for the core health service
■
The Phayao Health
Care Budget
10 %
90 %
Administrative
Costs 10 %
Funding the Core
Health Service
I
60%
30%
Reduction of
Mortality and
Morbidity
Reduction of
Suffering Increased
Autonomy
'I
A proposed approach follows for dis
cussion before it is tested as part of
health-care reform activities. (See
Figure 40).
ElLsl. the health-care reform team
would determine the public budget
available to support the core health
service. This it would do by deducting
from the total provincial health
budget a proportion allocated to
administrative costs, using the current
breakdown as baseline, and taking
into account planned efficiency gains
in administration.
Secondly, the health-care reform team
would determine the proportion
j—
of
the provincial health budgett to be
allocated to procedures aiming at
^educing mortality and morbidity,
' ’ >isa
This
political decision, which the
team would facilitate through a
review of practice elsewhere and by
consulting constituents through a
series of public hearings.
Thirdly, the health-care reform team
would exhaust the budget for the
reduction of mortality and morbidity
by selecting the most cost-effective
procedures. These are technical deci
sions involving public health special
ists and health economists.
fourthly, the health-care reform team
would allocate the remainder of the
budget to activities most likely to
reduce suffering and to enhance people s autonomy. These technical deci
sions would need the support of
health economists, medical doctors,
nurses, and development specialists.
EU'thly, throughout the process, the
health-care reform team would unsure
adhesion of all parties to the core
health service by holding regular pub
lic hearings, including of specific
groups such as people with
HIV/AIDS.
The output of this elaborate process
would consist in a blueprint for a core
health service, including cost and
financing of its elements. This has
been done elsewhere, most recently
in Zambia.30 The development of the
blue print has led to a common
understanding among a multitude of
partners of what services the
Government would guarantee to its
population. However, the “proof is in
the pudding ’, in this case in the effec
tive implementation of the package.
Why not then define the core health
sen ice by trial and error, through the
implementation of all its elements at
the various levels of the system? Costs
and financing possibilities would be
assessed on the basis of experience,
rather than in theory. This would
mean, however, that at least one unit
at each level functions effectively,
efficiently and in a sustainable man
ner. A proposal to address this issues
contains the following three steps:
1) From supplying a continuum of
care to organizing continuity of
care
We can see in Annex 1 that the
Phayao health-care system offers
most of the elements that would con
stitute a continuum of preventive and
curative care for HIV/AIDS. The chal
lenge of continuity of care for
HIV/AIDS, however, remains that
once clients seek HIV/AIDS-related
care and support, health services are
organized to assist the client in get
ting the care they need when and
where they need it.
Two main measures are required to
ensure continuity of care: the reform
82
83
Passing the HIV test
Passing the HIV test
of outpatient departments, and the
curative upgrading of health centres.
able resources at each contact with a
client, and in using agreed referral cri
teria for both health centres and outpa
tient departments. The consultation
with the doctor at the outpatient
departments would be phased out. so
that these staff are more available for
referral care (whether ambulatory or
inpatient), and for technical supervi
sion of curative care throughout in out
patient departments and health centres.
2) Reform of outpatient departments
The curative consultation in the health
centre faces unfair competition from the
hospital outpatient department. In the
outpatient department, the patient gels
direct access to a doctor. In the absence
of agreed standards of work, the doctor
is likely to prescribe more diagnostic
tests and more drugs than the nurse at
the health centre is. Patients needing
admission to hospitals arc readily admit
ted, while those referred by the health
centre are screened again at the outpa
tient department. This situation has seri
ous drawbacks. Outpatient departments
lend to be crowded, with adverse con
sequences on the quality of the contact
between client and provider. The health
centre is by-passed, its potential remain
ing untapped. Doctors are overworked
treating first-line cases, and have no time
to devote to upgrading the quality of the
overall system.
Making the health
centre the cornerstone
of success
To bring Phayao people on the road
towards success on HIV/AIDS, and
towards better health in general, the
health centres need to lx.1 reformed
beyond what was initially envisaged.
Situated at the first line of contact with
individual clients, at the interface with
the community and close to the
Tambon, the health centre is uniquely
placed to counsel individuals and com
munities, provide the care they require,
and to catalyse the support from all sec
tors in response to AIDS. Health centres
need real reform, and not the addition of
an AIDS component to existing activities.
Although justified on the grounds of
HIV/AIDS alone, such reform would
give the public health system the means
for addressing the socio-behavioural
3) Upgrading curative care in health
centres
To stop overcrowding of outpatient
departments, the first step would con
sist in developing agreed standards of
work for first-line contact, whether at
the health centre or at the outpatient
department.
This
would
assist
providers in making the most of avail-
issue characteristic of the turn of tliis
century.
ized for such a facilitating role.
HIV/AIDS is pointing at the need to
reconsider the very design and organiza
tion of health centres:
Our original plans for
health-care reform
So far. the Phayao Provincial Health
Office was well satisfied with the design
and organization of health centres. After
all. these units have greatly contributed
to our progress in achieving primary
health-care objectives. The issue seemed
rather to make our health centres work
better, and to improve urban primary
care. Hence, health-care reform has
been aiming at: (i) improving overall
performance of health centres, and (ii)
expanding urban coverage through the
implementation of family practice.
•
People with AIDS are least satisfied
with the performance of health cen
tres. Tl.iis is quite understandable, as
we have yet to develop standards of
care for HIV AIDS in health centres.
Ibis can only l)e done h(ureter in the
context of a general upgrading of
curative care standards for health
centres.
•
People with AIDS wish that health
centres operated weekends. Ihat they
were closed over weekends was
understandable given the preventive
role formerly assigned to them. Ibis
is unacceptable if health centres are
to become the gatekeepers of the
refemtl system.
•
Health centre staffare still kept out of
the information loop regarding HIV
status of their clients. For instance,
all consenting pregnant women are
sent to the community hospitalfor an
HIV test. If the result is positive, they
are followed at that hospital, and
given zidovudine to prevent motherto-child transmission of HIV. If the
result is negative, they continue the
prenatal visits at the health centre. As
the list of names is kept confidential
at the level ofthe hospital, health cen
trestaffcan only suspect that women
The message from HIV/AIDS
There is growing evidence that, while
health centres have done a great job in
dealing with acute infections which
make up the bulk of the case load
before the epidemiological transition, it
is much less equipped to deal with the
socio-behavioural health problems typi
cal of our current health situation. Before
that transition, health-centre staff were in
control: they could target people (mainly
children and theif. mothers) through
effective, mostly preventive interven
tions. The health centre now has to facil
itate health decisions made by individu
als, families and communities. They
were not conceived and are not organ-
84
85
whjutu'
Passing the HIV test
>
j
I
i
who do not come back for the prena
tal care have HIV. Of course, all
women who went together to thefust
prenatal clinic know who has HIV.
as the latter women continue their
prenatal care at the hospital.
Ironically, the measure to protect
confidentiality amounts to a public
disclosure of HIX 'status, and disables
the health centre to support pregnant
women with HIV
• A formal mode of interaction
between health centre and its
(intended) useis also needs to he
established. In some health centres,
self-help groups of people with
HIX/AiDS have shown the way. Hwy
discuss with health centre staff how
to improve the health centre contri
bution to their tveil-being, and to the
community's response to HIV/AIDS.
Ibis is the exception, rather than the
rule, and health centre staff need to
lx1 trained and encouraged to nur
ture such interaction with the com
munity about health matters.
• The health centre could play a key
role in multisectoral actionfor health.
We hate seen in section 4 how the
province intends to encourage the
Tambon Administrative Organiza
tions (TAO) to adopt local strategies
in response to HIV. Health centre staff
would play a major role in stimulat-
86
ing this process- informing the TAO
about the HIV/AIDS situation (while
respecting people 's right to confiden
tiality), providing information on the
costs and effects of strategic options,
and assisting in monitoring imple
mentation. Such a key role could be
expanded to various health problems,
such as alcoholism, drug use, and
teenage pregnancy.
Excellent health centres
\Xc think that the case is macle for a thor
ough reform of health centres. But how
would the reformed health centre really
look like? How would its new functions
be fulfilled? How would its staffing lx?
organized? Which physical layout would
best support its revised mission? No
amount of seminars will ever resolve
these questions. Only practice will tell.
I lence. each district would lx? transform
ing each health centre into an Excellent
Health Centre, or "Satani Anamai Dee
Tisut". The reform of health centres
would be done one by one. to allow a
maximum of learning of the full opera
tion of the reformed health centre before
moving to the next one. As much as pos
sible. the health centre reform would be
done in pace with the strengthening of
the Tambon Administrative Organization.
87
Conclusion and^xt steps
Conclusion and next steps
A great learning
experience
3
■
43
4.
I
All participants in the study of health
care reform and HIX’ in Phayao have
learned something. Those of us who
thought that the Phayao Provincial
Health Office (PPHO) might have had
a major impact on the epidemic now
know that so far Phayao people have
made most of the difference. We all
realize now that progress against
HIV/AIDS in Phayao. while real, is frag
ile and even has been stalling for the
past few years. Now comes the hard
part: making individual and community
J® counselling a matter of course for the
whole health-care system, and combinI ing effective support from various sect
tors to key participants to the response
to HIV and AIDS. Initially, we thought
that there might be some merit in
exploring health-care reform from the
angle of AIDS. We now realize that on
the road to success on HIX7AIDS. effec. tive health-care reform is a must. We
intend to act without delay.
Action without delay
We are decided to start "doing every
thing” at tambon level to respond to
HIV/AIDS. Together with colleagues
from other sectors, we shall build on
our understanding acquired through
the implementation of more than 200
89
projects over the past three years, to
firm up our commitments towards
communities and key participants to
the response to AIDS. To support tam
bon level action we shall progressively
transform each health centre into an
AIDS-competent health centre, able to
combine provision ol care, community
counselling, and catalysis of multisec
toral action. To support this health cen
tre reform, we arc reorganising the
responsibilities for provision and man
agement
of
health-care
among
providers and purchasers.
Preparing for
the future
Our knowledge gaps have come out
very clearly in the course of our study.
As w’e took the decision to exploit
existing sources of information, and
not to gather additional data, we often
have been frustrated in our efforts to
understand the epidemic, and the
responses to it. We will adopt four
complementary' strategies to build and
maintain our knowledge base: further
assess the current situation; equip our
selves to monitor the epidemic and the
response to it; address major AIDSrelated policy issues; network within
Thailand and elsewhere to exchange
experience and resolve common
issues.
r-
Conclusion and next steps
Assessing the Current
Situation
Understanding the Dynamics of
HIV Transmission
I
I
Our capacity to deal with the future
starts with better understanding the
present. XXe need to better grasp the
dynamics of HIX’ transmission. What is
the distribution of HIX’ in Phayao vil
lages and towns? Are there geographi
cal factors of vulnerability, making
some communities more vulnerable to
HIV than others? XXhat is the rate of
migration in Phayao.'' Arc women and
men migrating less or more, and why?
What is the relative contribution of var
ious factors of risk and vulnerability to
HIV transmission? I low prevalent is the
practice of anal sex among Phayao
people? How prevalent is injecting
drug use? NX hat proportion of current
HIX infections arc acquired inside and
outside Phayao Province?
Getting to grips with costs
We have seen the need to identify unit
and total costs of the core health serv
ice. including health-care procedures
for HIV symptomatic patients. We also
saw that patients are charged very dif
ferent prices, depending on the financ
ing scheme they belong to. These dif
ferences in price might just reflect cross
subsidization from users of the more
liberal schemes to those of the less lib-
eral ones. However, prescribers might
in fact adhere to different standards of
care according to the financing schemes
of their patients, thereby leading to
major inequities in access to care.
develop such a monitoring system,
testing a draft instrument developed by
UNAIDS for that purpose.
Addressing major policy
issues
Understanding private health care
expenditure
Revisiting our population policy
To tailor our health-care system to cur
rent level of resources, we need to bet
ter understand direct health-care
expenditures. How much do people
spend for health care? So far, we have
only access to anecdotal reports from
focus group interviews, and to hospi
tal-based data.
Every year the
Provincial Statistical Office carries out
a very' extensive economic survey. This
survey does not include specific ques
tions about health-care expenditures.
XXe plan to approach the Phayao
Statistical Office to propose incorpora
tion of health-care expenditures in
their upcoming survey. Given the par
ticular importance of HIX’. AIDS in the
province, we propose to add to the
survey a specific inquiry regarding
health-care expenditures by HIV/AIDS
patients.
In Phayao, so many young people are
dying from AIDS that the population
may already be shrinking (see Figures 3
and 4). What arc the facts? Is the infor
mation accurate? If so. is there a need
for action? What can be done about it?
Would a simple reduction of emphasis
on family planning be enough to boost
natality? Is there a need to introduce
incentives
that
would
stimulate
increases in desired family size? What do
Phayao people think about it? What pol
icy options are available?
Preparing for the triple therapy
Contributing to global
learning and gaining from it
Phayao Province is not alone in its
effort to better understand AIDS and
its implications for health reform. It
can count on exchanges within
Thailand and with other countries. It is
looking forward to the exchange of
experience with other Thai Provinces
participating in health care reform.
Moreover, it is looking forward to
worldwide interaction with colleagues
working on the same issue. At the sug
gestion of UNAIDS and its co-spon
sors. some countries in Asia and
Africa' are reviewing their Health
Reforms in the light of HIV/AIDS\
Even in the most affected countries,
health systems remain relatively
unchallenged by the HIV AIDS pan
demic. Countries have tended to sat
isfy themselves with the creation of a
separate HIX AIDS programme, while
failing to adapt their health systems to
the new needs stemming from
HIX' AIDS. The UNAIDS HIV and
Reforms for Health Agenda represents
an attempt to resolve that issue.
UNAIDS will act as a catalyst, both
locally to suppon the review and glob
ally to facilitate the interaction among
panicipating countries and dissemi
nate lessons learned.
♦
Realizing the key role of people with
HIX' AIDS in the solution to the AIDS
problem, we are determined to do our
part and resolve to start immediately to
prepare our health-care system for the
eventuality of a combination therapy
of acceptable cost and efficacy. The
conceptual framework of our pro
posed action-research is presented in
Figure 41 (page 92).
»
5 Burkina Faso, Ghana. Thailand. United Republic of Tanzania and Zambia
Monitoring the epidemic and
the response to it
The study has also highlighted the
need for developing a monitoring sys
tem of the implementation of the
response to HIV/AIDS. We will
Conclusion and next steps
I
91
: ...
i
Conclusion and next steps
i
Look at all these figures. Do
you think we will ever
understand HIX /AIDSfrom
thesefigures? XXbat we need
is to take pa)1 in people's
lives. To understand what
is going on. we will need to
use both parts of the brain."
Khun Suwat, Phayao AIDS
Action Centre
Combining the two sides of
the brain
If we had one last word, it would be to call for
balance in our approach to HIV/AIDS. Let us use
both sides of the brain, mixing figures with qual
itative information. Let us consider both biologi
cal factors of risk and social factors of vulnera
bility. When we work with people, let s use both
heart and brain.
Figure 41: Proposed conceptual framework for a feasibility study on
provision of antiretroviral combination therapy for HIV-infected patients
Phase II: Implementation Phase III: Evaluation
Phase I: Model Formulation
Application of the Study
Financing policy
' -target price
■cost sharing
£
r*
ACTION
RESEARCH
^Model Evaluation
[quantitative & qualitative)
Clinical Management^
Policy
-effectiveness
-QCL
-compliance
-cost & financing
V-clinical criteria for patients I
Systemic Measures
^for Compliance^
-continuity of care
92
Application of the Modified
.Model to the National Level
aAIU.
.
I1""Annex 1
Annex 1
...
■
Annex 1:
Health-care reform in Phayao
The Phayao health-care system
Phayao Province is equipped with a considerable
health-care infrastructure (see Table 10).
Table 10: Health-care infrastructure in Phayao
(I
Government faci I ities
Private facilities
2 General hospitals
5 Community hospitals
1 Military hospital
88 Health centres
17 Health posts
1 Municipal health centre
1 Hospital
31 Medical clinics
7 Dental clinics
32 Midwife stations
3 Laboratories
45 Drug stores
Health personnel
Health volunteers
51 Doctors
13 Dentists
14 Pharmacists
374 Professional nurses
325 Technical nurses
1317 Other
13,960 people
Several village health volunteers live in each vil
lage. A motorbike ride to the health centre takes
a maximum of a few minutes. For most inhabi
tants of the province, even the community hospi
tal is close by. and two general hospitals offer a
wide range of referral services. In towns, patients
can choose between visiting the municipal health
centre, the outpatient department of the hospital,
or one of the 63 private clinics (31 staffed by a
qualified physician).
Health-care workers in Phayao made consider
able progress towards primary health-care goals.
Many’ communities in Phayao have reached the
standards presented in Table 11.
94
Table 11: Indicators of basic minimum health needs
Indicators _________
1. Birth weight > 3000 g
2. Low weight for children age < 5 years
Grade 1
Grade 2
Grade 3
3. Normal weight in children age 6-14 years
4. Households eat cooked food
5. Households eat ready-made food registered by FDA
6. Clean houses with good surroundings
7. Households have and use latrines
8. Households have sufficient clean water
9. Households have no pollution
10. Pregnant women receive ante-natal care
11. Pregnant women receive birth delivery and postpartum care
12. Children less than 1 year receive full immunization
13. Primary school students receive full immunization
14 Households whose members age >14 years know about AIDS
15. Households whose members age >14 years know how to prevent HIV
16. Households receive useful information
17. Households are safe from accidents
18. Couples (wife age 15-44) practise birth control
19. Couples (wife age 15-44) have less than two children
20. Households are members of development groups
21. Households have no alcoholic members
22. Households have no cigarette addicts
23. Households take care of elderly
24. Households join environment protection activities
Statistics displayed in each health facil
ity consistently confirm that progress.
The staff is competent and at work.
Health-care facilities stand out by their
cleanliness and level of maintenance.
Essential drugs are readily available.
Target (per cent)
70
< 10
< 1
0
>93
>60
>75
>90
>95
>95
> 80
>75
>80
>95
>99
>80
>80
>85
> 60
> 77
>75
>60
>90
>90
>90
>90
At the crossroads of
need and opportunity
Phayao province, however, left no
room for complacency, and decided in
1997 to join four other Thai provinces
in the Ministry’ of Health’s Health Care
Reform Project, supported by the
95
•
Annex 1
European Union (see Box: The Thai
national health-care reform).
That decision was based on a combina
tion of need and opportunity: (i) the mis
match is growing between what die
health-care system offers and what peo
ple need; (ii) economic growth calls for
the redefinition exacdy what health-care
the province can afford; (iii) the growth
of the private sector challenges the
province in its traditional role of health
care provider. Moreover, dramatic reduc
tions in communication cost make it
possible for the province to learn from
experience elsewhere as it occurs.
Growing mismatch between
health services and popula
tion need
The population of Phayao is ageing fast
(see HIV/AIDS in Phayao: the Crisis,
page 14), and its health-care needs are
changing accordingly. The health-care
system that was designed to deal with
acute infections in a young population
is now challenged to address those new
needs. Socio-behavioural diseases, both
old (such as alcoholism) and new (such
as HIV/AIDS), are taking a much greater
importance. The health-care system has
to learn how to deal with those prob
lems, against w’hich there is no “magic
bullet”, neither treatment nor vaccine.
6 At 1988 constant prices
Annex 1
Total fertility rates may now have fallen
below’ replacement levels, through the
combined effects of effective family
planning and increased infant and
childhood mortality due to HIV/AIDS.
Again, there is no technological solu
tion to this issue, and the health-care
system has to adapt its fertility message
and interventions to this new stale of
play.
Table 12: Annual expenditure of inpatient
departments per patient, according to a
health insurance scheme
fTl (M! I r-11
317
916
;•
815
141
^compensation fund ' 421
Priv^nsurance ,
933
Taking advantage of economic
growth
Phayao gross provincial product
increased 47 per cent in five years,
from 5.9 million baht in 1989 to 8.7 mil
lion baht in 1994? Total expenditure for
health care increased from 41,587,430
baht in 1989 to 236,257,942 baht in
1994. The challenge to the province is
to mobilize public and private
resources towards the utilization of a
core health service: the services that
the province can afford, and that would
contribute most to health.
A private challenge: inequity of
financial access to health care.
While services are geographically
accessible, the concomitant existence
of four different health-care financing
schemes perpetuates major inequities
(see Table 12).
There is an urgent need to harmonize
(hose various schemes. The private
health-care sector grew dramatically
in the province over the past five
years. As many as 38 per cent of the
primary health care facilities arc now
private.
The private sector represents both a
threat and an opportunity:
as a threat-, (i) the private sector
might “cream" the health labour mar
ket from its best elements, who
would cater only for a minority after
their move from the public to the pri
vate sector; (ii) the private sector
might invest excessively in high-tech
equipment, and then turn to the pub
lic sector for meeting operating costs.
as an opportunity, (i) private family
practitioners might represent a viable
option for the provision of the first
level of care in towns; (ii) private
clinics might provide an outlet for
(hose who demand sen . -s outside
the core health service and can pay
for it.
The Thai national health-care reform
Most countries initiate reforms of their health care systems during an economic
downturn. Such reforms, for example in the US, South Korea and Chile, have
focused on major administrative changes that would cut costs without prejudice
to the quality of health services.
Thailand actually launched its health care reform before the current economic
crisis set in, but "recent events have certainly added momentum to it. Practically
speaking, the aim of the reform is twofold: to establish a nation-wide health
insurance system and to strengthen primary health-care across the country. So
far, five provinces (Ayudhya, Yasothorn, Khon Kaen, Phayao and Songkla) have
volunteered to carry out reforms in health-care and two of these are reforming
their health-care financing on a pilot basis.
[
...... .
I
Annex 1
Annex 1
Health-care financing reform
Capacity building of people and communities
It '
.
Health-care financing reform is expected to contribute greatly to the efficiency
of the Thai health-care system. Currently most patients pay a fee for the serv
ice provided directly to their hospital. This payment mechanism incites hospi
tals to provide more services and medicines than really necessary, thereby
reducing the efficiency of the whole system and the affordability of the serv
ices it supplies. Following the reform, service providers will be paid on the
basis of the number of people registered with them and of diagnoses made.
Health-service system reform
The Thai economic boom of the past eight years has mainly benefited hospi
tal development, while primary health-care facilities have only received a lit
tle attention. For all illnesses people go directly to hospitals, which are often
overcrowded and provide services at a higher cost than is necessary owing to
high overheads.
i
'i
i
I
However, strengthening primary medical-care facilities can be an effective way
to lessen the workload of hospitals while decreasing costs for patients. Local
and small-scale health-care centres are less crowded than the larger hospitals
and therefore provide sen-ices at a reduced cost. The reform should transform
the way primary health-care is delivered. New methods to ensure the conti
nuity of care such as the registration of the patients with the provider of their
choice, a change in the record system, home visits, follow-up of the patients
who have been referred to the hospital. The prevention and the promotion
will be totally integrated to the curative care at this level because the centre
c
will have the responsibility for the line facilityj level._ The
____more
serv— personal
ice usually improves the climate of confidence between patient and doctor or
nurse and increases the efficiency of care. Such centres are only effective,
however, if education and training of staff is of a high standard and if there
are positive financial incentives for the patients. It is envisaged that such pri
mary health-care centres would provide basic health-care services, while
patients would still be referred to hospitals for special examinations or’special
treatments.
—>
... .... ..
Services that affect people’s everyday life can only be a success if they are devel
oped and carried out in co-operation with their users. This is undoubtedly true
in the case of health-care. Beneficiaries or potential beneficiaries of health-care
services should be able to shape these services to make sure they correspond to
their needs. One way of achieving this is to promote consumer choice in select
ing individual and family health service facilities. Another way is to include com
munity representatives in advisory or decision making bodies taking care of the
health service management of communities. The Health Care Reform Project will
help to implement both these methods.
upgrade the health centre in curative
care, and in the required shift from
controlling disease to facilitating com
munity responses to health problems.
The health-care
reform plans
An overview
To address that issue, the Phayao
Provincial Health Office plans to divide
health workers in the civil sen. ice into
two groups: purchasers and providers.
Purchasers would consist of some
members of the current provincial and
district health offices. In each district,
public sector providers would be
organized in one team. Providers
would be accountable for the quality
and coverage of a specified population
by the core health service. Purchasers
would negotiate the core health serv
ice. offer technical resources to
enhance quality and coverage, audit
quality and coverage data, ensure ade
quate flow of information between
users and providers at individual and
collective levels, and serve as brokers
in case of conflict. Providers from the
The Phayao provincial health-care
reform plans are summarized in Table
13.
Separating purchasers from
providers.
A particularly important reform now
under consideration is the separation of
purchasers and providers. Today, doc
tors do not consider technical supervi
sion of the health centre as their job.
Rather, that is the job of a public health
nurse and his/her team. That team is
very competent in the programmatic
areas of traditional primary health care,
such as immunizations and family plan
ning. However, it has little to offer to
99
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I
Table 13: The Phayao provincial health-care reform plan
....
■
Development of essential elements for health-care reform
Development of the core health service
Defining the services that Phayao people can access without any barriers
Development of quality control system
Defining the standard of care and the system ensuring the quality of services
Development of management information system
Design the information system to be utilized for management and services units
Human resource development
Training various categories of personnel
Development of service providers units
Health centre development
i
Reorganising the services corresponding with the core health service and local health problem
Drug stores development
Involving drug stores in provision of qualified services
Private clinic development
Seeking modes of co-operation between private clinics and the public sector
Community and general hospital development
Reorganising the services system aiming at better quality and more efficiency
* -rr; v—
—
Development of administrative units
District health office development
Determining the health service provider functions and reorganising the office accordingly
District health co-ordinating committee development
!
Provincial health office development
I
■*"
■■■■'■
■
Evaluation
—.
.
v
llt
,
,,,
______
_
Determining co-ordinating roles between health service purchasers and providers
Determining the health service purchaser functions and reorganising the office accordingly
Assessing the healthcare reform process and its impact on health status of Phayao people
...
Annex 2
Annex 2
Annex 2:
111
Framework used to analyse the response to
HIV/AIDS in Phayao province
i
The private response
"yvyhether people respond to
W HIV/AIDS
effectively
•i
depends on two main factors: a) the
biological factors affecting their spe
cific risk of acquiring HIV, and, once
infected, to keep the virus under
check, and b) their capacity to avoid
risk situations, and. once affected, to
mitigate the impact of HIV/AIDS.
11
Factors affecting the probability of
HIV transmission include: i) the viru
lence of particular HIV strains; ii) the
presence of STDs in one or two part
ners, which can increase the risk to
ten percent and more; iiD the trans
mission route, where the risk of trans
mission through anal sex is much
higher than through vaginal sex; iv)
whether the male partner is circum
cised or not. as circumcision reduces
the risk of HIV transmission; v) per
sonal resistance, as the evidence is
growing (hat a minority of individuals
resist multiple exposures to the virus.
By the same token, people with HIV
depend on a range of biological fac
tors that determine (he outcome of
their infection.
J
I
Figure 45: Risk and vulnerability factors and the response to HIV/AIDS
1
Protection
Reduce risks
Reduce vuhierabilities
Whether
HIV positive or
HIV negative
use condoms when having casual sex
reduce anal sex practices
have concomitant std treated
use clean needles (in the case of
injecting drug users)
enhance economic
People are more or less vulnerable to
HIV. individually and collectively. Their
capacity to respond to HIV depends first
on their knowledge of HIV/AIDS. That
knowledge, however, is not the only
factor invoked. In strong communities,
people value mutual fidelity, men and
women have equal status, are inde
pendent from alcohol and drug addic
opportunity
reduce alcohol consumption
enhance self esteem
reduce drug use
tion. and have their basic needs met.
Seasonal migration is less prevalent, or
takes place in couples. Men may have
affairs, but don't visit sex workers.
Maybe most importantly, in strong com
munities, people are ready to face prob
lems. analyse them, and act on them.
This may lead to rapid adaptation of
local cultural values, and translates in
behavioural change. Conversely, in vul
nerable communities, people attach less
importance to mutual fidelity, women
have a lower status than men do, and
consumerism combined with poverty
leads them to trading sex. Maybe more
importantly, weak communities do not
assess their problems and act on them,
but attribute suffering and death to
causes beyond their reach. They tend to
adhere to cultural traditions and main
tain corresponding behaviours even
when they become harmful in the new
situation created by HIV/AIDS. By the
same token, several factors influence the
degree to which HIV affects people and
communities.
Once they are faced with the reality of
AIDS, (whether through information or
through the direct experience of disease
and death) people respond. They resort
to their networks of relatives, friends,
and communities to obtain additional
information and adapt their behaviour
to the new situation. For instance, men
migrating for work might take a partner
with them: some people may stop
drinking alcohol: men might stop visit
ing sex workers, but have a second wife
instead. Other men might have anal,
rather than vaginal sex, thinking that this
practice might be safer practice. They
might also exploit the services of
younger and younger girls. Families
affected by AIDS might draw girls from
schools to anend to the sick relative;
they may shift agricultural production
from labour intensive crops to less
intensive crops. All these changes com
bined can be called the "community” or
the “private” response. It is the response
by people in their private capacity'.
The response by
institutions
The private response to HIV/AIDS is
imperfect. Communities left on their
own are unlikely to be totally effective
in dealing with AIDS and in mitigating
its impact. They need information (such
as the high transmission rate of HIV
through anal sex) and supplies (such as
tests and condoms) which they cannot
mobilize on their own. Some factors of
vulnerability stem from policies (such as
job discrimination, which lead women
with HIV to return to sex work as their
only option to earn a living) that are
beyond their immediate control. Hence
the need for an institutional or organ
ized response. Public and private organ
izations can provide sen ices and ensure
a supportive policy environment to the
community response.
Provision of services
Private and public institutions can pro
vide services that modify risk of their
clients or constituents in various ways.
For instance, health-care institutions can
treat STDs, treat opportunistic infec-
1
102
103
-....
.nnex 2
A
lions, prevent transmission through
blood, and prevent mother-to-child
transmission of HIV. A whole range of
public and private institutions can dis
tribute or sell condoms. Schools can
provide information about HIV trans
mission, and leach the appropriate use
of condoms.
the community’s understanding of HIX7,
and hence its capacity to respond.
Monks refusing men with HIV into
monkhood put a stigma on people with
HIV, even if their individual behaviour
may not have been different from that of
the community in general. That stigma,
in turn reduces the capacity of the com
munity to assess the situation objec
tively, and act on it. Churches con
demning condom use increase the risk
of HIV transmission even within married
couples. By saying that condoms are
ineffective in resolving the AIDS prol>
lem, they turn away people from its use.
without providing any viable alternative
for discordant couples, for sex workers,
or for people who are unable to be 1(X)
per cent faithful to their spouse or
remain abstinent before marriage.
Private and public institutions can also
provide services that modify vulnerabil
ity of communities and their members.
A few instances follow. Health-care
institutions can put in place testing and
counselling facilities. Schools can put in
place life-skills programmes, while nongovernmental organizations can reach
out-of school children. Churches and
government services can help modify
harmful traditional values and related
practices. Community extension work
ers can assist communities in assessing
their own factors of risk and vulnerabil
ity, and in developing their own
response; welfare agents can help poor
families through the difficult period
when they lose their income earner.
Private and institutional responses are
greatly influenced by Government pol
icy, whether these policies are geared
towards AIDS or not. Leadership, fiscal
policy, laws and regulations are inalien
able roles of Government.
Policies
Through their policies, private and pub
lic institutions affect people's risk and
vulnerability to HIV, either positively or
negatively.
Through a hospital handling corpses of
people with HIX7 as though they were car
tying a risk of HIX7 transmission reduces
Leadership
Only Government can exert the neces
sary leadership to face the facts, create
the debate that is essential for adopting
a national strategy, orient all partners
according to that strategy.
104
I
I
I
i
2
Go
res*
inc
can i
gro .■
main
tho..
can also weaken the
the promotion of factually
ssages. For instance, a
using exclusively on -risk
a sense of false safety to
who do not identify with
Fisc;
tax c
cy: subsidies and
OnL
activii
large.
buiioi
testing
ent can subsidize those
■cncfit the community at
nent of STD’s, the distriJoms, counselling and
and training of staff.
Gov< -i
the l>c
nera’ib
beer c ■
hat grant subsidies to
ry thereby increase vulnsumers; those that tax
>n reduce vulnerability.
Law j
illation
Gove i
mentr
infc
make
with b
also m
sexual ■
for neo
unprottedge a
can als<
entranc
scrip: io;
n use its legal instru
ct the rights of both
nfected persons. It can
to exclude someone
the workforce; it can
rime for men to have
vith under age girls, or
>sed with HIV to have
without the knowlnt of their partner. It
testing for HIV at the
ersity, or before coni rmy.
I'lK
Government can also take measures
that enable the social sector as a whole.
Governments can modify legislation
that discourage marriages, or modify
inheritance laws to protect widows and
their children. It can lake measures to
strengthen the status of women, or
decentralize the management of sector
operations, to enable them to be more
responsive to local needs and facilitate
multisectoral action.
>
i
i
: _■ '-Ji '»..»(',2!., 44-- /, ,3>h
-a
Annex 2
i
i
....... . .
Annex;
tions, prevent transmission through
blood, and prevent mother-to-child
transmission of HIV. A whole range of
public and private institutions can dis
tribute or sell condoms. Schools can
provide information about HIV trans
mission, and teach the appropriate use
of condoms.
the community’s understanding of HIV,
and hence its capacity to’respond.
Monks refusing men with HIV’ into
monkhood put a stigma on people with
HIV. even if their individual behaviour
may not have been different from that of
the community’ in general. That stigma,
in turn reduces the capacity of the com
munity to assess the situation objec
tively, and act on it. Churches con
demning condom use increase the risk
of HIV transmission even within married
couples. By saying that condoms are
ineffective in resolving the AIDS prob
lem. they turn away people from its use,
without providing any viable alternative
for discordant couples, for sex workers,
or for people who are unable to be 100
per cent faithful to their spouse or
remain abstinent before marriage.
Private and public institutions can also
provide services that modify vulnerabil
ity of communities and their members.
A few instances follow. Health-care
institutions can put in place testing and
counselling facilities. Schools can put in
place life-skills programmes, while non
governmental organizations can reach
out-of school children. Churches and
government services can help modify
harmful traditional \ allies and related
practices. Community extension work
ers can assist communities in assessing
their own factors of risk and vulnerabil
ity. and in developing their own
response: welfare agents can help poor
families through the difficult period
when they lose their income earner.
The government response
Private and institutional responses are
greatly influenced by Government pol
icy, whether these policies are geared
towards AIDS or not. Leadership, fiscal
policy, laws and regulations are inalien
able roles of Government.
Policies
Through their policies, private and pub
lic institutions affect people’s risk and
vulnerability to HIV. either positively or
negatively.
Through a hospital handling corpses of
people with HIV as though they were car
rying a risk of HIV transmission reduces
Leadership
Only Government can exert the neces
sary leadership to face the facts, create
the debate that is essential for adopting
a national strategy, orient all partners
according to that strategy.
104
Government can also weaken the
response by the promotion of factually
incorrect messages. For instance, a
campaign focusing exclusively on “risk
groups" gives a sense of false safety to
many people who do not identify with
those groups.
Fiscal policy: subsidies and
taxes
Only government can subsidize those
activities that benefit the community at
large: the treatment of STD’s, the distri
bution of condoms, counselling and
testing services, and training of staff.
Governments that grant subsidies to
the beer industry thereby increase vul
nerability of consumers; those that tax
beer consumption reduce vulnerability.
Law and regulation
Government can use its legal instru
ments to protect the rights of both
infected and uninfected persons. It can
make it illegal to exclude someone
with HIX’ from the workforce; it can
also make it a crime for men to have
sexual relations with under age girls, or
for people diagnosed with HIV to have
unprotected sex without the knowl
edge and consent of their partner. It
can also mandate testing for HIV at the
entrance to university, or before con
scription in the army.
105
Government can also take measures
that enable the social sector as a whole.
Governments can modify legislation
that discourage marriages, or modify
inheritance laws to protect widows and
their children. It can take measures to
strengthen the status of women, or
decentralize the management of sector
operations, to enable them to be more
responsive to local needs and facilitate
multisectoral action.
rt.
-- i-
-
.
Annex 3
■
’
Referena
Annex 3:
a
I
•H
Epimodel projections of HIV/AIDS cases
in Phayao (1986 - 2001)1
Year
HIV new
HIV
cumulative
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
|2001
0__
8__
360
969
1832
2852
3929
4975
5920
6720
7350
7799
8073
8183
8148
7990
'o_____
1
i |l
i
i
i
li
II
References
HIV current AIDS new
0___
8________ 8___
368
368
1337
1335
3169
3153
6021
5949
9950
9738
14925
14428
20845
19850
27565
25788
34915
32000
42714
38245
50787
44303
58970
49987
67118
55149
75208
59678
0__
0__
0__
2__
14_
55
140
285
498
783
1137
1555
2015
2499
2986
3461
AIDS
cumulative
0
0
0_______
2_______
16______
72______
212
497
995
1777
2915
4469
6484
8983
11969
15430
1 Silarug N et al. Situation Analysis of
HIV and AIDS in Phayao.
Epidemiological Review. 1996
2 National Statistic Office. Office of the
Prime Minister, Statistical Reports of the
Cbangwat. Phayao. 1996
AIDS current Death new
0__
0__
0__
1___
7__
28
70
142
249
391
569
777
1007
1249
1493
1731
9
0__
0__
0__
1__
8__
35
98
213
391
640
960
1346
1785
2257
2742
3224
10 Kunanusont C et al. Medical Services
Situation for AIDS in Thailand in 1995
- 1996. AIDS Division, Department of
Communicable Disease Control,
Ministry of Public Health
3 Pramualratana, A, Kanungukkasem U,
Guest P. Community Attitudes and
Health Infrastructure Impacts on
Identification of Potential Cohorts for
HIV Testing in Phayao Province.
Preliminary Assessment. December
1994.
11 Havanon N. Sustaining Partnership
Network on Care and Support for People
Affecting by HIV and AIDS at the Local
Level. 1997
4 Suwanphanhana N. ne Expectation of
the Family and the Daughter’s Role in
"the Prostitution Communitya Case
Study of a Village in Phayao Province
(MA Thesis in Social Development).
12 Pramualratana P, Kanungukkasem U,
Guest P. Community Attitudes and
Health Infrastructure Impacts on
Identification of Potential Cohorts for
HIV Testing in Phayao Province.
Preliminary Assessment. December
1994.
s Van Griensven F, Surasiengsunk S. The
use of Mortality Statistics as a Proxy
Indicatorfor the Impact of the HIV
Epidemic on the Thai Population.
January’ 1998
l!1
13 Phayao AIDS Action Centre. Sexual
Behaviour Surveillance Data. 1998
14 Relationships of HIV and STD declines
in Thailand to behavioural change: a
synthesis of existing studies. UNAIDS.
1998
6 Argkian V et al. The Deaths Under Five
and Pediatric AIDS Deaths in Phayao
Province. Northern Epidemiological
Centre of Thailand, Lampang Province
and Phayao Provincial Health Office,
1996
15 Phayao Provincial Health Office. HIV
Risk Behaviour Sentinel Surveillance in
Phayao (June - August 1997),
Jones G.W. Douglas R.M. Caldwell J.C.
The Continuing Demographic
Transition. Oxford University Press,
1998
8
106
Gray R. Waver M, Serwadda D.
Population-based study offertility in
women with HTV-l infection in
Uganda. Lancet 1998, 351: 98-103
Masaki E. Review of Current Situations
and Issues ofARV Therapy: Facts. Hopes
and Needs. 1998
16 Phayao AIDS Action Centre. Focus
Group Interviews in Three Districts in
Phayao Province. August 1997
17 Phayao Provincial Health Office.
Guidelines for developing HTV/AIDS
Projects. 1997
18 National AIDS Committee. National
1A7
References
Plan for Prevention and Alleviation of
HIV/AIDS. May 1997
Y
J
1
J
J
1
19 Capra F. The Turning Point: Science.
Society and the Rising Culture. Bantam
Books, London, 1988
29 Zeldin T. An Intimate History of
Humanity. Minerva, 1995
20 O’Shaugnessy T. Beyond the Fragments:
HIV/AIDS and Poverty. Issues in Global
Development. World Vision. Australia
Research and Policy Unit, 1994; 1:91.
21 Larson H. Intewiews of key actors in
Pbayao Province (unpublished data).
_1
J
J
J
d
J
L'
I;
in Thailand. International Family
Planning Perspectives, Vol. 22. N 3,
Sept. 1996
30 Designing an Essential Package of
Health Services in Zambia: A Case
Study, Flagship Course on Health Sector
Reform and Sustainable Financing.
World Bank Economic Development
Institute.
51 Masaki E. Feasibility Study on Provision
of Antiretroviral Combination Therapy
for HIV-Infected Patients in Thailand.
22 Thairieua V et al. From Efficacy to
Effectiveness: Routine Pretention of
Mother-to-Child HIV Transmission by a
Short Course of Zidovudine in
Horthernlbailand. South East Asian
Journal of Tropical Medicine and Public
Health, June 1998
1998
32 HIX ’ and Reforms for Health Agenda.
UNAIDS, 1998
■A Scandlen G. Acceptance of New Practices
and Behaviours. Tamathai Fund (unpub
lished data).
21 Paris Summit on HIV/AIDS, December
1994 (extracts).
2$ Allen S et al. Effect of Serotesting with
Counselling on Condom Use and
Seroconversion among HI\' Discordant
Couples in Africa. Brit. Med. J, 1992;
53 Soucat A et al. Consequences of the HIX'
Epidemic on the Health Sector in Cote
d 'Ivoire: the Implementation of the
Expanded Response to AIDS Required
Operational Strategies for Health
Reform. 1997
The Joint United Nations Programme on HIV/AIDS (UNAIDS) is the leading advocate for global action
on HIV/AIDS. It brings together seven UN agencies in a common effort to fight the epidemic: the United
Nations Children’s Fund (UNICEF), the United Nations Development Programme (UNDP), the United
Nations Population Fund (UNFPA), the United Nations International Drug Control Programme (UNDCP)
the United Nations Educational, Scientific and Cultural Organization (UNESCO), the World Health
Organization (WHO) and the World Bank.
304:1605-9
26 Confronting AIDS. World Bank PolicyResearch Report, 1997
2 The Guide on Rapid Assessment Methods
for Drug Injecting. Eds. Stimson G, Fitch
C, Rhodes T. World Health Organization,
Programme on Substance Abuse. 1997.
UNAIDS both mobilizes the responses to the epidemic of its seven cosponsoring organizations and
supplements these efforts with special initiatives. Its purpose is to lead and assist an expansion of the
international response to HIV on all fronts: medical, public health, social, economic, cultural, political
and human rights. UNAIDS works with a broad range of partners - governmental and NGO, business,
scientific and lay - to share knowledge, skills and best practice across boundaries.
28 Knodel J, Pramualratana A. Prospectsfor
Increased Condom Use within Marriage
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Female sex worker
HIV prevention projects:
Lessons leornt from
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