This study is concerned with two cornerstones of Primary Health Care: Community Health Workers (CHWs) and drugs. The community health worker has been the distinguishing feature of primary health care programmes in many developing countries since the Alma-Ata conference in 1978. Many countries launched a national scheme resulting in the nationwide training of CHWs1, The general goal of these schemes is similar: to head toward Health For All by providing equitable, accessible and low cost health care to the majority of the population.
Drugs, in particular essential drugs, according to the primary health care strategy as defined by WHO, are important elements of primary health care and “should be available at the various levels of primary health care at the lowest feasible cost”2. In many countries, to attain such an objective, drugs are provided by the CHWs3.
The involvement of the CHWs in drug provision has two important aspects. On the one hand, the goal of making essential drugs available at the lowest feasible cost to the population at the peripheral level can be met in this way. Although the concept of rational use of drugs by consumers has not been explicitly stressed in the WHO-defined PHC, this can be expected to be promoted through the availability of essential drugs as well as by the educative activities of the CHWs. On the other hand, the CHWs’ involvement in drug provision may result in strengthening their position in the community.
Distribution of drugs by community health workers in Thailand
Thailand is one among many developing countries which has launched a CHW programme at the national level. A large number of two types of CHWs: Village Health Volunteers (VHV) and Village Health Communicators (VHC), have been involved in the national Primary Health Care Programme since 1977. By 1986, in almost all villages VHVs and VHCs had been trained. The total numbers of these CHWs were 510,286 and 53,498 for the VHCs and VHVs respectively4. Such a large number of CHWs has made the VHV/VHC scheme the most important activity of the Thai national PHC Programme.
Aside from the other assigned tasks, the VHVs/VHCs are also expected to be involved in drug provision in their communities. The Village Drug Fund (VDF) is a community-based organization introduced by the Ministry of Public Health (MoPH) to be established in all villages. Its objectives are fivefold; 1) to be a distributing outlet of essential, cheap, and good quality drugs; 2) to enhance the CHWs’ work performance; 3) to encourage community participation; 4) to raise funds for other community development activities; and 5) to contribute to protection of consumer’s rights5. The VDF scheme has been implemented nationwide. As of 1991, 35,819 VDFs were reported to have been set up throughout the country6.
However, the drug provision role of the Thai CHWs has been continuing amidst many obstacles. The national PHC Programme has been faced with the problem of a high VHC drop out rate and difficulties in maintaining the active VHVs7. In addition, the drug distributing role of the VHV/VHC has evolved in an environment of abundance of drugs. As of 1993, Thailand had about 30,000 drug formulations, which makes one of the countries with the highest number of drug formulations in the world8. The total drug consumption in 1993 was about fifty thousand million Bahts; about 35% of total health expenditure. One-third of this was consumed through people’s self-medication9. In the provinces, modern pharmaceuticals can be obtained through a vast variety of outlets, from drugstores in provincial towns to grocery shops in the villages, from legal channels to illicit ones such as drug peddlers, injectionists and traditional practitioners. Most of the drugs from these sources are usually obtained without a prescription.
Background and focus of the
This study is a part of the research project “Inter-country study on Implications of Community Health Workers Distributing Drugs (Ghana and Thailand)” which has been technically and financially supported by WHO’s Action Programme on Essential Drugs and technically supported and coordinated by The Royal Tropical Institute (KIT) in Amsterdam. The composition of the Thai research team was as follows: Professor Dr Thavitong Hongvivatana (project director and principal investigator); Luechai Sringernyuang (senior researcher) and Penchan Pradabmuk (researcher). Professor Dr Pieter Streefland of the Royal Tropical Institute was the project’s advisor.
The focus of the whole project (Thai-Ghana Studies) is on three important aspects of the central theme of CHWs distributing drugs: 1) the implications for utilization of CHWs services and the attainment of other PHC objectives; 2) the implications of CHWs receiving payment for drugs; and 3) the implications for rational use of drugs by the consumer. On the basis of this approach, research objectives and questions are listed as follows:
1. To determine the extent to which CHWs distributing drugs contribute to rational use of drugs by consumers. To determine whether BHS support has contributed to strengthening the capacity of CHWs to enhance rational drug use by consumers.
2. To determine the extent to which involvement of CHWs in provision of drugs/management of drug funds influences their range of activities.
3. To determine the implications of involving CHWs in financing mechanisms using drugs.
Given the above objectives, specific research questions for Thailand were defined as:
1. Which village drug provision profiles (VDPP), including the relevant activities of BHS and private sources of drugs, prevail in the villages of Thailand?
2. How are these VDPPs differentiated by socio-economic and cultural area characteristics?
3. What is the current status/performance and relative importance of VDFs and VHVs distributing drugs in the villages?
4. With regard to involvement of VHVs in distribution of drugs/management of drug funds in the context of the total range of sources of drugs used by villagers:
4.1 What is the relative importance of various sources of drug distribution in the drug consumption pattern of the village population?
4.2 How do, respectively, BHS staff, VHVs and villagers perceive the provision of drugs by VHVs, VDFs, groceries and other sources?
4.3 What is the range of drugs VHVs and other sources distribute and where are they obtained?
4.4 Within the total range of activities of village cooperative stores what is the relative importance of distributing drugs?
4.5 What is the relative importance of distribution of drugs in the daily activities of, respectively, VHVs who are involved and those who are not involved in the management of VDFs?
4.6 How are the payment of VHV services and the operation of the VDF arranged?
4.7 Do VDFs make any special allowances for poor villagers?
4.8 What practical problems occur in the operation of VDFs?
4.9 What are the drug demands villagers make to VHVs and other sources and how do they cope with these demands?
4.10 Do the VHVs issue the correct dosage of drug for the appropriate length of time for the symptom/disease diagnosed, according to a defined standard?
4.11 What advice do VHVs and other providers offer to their customers concerning use of drugs?
5. Do/did the BHS provide support to the VHVs to strengthen their capacity to enhance rational drug use by consumers?
Structure of the report
This report is divided into five chapters. Chapter I serves as an introductory note, providing an overview of background and study objectives. In Chapter II, the situation of the PHC and CHW Programme of Thailand is analyzed on the basis of review of documents and field survey data. Roles and performances of VHV/VHCs and VDFs are discussed, with emphasis on their drug supply role. The situation of village drug provision profiles (VDPPs), specifically from the 195 surveyed villages, is analyzed in Chapter III. Sources of drugs and the range of drugs available in the villages are extensively described and compared. In Chapter IV, data on community drug use, mainly derived from the fifteen-case-study villages, are presented. Patterns of drug use and their sources in self-medication of the sample households are analyzed; the relative importance of each drug source, specifically the VDF is described. Chapter V provides the conclusion of the study and gives some recommendations based on this study. Details about the research methodology are presented in Annex 3.