The concept

The concept of involving villagers as volunteers in government service development projects in Thailand was first introduced with the Malaria Eradication Project in the early 1950s, In that project a village health volunteer, namely the malaria volunteer, was trained⁷. In the operationalization of the national PHC programme, the same concept was applied through the development of two types of CHWs known as the VHVs and VHCs. Their involvement was considered as a human resource development strategy. They were envisioned as a concretization of the principle of community participation in PHC, which would contribute significantly to expanding the coverage of basic health services to the rural communities.

The involvement of village members as CHWs in the PHC programme was also considered as an appropriate solution to the situation of the country as such that: 1) People’s health is largely affected by the state of poverty and the lack of education; and 2) The resources for national development are limited. Through the activities of VHVs and VHCs, health services in the country would be made available, accessible and acceptable to the majority of the population⁸.

The expected roles

According to the national PHC programme, the VHV and VHCs were selected from among the ordinary villagers. They were recruited to voluntarily assist the government in helping their neighbours and relatives⁹. In a typical size village (100 households) there would be one VHV and about 10 VHCs (1 VHC for every 8-15 households)¹⁰. In the MoPH’s instruction, the VHCs had to be recruited by the responsible tambon health workers using a sociogram technique¹¹. The VHVs were, subsequently, chosen from among the VHCs after a 3-4 month work period. The qualifications of those who were selected as a VHV were quite high: he or she had to be willing to work devotedly for the community and have enough time to do so, be literate, trusted by the villagers, have a good health and a self-sufficient economic status¹².

Once recruited, the new VHCs had to attend a 5-day-long orientation training. Then, within six months, a refresher course followed. For the VHVs, the 15-day long orientation training would be followed by a refresher course within a period of three months. In addition, both VHVs and VHCs were expected to receive continuous training through the process of regular supervision by the responsible tambon health officials.

Those courses were designed to train both the VHC and VHVs towards becoming effective community health workers. The curriculum included elements of basic health and medical knowledge such as first aid, communicable disease control, sanitation and environmental health, personal hygiene and family health (family planning, maternal health and child care), and care for minor ailments. Topics on community health problem analysis and group-work techniques were provided as well.

In the curriculum, only two topics dealt with the issue of drug use. The first one was the use of common or household drugs; the other the use of traditional medicines. However, the details of both were focused more on how each specific drug should be taken appropriately rather than on discussing the community drug use issue in more general terms. Nothing relating to the rational use of drugs concept was elaborated in the content of both topics¹³.

The VHCs were expected to fulfill a narrow range of tasks in the community. They disseminated information on health problems that affected the village, relayed the health needs of the villagers to the VHVs and/or local health officials, and coordinated health and other development activities in the village¹⁴. The tasks of the VHVs, on the other hand, included those of the VHCs and, in addition, the provision of basic curative treatment, particularly by using household drugs supplied or recommended by the MoPH. However, the VHVs were also expected to do other activities, that might relate to people’s drug use. They were: 1) following-up patients referred to them by health facilities, e.g. patients undergoing treatment for tuberculosis, leprosy, or malaria; 2) taking blood samples for malaria detection; and 3) dispensing condoms and contraceptive pills. In addition, the VHVs were also expected to be the team leaders of all the VHCs in the village.

It should be noted that although the VHV and the VHCs were expected to work voluntarily, some incentives were provided for them by the MoPH. The important one being free medical service at government health facilities for individual VHCs, and for the VHV and his/her family. In addition, activities aiming to provide moral support for the active VHVs and VHCs were also organized by the MoPH e.g. awards for the outstanding VHV and VHC.

Performance and retention

After almost two decades of implementation, the VHV/VHC scheme can be considered very successful in attaining full coverage of villages. However, the programme has also been confronted with problems affecting its sustainability. Most important are the high drop out rate, and the inactivity of the majority of the VHCs.

Many studies on VHV/VHCs’ performance conducted during the past 10-15 years have consistently revealed that the number of active VHCs per village was less than a half of those ever trained¹⁵. In 1987 a national survey reported that during the first decade of the PHC programme (1977-1986), the attrition rate among VHCs was high at 62.4% and the average number of active VHCs per village was only 4-5, regardless of village size.¹⁶ For the VHV, the problem of attrition was less serious than in the case of the VHCs. Results from the same survey showed that the VHVs’ attrition was about 25%. However, that study concluded that the performance of the VHVs seemed to be problematic¹⁷.

What have the VHCs actually been doing in their villages? Many studies, particularly village case studies during 1984-1986, found consistently that they were engaged mostly in communication to the target villagers about scheduled activities (e.g. child weighing sessions every three months, outreach immunization sessions and information collection) at the request of tambon health officers and the VHVs. Health education, their major task, was found to be only rarely practiced.¹⁸

For the VHVs, our mailed survey data (Table 1) indicate that most of the activities they usually engaged in were those requested or initiated by the tambon health officials. The relatively high proportion of VHVs involvement in campaign activities such as in aids prevention, accident prevention, consumer right’s protection, and environmental health promotion (31.3-35.9%) could be expected. The high percentage of VHVs who had no role in curative care and in dispensing of contraceptive pills (45.1 and 60.6%), was quite unexpected. The high proportion of VHVs who had been engaged in the child weighing and water container and latrine construction activities was also found in many studies.

In our village case study data, both in Chiangrai and Chaiyapoom, the activities most frequently mentioned by the VHCs and the VHVs as their main tasks were child weighing every three months, information gathering and coordinating health activities requested by tambon health officials. Health education and information dissemination to their neighbours were also claimed to be done, but in a less frequent and unsystematic manner. Even in the villages where the majority, or all, of the trained VHCs and VHVs were reported to be still active, those who were really operational were only a few. Many of the VHCs were reported functioning only because they were still living in the villages and potentially ready for the tambon health workers to be mobilized.

It can be concluded that the problems in the VHV/VHCs programme are still the same as were found in previous studies: how to keep the trained VHV/VHCs and maintain their activities. A study in 1988 directly addressed the possible explanation of the degradation of the VHV/VHC programme, by pointing at the possible major drawbacks of the model, particularly the unrealistic expectations regarding 1) the number of VHCs per village and their preventive/educative oriented roles; and 2) the VHV and VHCs' willingness to work endlessly as volunteers¹⁹. However, the MoPH still seems to be optimistic. In the present national health plan (1992-1996), the MoPH insists on going on with the model. The ineffectiveness problem of the VHV/VHCs is explained as being caused by: 1) lack of definite work schedules for the VHV/VHCs to follow; and 2) insufficient knowledge among VHV/VHCs to enable them to work confidently²⁰. These explanations are, subsequently, the justification for the introduction of a new type of community-based organization: the Community Center for Primary Health Care (CCPHC), which is targeted to cover all villages of the country by 1996, and retain many of the principles of the VHV/VHC scheme.

Table 1: VHV involvement in community-based PHC activities