Women's Health and Development
Country Profile, Thailand
A.1. Physical features
Thailand is situated in the heart of Southeast Asia and is the gateway to Indochina. It borders the Lao People's Democratic Republic in the North and Northeast; the Union of Myanmar in the North and West; the Andaman Sea in the West; Cambodia and the Gulf of Thailand in the East; and Malaysia in the South. The Kingdom has a total land area of 513,115 square kilometers (100; 2), stretching 1,640 kilometers from North to South and 780 kilometers from East to West at its widest point (101; 1).
The climate is tropical with long hours of bright sunshine and high humidity. There are three seasons; hot (from March to June), rainy from July to October) and cool (from November to February). The temperature ranges from an average low of 23.7o C to an average high of 32.5o C (100; 4). The geographic and climate conditions are suitable for the cultivation of a wide range of tropical and semi-tropical agricultural crops. Earthquakes are rare and mild, but typhoons regularly threaten during the rainy season, and severe floods occur every few years.
Thailand is divided into four regions; the North, the Central Plain, the Northeast and the South (100; 3-4). The North consists primarily of mountainous and hilly terrain, with many natural forests. The Central Plain, often described as the Chao Phraya River Basin, is the richest and most extensive rice-producing area. The capital city of Bangkok is located in this region. The Northeast region is characterized by undulating hills with harsh climatic conditions resulting in frequent floods and droughts. The Southern region is partly hilly with thick forests and rich deposits of minerals and ores and also features many islands.
A.2 History and political structure
By the 13th century Thais had become a distinct cultural and political entity, and a force to be reckoned within mainland Southeast Asia. Thai princes ruled over states as far apart as Lanna (in modern Northern Thailand) and Nakhon Si Thammarat (in the modern south). However, the Thai historical imagination has been most stirred by the Kingdom of Sukhothai (13-15th centuries) and that has been viewed as the predecessor of the modern Kingdom of Thailand (100; 15).
After the decline of Sukothai, and the rise and fall of the kingdom centered on Ayudhaya, the national capital moved to Bangkok. The nation remained an absolute monarchy until the establishment of a constitutional monarchy in 1932. King Bhumibol Adulyadej last year (1996) celebrated his 50th year on the throne. Due to the great respect in which the monarchy is held, it is common for the monarch to offer informal guidance on the political development of the nation (103; 5).
The parliament is bi-cameral, consisting of the House of Representatives and the Senate. Members of the House are elected in multi-member electorates, typically with three members per electorate, and the maximum term of parliament is four years. All citizens over the age of 18 years are eligible to vote. (This was lowered from 20 in 1995.) Members of the Senate are appointed to four-year terms by the Monarch, who is advised at the sole discretion of the Prime Minister. The Senate has the power to block or amend any legislation, although substantial amendments must then be referred back to the House of Representatives for approval.
Thailand has a multi-party system and there are a large number of parties represented in the House of Representatives. Traditionally the leader of the largest party becomes Prime Minister, provided he or she can form a coalition government and gain the confidence of the house (103; 5). However, over the past 60 years Thailand's government has most frequently consisted of military-dominated administrations, often established after army coups. Since 1992, however, there have been three elections and four elected administrations. A new democratic constitution is now being implemented, designed to reduce or eliminate vote-buying and improve democratic participation.
Administration is conducted on two levels - national and local, with the latter being divided into progressively smaller units termed provinces, districts, sub-districts, tambons and villages. The chief executive of each province is a governor, appointed by the Ministry of the Interior. District and sub-district officers are also appointed. Village heads are elected, with those taking office before 1992 serving until the retirement age of 60, while those elected after that date serve five-year terms. In 1995 the first elections for sub-district government bodies were held, as part of a plan to decentralize decision making (103, 6).
A.3 Demographic features
The Thai population was estimated as 60.44 million on July 1, 1997. In 1995, urban areas were home to 18.856 million people while 40.853 million lived in rural areas. Of the former, 7.486 million lived in Metropolitan Bangkok (106, 1-2).
During the past 30 years, the population density has doubled, from 51 persons per square kilometre (p/sq. km) in 1960 to 115.2 in 1995 (73). The Bangkok Metropolis has the highest population density of about 3,758 p/sq. km in 1990 (107). In the same year the Central and Northeast Regions had a higher population density than average, at 118 and 113 p/sq. km respectively. Population density in the South was 99 p/sq. km and the North had the lowest population density of 62 p/sq. km (107).
The 15.7 million young people aged under 15 years accounted for 29.2 per cent of the country's population in 1990, down from 38.5 per cent in 1960 (72). The working age group (15-59 years) increased from 56.9 per cent in 1960 to 34.8 million persons or 63.4 per cent in 1990. About 3.97 million persons or 7.4 per cent were aged 60 year and over (72). The Northeast had the highest proportion of the young people, while Bangkok Metropolis had the lowest. The highest proportion of the senior citizens was in the North and the Northeast.
The age dependency ratio, the ratio of persons in the dependent ages (under 15 years and 60 years of age and over) to those in the working age (15-59 years), was 56.5 in 1990 (72). In other words, there were about 57 dependents for every 100 persons of working age, much reduced from recent decades, when the figure was well over 100 (72). If the age dependency ratio is divided into child dependency and old age dependency, it is found that the child dependency ratio was 45.1, reduced from 90.3 in 1960, and the old age dependency ratio increased from 10.0 in 1960 to 11.4 in 1990 (72).
The number of single people over 13 years of age (the statistic selected by the NSO, although it would be expected there would be very few married people under 16, due to legal restrictions) increased between 1960 and 1980 and reduced in 1990 (72). There were 17,710,300 persons aged 13 years and over were single or 36.3 per cent in that age group. The proportion of single males was greater than that of single females (36.8 and 30.4 per cent respectively).
Those who currently exhibited marital dissolution consisted of 5.8 per cent widowed, and 2.1 per cent divorced and separated. The proportions of marital dissolution were remarkably different between males and females (3.5 and 12.1 per cent respectively). The proportion of single individuals was much higher in municipal areas than non-municipal (42.8 and 31.2 per cent respectively).
By region, the Bangkok Metropolis had the highest proportion of single individuals (45.3 per cent), while the North had the lowest proportion (29.1 per cent). The proportion of marital dissolution was similar for all regions (around 8 per cent), although the Bangkok Metropolis had the lowest proportion of individuals whose marriages had ended, at 6.7 per cent.
Among ever-married women aged 15 years and over, the fertility rate showed an average of 2.9 live births, with the average number of living children of 2.7. These figures were lower in municipal areas than in non-municipal areas.
The crude birth rate had been reduced from 44.2/1,000 people in 1965 to 17.14/1,000 in 1995 (73). In 1994, the highest crude birth rate was in the South (25.8/1,000) while the second highest level was in the Northeast (22.8/1,000). The North and the Central had similar crude birth rates of 17.8 and 17.6 respectively. The lowest rate was in Bangkok Metropolis (14.7/1,000 population) (107).
The country's crude death rate has been reduced from 10.9/1,000 population in 1965 to 6.1 in 1995. The North had the highest rate through out 1994-1995. The South had the second highest rate of 6.6/1,000 population in 1991. The Northeast and The Central had crude death rate of 6.3 and 5.6 respectively and Bangkok Metropolis had the lowest of 3.3/1,000 population (107).
The difference between the crude birth rate and the crude death rate has had an impact on the population growth rate. The highest annual population growth rate was 1.9 per cent in the South. The Northeastern rate was in the second (1.6 per cent). The Central rate was 1.2 per cent. Bangkok Metropolis and the North had about the same rate of 1.1 per cent population growth (107).
A.4 Social features
Buddhism is the state religion. About 95 per cent of population are Buddhists with an almost equal proportion between males and females (72). Under the constitution, the Monarch must be a Buddhist, but is also the upholder of all religions, with freedom of religion guaranteed. Muslims are the largest religious minority and are concentrated in the south of Thailand. According to the 1990 Census they comprised 4.1 per cent of the population. Christianity, the second largest minority religion, is followed by 0.53 per cent of the population (100; 151). Others are Hindu, Sikhs, Brahmins and Confucians, under the classifications applied by the census.
Although Buddhism is the main influence in the Thai society, it is by no means the only one. Underlying this national religion are a host of other faiths and beliefs that are often so intertwined, including beliefs in various forms of the supernatural such as ritual charms, potions and amulets that are believed to provide the wearer with strength, protection, or a general well-being.
Thai is the national and official language and is spoken and understood by nearly all of the population. In addition regional dialects are spoken, particularly in the south and the north-east, where the people have strong cultural and kinship ties with the citizens of neighboring Lao. In the mountainous regions of the north and along the western border with Burma there are minority groups known as hill tribes, which have distinct linguistic and cultural identities. (100)
In addition, Thailand has on its soil a large number of undocumented migrant workers, with the National Security Council estimating between 700,000 to two million foreign laborers in Thailand (130; 1). Attempts have been made to develop measures to regularize their status, but none have yet achieved widespread acceptance and following the economic downturn, moves are being made to expel many of them.
The proportion of the poor among the total population dropped from 26.3 per cent in 1986 to 13.7 per cent in 1992. But this has been accompanied by an increase in income disparities, with the gap between the income of the top and bottom 20 per cent of households rising from 12.2 times in 1988 to 15.8 times in 1993 (101; 4). Expressed in other terms, the top-earning 20 per cent of households now collect 60 per cent of the total income, while the lowest-income 20 per cent of households earn only 4.5 per cent of the total (101; 4).
Regionally, the north-east's average income was 10.2 times lower than that in Bangkok in 1991 and this gap widened to 11.9 times in 1994 (101;4). The difference in social and economic status among regions has induced significant internal migration, chiefly from rural to urban areas (particularly Bangkok and surrounding areas). A study covering the period from 1983 to 1988 found migrants were predominately young adults who actively participated in the labor market, implying that their major reason for migration was employment, a situation which continues. In 1992, about 7.3 million people migrated (97, 1992). Among these, about 75 per cent or 5.6 million, had been living in rural areas. Male migrants slightly outnumbered their female counterparts.
An interesting characteristic of the Thai pattern of migration is, however, its relatively temporary nature. The 1992 National Migration Survey found 1.5 million people had moved back to rural areas after spending an average of five years in urban areas - mostly Bangkok (102, 99). The reason giving by the returning migrants themselves was mostly the unpleasant nature of city life, including pollution, traffic jams and poor infrastructure, although researchers concluded that being discarded for younger or better-qualified workers was also a factor in some cases.
A.5 Education
In 1996, the national budget allowed for expenditure of 171,914.1 million baht on education, 20.4 per cent of the total budget and 3.54 per cent of GDP, as shown in Table 1. This reflects a substantial increase in spending over recent years. Social services and national security were the second and third categories, with 117,705.1 and 108,015.6 million baht or 14 and 12.8 per cent respectively (108; 1996).
Primary school facilities are available to almost the entire population. In 1994, the proportion of students in the school-aged population was 94 per cent. The literacy rate was 91 per cent in 1985. It rose to 94 per cent in 1992 (109). It would appear this statistic relies on census data, augmented by graduation records, with the assumption being made that each person who has graduated from school is literate. Problems with later loss of literacy, or schooled illiteracy, have not been investigated.
Education in Thailand starts from three years of pre-school for children aged 3-6 years, although this is not compulsory. Six years of primary education, for children generally aged from 6-11 years, is compulsory. Secondary education is divided into two parts; three years for lower secondary level and another three years for upper secondary.
In the past few years there have been significant efforts to increase pre-primary education, particularly among disadvantaged sectors of the population. In 1996, 200,000 pupils were enrolled in Ministry of Education-funded pre-school centers, up from 20,000 in 1993. They attended 3,474 centers concentrated in the poorer northern and north-eastern regions (101; 36).
The enrollment of students in lower secondary schools has historically been low. It rose from 29 per cent of the population aged 13-15 years in 1980, to 35 in 1985, 40 per cent in 1990 and 64.5 percent in 1994 (108). This is low compared to other South-East and East Asian countries, with comparable figures in 1988 being 48 per cent in Indonesia, 57 per cent in Malaysia, and 87 per cent in the Republic of Korea (110). The government is now moving to make lower secondary education compulsory for all Thai students. The transition rate of students from the final year of primary school to the first year of lower secondary school rose from only 40 per cent in 1988 to 85 per cent in 1994 (108).
The enrollment in upper secondary school was 34.2 per cent of the relevant age groups in 1994. It rose from 21.6 and 24.3 per cent in 1982 and 1987 respectively. University enrollments are also increasing. They rose from 5 per cent of the relevant age group in 1982 to 15.7 per cent in 1994 (108).
In 1993, 80.3 per cent of total work force in Thailand had only primary education or lower attainment. It was estimated that by the year 2000, more than 70 per cent of country workforce will still have only primary education. It is clear that future demand will be for an educated workforce to produce high technology products for exports (109), but this demand will be very difficult to meet.
Although the provision of education in Thailand has improved in terms of the amount of students' attainment, very significant educational inequalities still exist, with huge regional disparity and differential access based on socio-economic status. The majority of students in universities are from business or professional families (110).
A.6 Economy
Over the past decade the driving force for change in Thai society has been economic growth, with the nation recording the world's fastest rate of economic growth between 1985 and 1994, an average of 8.2 per cent. Per capita income rose to a forecasted $US3,139 in 1995 (111). In the last year, however, there has been asignificant economic downturn, the impact of which will certainly be significant, although as yet this is difficult to assess.
A long-term trend has seen the importance of agriculture declining and industrial production and services increasing as a proportion of GDP has also accelerated. Agricultural production contributed 38 per cent of GDP in 1960, but only 11 per cent in 1995 (111). Manufacturing production rose from 13 per cent of GDP in 1960 to 30 per cent in 1994 (111). Bangkok and surrounding regions have been the primary contributors to the growth of the manufacturing and service sectors. In 1993, the share of GDP at 1988 constant prices of Bangkok and vicinity was 56 per cent of the national total (111). Thailand's manufacturing sector was originally based on value-adding to primary products. Initially growth in manufacturing was in low-tech industries such as clothing and footwear production, but since around 1990 investment has increasingly swung towards medium-tech industries producing goods such as electronics, computers, petrochemicals, machinery and motor vehicles (102, 36).
Tourism has also been important in economic development. Since 1987 (Visit Thailand Year), it has outstripped other sectors as a source of foreign exchange. Tourist arrivals topped 5.4 million in 1995, a 13 per cent increase from 1993, and they provided an estimated 170 billion baht in national income (103; 3).
The proportion of people employed in the agriculture declined from 84 per cent in 1960 to 51 per cent in 1992 (113). This was balanced by a rise in industrial employment, from 4 per cent in 1960 to 15 per cent in 1992. With this employment concentrated in Bangkok and surrounds, this has led to significant migration, with 1.1 million people in the 15-30 age group leaving the poorest north-eastern region from 1980 to 1990, most moving to Bangkok (103; 99).
Overall, unemployment has usually been low, although with the current economic problems is again becoming a problem. The latest available study found that 375,100 people were unemployed (1.1 per cent of the labor force), of whom 55 per cent were female. The majority of both males and females in this group had only primary education or less. Shortages of some skilled and unskilled workers are experienced frequently in various regions and economic sectors, although there is believed to be significant underemployment in rural areas. Various estimates suggest that in the near future between one and two million people will be unemployed.
The rapid growth of exports and imports indicates the increased openness of the Thai economy. The share of merchandised exports (fob) plus merchandised imports (cif) to GDP (at current prices) increased from 26 per cent in 1970 to 67.9 per cent in 1994 (112). However, in 1995, exports grew at the rate of 22.5 per cent while the imports grew at the higher rate of 27.6 per cent, leading to a trade deficit amounting to 8.3 per cent of GDP (112). The composition of imports has moved increasingly away from consumer goods towards capital, intermediate and raw material goods. The import of capital goods alone has grown from 25 per cent of total imports in 1960 to 55 per cent in 1994 (112). Inflation has been moderate, at around 5-6 per cent, (114), but is expected to rise significantly in 1997-8..
The Thai government has sustained a budget surplus since the 1988 fiscal year. In 1995, the surplus was $US5.6 billion. However, external debt as at September 1995 was $US 63,884 million (39 per cent of GDP), made up of public sector debt of $182 million and private sector debt $47,536 million (101; 3). This problem has been made more serious, and the ratio of debt to GDP significantly worsened by the recent devaluation of the Thai currency.
The high rate of economic growth and rapid structural change in the Thai economy have created some significant problems. Infrastructure bottlenecks are a serious problem, mainly due to the concentration of growth in Bangkok and other large cities. The average speed of vehicles in Bangkok is 10km/h (114; 14). Pollution levels have been rising in waterways and in the urban atmosphere.
Since 1961, government development measures have operated within the framework of successive five-year plans, most of which have focused almost solely on encouraging growth in the gross domestic product, with the assumption that benefits of such growth would eventually "trickle down" to disadvantaged areas and society sectors (115, 299). The focus of the eighth such plan, which came into effect on October 1, 1996, is, however, somewhat different. It aims for a slightly lower annual growth rate of 8 per cent, with an increased stress on human development and social improvement, rather than simply on increasing the GDP (116, 23). Attempting to address the increasing disparities in income distribution discussed above, the plan states agricultural workers' average wages should not fall below 1/13 of that of workers in the non-agriculture sector.
The plan sets a target for the reduction of the percentage of people classified as poor from the 1992 level of 13.7 to 10 per cent in 2001. The plan also focuses on dispersion of property ownership through fiscal and monetary policy, upgrading quality of life of rural people, carrying out agricultural restructuring and dispersion of industries and services to regions, developing regional centers, and occupational development and upgrading of the quality of life of the urban poor (116, 16).
A.7 Environment
Environmental problems can be broadly divided into two groups - those which primarily affect rural areas, and those which predominate in urban areas. The latter are mainly found in the Bangkok region. Bangkok alone accounted for 51 per cent of country's energy consumption for local transport (118; 15).
Lead pollution has been one major problem. Throughout the early 1990s lead levels in congested areas of Bangkok consisted exceeded the standard set by the National Environment Board. (117; 25). An associated problem is lead levels in food (which is often stored, cooked and consumed at road-side stalls). This problem, however, appears to be being brought under control with the introduction of unleaded gasoline in 1992 and its increasing use (118, 1993; 15).
Concern has been growing, however, about the dangers presented by dust and other airborne pollutants. Tests in mid-1996 indicated that in many areas of Bangkok the level of dust particles smaller than 100 microns was 11 to 58 per cent above the safety standard. Levels of particles under 10 microns exceeded the standard by up to 100 per cent. This is believed to be a major contributing factor to respiratory problems, with an estimated 1 million residents of the capital suffering from problems created by the dust. A Chulalongkhorn University study found families of students attending a selection of Bangkok schools were on average spending 1,500 baht a month on treatment for respiratory illnesses (131).
The hazardous waste problem associated with industry (which affects both urban and rural areas) has also dramatically worsened in recent years. It is estimated that Thailand will produce 2.8 million tons of hazardous waste per year by the year 2000. Disposal facilities are limited. (119) Water quality is being significantly affected by industrial waste, affecting both domestic supplies, agriculture and the natural environment (120; 13).
Industrial chemicals are also having an increasing negative impact on the health of workers. The Ministry of Public Health reported a substantial increase in incidence of occupational health problems from 2 per 100,000 population to 9 between 1978 and 1987. One of the most important occupational ailments is lead poisoning. A MOPH study in 1987 showed that more than 14 per cent of cases of occupational exposure to recorded lead-in-blood levels exceeding 60 mg per 100 milliliters, with 0.5 per cent of the sample reaching the critical risk level of more than 100 mg per 100 milliliters. Twenty per cent of the sampled workers in lead-associated plants registered above-normal concentration levels.
In rural areas, forest depletion is the major environmental problem. In Thailand, the percentage of land covered by forest has been depleted from 53.3 per cent in 1961 to 26.6 per cent in 1991. From 1976 to 1982 the average rate of loss was 3.8 per cent per year, one of the highest among the tropical countries (121; 19). Forest loss is a major cause of CO2 emissions into the atmosphere, contributes to increasing severity of floods due to increased run-off and is believed to be a contributing factor to the increasing frequency and severity of droughts, particularly in the north-east region.(121; 19).
Another environmental problem in rural areas is contamination through the increased use of chemicals in agro-industries. An Agriculture Toxicology Division survey in 1982-1985 found that 90 per cent of rice and cereal specimens on the market contained organo-chlorines, which can cause cancer in the human body. Exposure of workers to these chemicals, often without appropriate safety equipment and education, is also a serious problem.
Thailand also faces a number of problems in what might be regarded as the social environment. The abuse of illicit drugs, particularly amphetamines, has been identified as a major health and social problem, one which has spread widely through society. The number of drug addicts seeking medical attention increased from 53.7 per 100,000 people in 1981 to 102.4 per 100,000 in 1985, and is believed to have continued to increase since then (96; 10).
A TDRI survey in 1993 found that there were 247,965 registered amphetamine addicts in 1993-4, but this figure did not include unregistered addicts, and it is believed that since this time the level has risen further. Concern about the problem has led the government to increase penalties for dealing in and supplying amphetamines to equal those for heroin, reflecting the level of concern about the problem (132; 2).
Changing social structures, including the breakdown of the extended family, increased rate of marriage breakdown and separation of families for long periods due to inter or intra-national migration for work, has also significantly changed the social environment. An increasing number of broken families has exposed many children to high risk of adopting drug use, or of becoming homeless or delinquent.
Particular concern has been expressed about increasing suicide rates, believed to be related both to increasing mental health problems and general problems in society. The number of cases reported to the Police Department rose from 1,029 in 1990 to 1,451 in 1994. Department of Health figures show that from October 1993 to September 1994, 1,909 people committed suicide, a rate of 48.67/100,000 people. This increase has been generally attributed to an increase in social, economic and personal pressures related to "modernization" (103). Its extent may not be fully recorded in the above figures, due to the social stigma attached to it and the resultant desire to avoid classification of deaths as suicide whenever possible..
A.8 Health
(a) Organization of the health care system
Provision of health services is the responsibility of the central government. Free health care is available in State hospitals to those who cannot afford to pay for treatment. Individuals earning less than 2,000 baht per month and couples earning less than 2,800 baht per month are eligible for a social welfare card that provides free treatment in government hospitals. Senior citizens (over 60 years of age) and children under 12 automatically receive free treatment and welfare schemes run by individual hospitals provide for care for those who had do fall within these groups, but cannot afford to pay (103; 48).
In addition, free services are provided to government workers, many factories and enterprises have social security schemes, and there is a health card system for workers in the informal sector (of agriculture). Free treatment schemes cover doctor's fees, medication, in-patient accommodation, surgical fees and necessary medical equipment. However, there is greater demand than supply for these services, public wards are often overcrowded, and patients may wait months or years for treatments such as joint replacements or organ transplants (103; 48).
The Ministry of Public Health (MOPH) is the principal government organization responsible for organizing health care facilities. Additionally, there are some other government agencies contributing their health-related activities to improve the health status of specific groups of the population that they serve. These government organizations are the Ministry of Interior, the Ministry of Defense, the Ministry of University Affairs, and so on. Health care services provided by government organizations encompass preventive and promotional, curative, and rehabilitative services.
MOPH has eight major departments (98): the Office of the Secretary to the Minister; the Office of the Permanent Secretary for Public Health; the Department of Medical Services; the Department of Health; the Department of Communicable Disease Control; the Department of Medical Sciences; the Office of Food and Drug Administration; and, the Department of Mental Health. These organizations are responsible for planning, supporting monitoring and evaluation of public health services provided mostly at provincial level. MOPH provides medical and health services through peripheral health facilities located at provincial, district and village levels. In order to launch the policy of "Health for All", at household level, the MOPH trained village health volunteers (VHVs) and village health communicators (VHCs) to serve every household with primary health care all over the country.
The primary purpose of health service outlets organized by MOPH is to serve a majority of the population outside Bangkok. These encompass regional hospitals and general hospitals at provincial level, community hospitals at district level, and health centers and community health service stations at tambon and village level. The services provided by the hospitals are predominantly curative, with a certain amount of preventive promotion, and rehabilitation services. Preventive and promotion health services, predominantly MCH and FP services, and basic curative services are available at rural health centers. The rural health centers, the grassroots health facilities located nearest to the rural communities, serve as referral units at the primary level of the government health care delivery system.
In addition, community health service stations (CHSSs) are the smallest health facilities providing basic health services in politically sensitive areas, some remote rural areas with scattered populations along the border of the country or in ethnic minority villages. Beyond the government sector, many NGOs are also providing health care services to some segments of population. These NGOs are mostly non-profit or charitable organizations. In Bangkok and other urban areas, private hospitals, private clinics, and private drugstores are playing a significant role in health promotion and curative activities. In rural areas of the countries, most of the prevailing private health facilities are local shops where basic drugs are available for sale, local healers such as Buddhist monks, injectionists, herbalists, traditional doctors, traditional birth attendants (TBAs), as well as spirit doctors. MOPH licenses and trains producers of herbal medicine. In 1995, there were 381 herbal medical health facilities and 2,313 herbal drug stores. There has however been a policy to discourage the use of traditional healing in unsupervised circumstances due to the dangers of misuse and mistreatment.
The private sector is playing an increasing role in providing health services in Thailand, due to increasing prosperity and government support through Board of Investment policy. Under this policy, private hospitals are taxed at a low rate during the first three to five years after establishment. According to the Bureau of Health Policy and Planning Division, the number of private hospital increased from 164 in 1982 to 122 specialized and 209 general service hospitals in 1991 (63).
(b) Investment in the health sector
In 1992, per capita health expenditure in Thailand was $US101, up from $US55.5 in 1988. Average household expenditure on health per annum in 1992 was $US120 (122).
In 1995, the national budget for the MOPH was 46,412.2 million baht (6.31 per cent of the total national budget and 1.1 per cent of GDP). This increased from 20,568.6 million baht in 1990 (4.84 per cent of total national budget and 0.9 per cent of GDP), or 125 per cent within five years. In term of budget expenditure classified by sector, public health consumed 44,335 million baht in 1994. It increased to 52,596.9 million baht in 1995.
In 1994, there was a total of 1,127 hospitals with 93,540 beds in Thailand. Of those beds 22,404 were located in Bangkok and 71,136 in the provinces. The ratio of population to beds in Bangkok was thus 1:249, as compared to 1:628 in provincial areas. The national average was 1:747. (63, 1994; 146)
In 1994 there was one physician per 4,165 people (63, 1994; 153), although also in 1994 the Medical Council Association of Thailand calculated the ratio was 1:3,012 for both public and private sectors. The numbers of other health workers are still considered to be very low and they are concentrated in Bangkok.
(c) Nutritional and Health Status Indicators
The 1993 National Food and Drug Committee Report showed the Thai people had an average calorie intake equal to 2,443 Kcl/day, 126 per cent of the Recommended Dietary Allowance of 1,936.3KcL, calculated in 1986 (RDA). However, malnutrition remains a problem, especially among pre-school children, although the problem has decreased with increasing average incomes.
In line with increasing levels of general prosperity and increased health services, there have been significant changes in the causes of morbidity and mortality, which have seen Thailand go through what has been described as a "demographic transition". This has seen a decrease in the importance of infectious diseases and those related to undernutrition and sanitation problems, but an increase in chronic health problems associated with industrialization and lifestyle and traffic and work accidents.
Overall there has however been significant decreases in crude death rates (as discussed above), which are demonstrated in increased average life expectancies, which are currently 71.7 years for women and 66.6 years for men. Life expectancy at 60 (additional years) is 22 years for women and 18.8 years for men (103, 2).
Death rates have significantly declined over the past two decades, from 9.5 per 1,000 in males and 7.9 in females (in 1976), to 6.3 and 4.1 in 1994. The major causes of death during 1987-1992 were heart disease (56.0 per 100,000 people), accidents (48.5), and malignancies (43.5). The rates for hypertension and cerebrovascular disease, liver and pancreatic disease and tuberculosis were 16.4, 13.0 and 6.1 respectively (67).
From 1987-1991, diarrhea was recorded as the most significant infectious disease (1,435.7 per 100,000 population in 1991) (63). Others were dysentery (156.3), food poisoning (106.3), measles (47.4) and hepatitis (31.6). The reported rate of cholera, 9.9 per 100,000 in 1987, had dropped to zero in 1991, while reported diphtheria rates had also dropped to zero.
Not included in the above statistics, but of major importance in considering health issues in Thailand, is HIV/AIDS. Its rapid spread is discussed in Module C.
The ten leading causes of death in rural and urban areas accounted for greater than 90 per cent of all deaths. While cancer was responsible for 50 per cent of the urban deaths, respiratory diseases were the principal killer in rural areas, accounting for 25 per cent of deaths. The rural population was proportionally more likely to die from injuries and poisoning, infectious diseases, and neonatal complications than their urban counterparts, who were more likely to die from heart diseases and cancer. In both rural and urban areas, males were more likely to die from cancer, injury and poisoning, digestive system diseases and infectious diseases than females, who were more likely to die from respiratory and heart diseases.
The rate of many other communicable diseases has also been reduced through an expanded program of immunization (EPI), with the total number of tetanus cases between 1990 and 1993 falling from 813 to 502. Over the same period the cases of diphtheria fell from 58 to 28, and measles fell from 29,463 cases to 17,851 (99). The EPI program aims to immunize every newborn baby and to ensure all children under five have received appropriate courses of BCG, DTP, polio and measles vaccines. In 1991 the rate of immunization of school children had reached 98.42 per cent, while the figure including pre-school children exceeded 90 per cent (103, 51).
Mother and Child Health and Family Planning (MCH/FP) programs have also been successfully implemented. Different calculations of the rate of infant mortality are presented (see Module C for further discussion). In 1993 the North had highest infant mortality rate, of 42.4 per 1,000 live births and Bangkok had lowest (22.5 per 1,000 live births). (63) The causes of these deaths are widely scattered across congenital and infectious diseases, and no obvious patterns are evident, except that the rate of death across all categories is declining. Considering regional mortality rates, they were lowest in the Bangkock Metropolis (22.5) and highest in the north (42.2)
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