World Health & Population
The World Health Organization handbook on Strategizing National Health in the 21st Century has emphasized the importance of the process of population consultation on needs and expectations. According to Thailand National Health Act 2007, three innovative social tools for participatory healthy public policy process were proposed, i.e., health assembly, health impact assessment and health system statute (charter). In practice, population consultation process is required in the process of the tools implementation. Therefore, this paper aims to illustrate how local health statute implementation supports population participation and consultation at the local level.
The first local health statute owned by Cha-lae sub-district in Songkla Province had been introduced in 2009. So far, there are above 500 sub-districts or “Tambon” having their own health system statutes. Tambon Administrative Organization (TAO), health and non-health sectors, community leaders and civil society seemed to be key actors or a mechanism for the local health statute. This demonstrated three crucial elements or sectors for policy development, i.e., policy maker, evidence support and society. Contents of the local health statute are wide ranged, including social determinants, risks and diseases, life style, health services, health fund, to mental and social health in regard to the local problem and context. Therefore, it needs the process of discussion and consultation to seek their common interest and expectation.
Local health statute in Thailand is an example of engagement and consultation of the population for health policy. This confirmed the process of population consultation on their needs and expectation that can be implemented both at national and local levels. This is also the strategy to improve the accountability of policy makers for health impacts at all levels of policy making. The challenges of local health statute include the mechanism to maintain and ensure the engagement and ownership for sustainable implementation. Lastly, the local government’s continued commitment toward providing funding support through the implementation process and the self-assessment framework of implementation is needed.
The World Health Organization handbook on Strategizing National Health in the 21st Century emphasized the importance of population consultation on needs and expectations (Rohrer and Rajan 2016). Methods and approaches are documented and recommended taking the national context into account. Although the legal status of any country, territory or city or the area of its authority are considered, the case study of its implementation at the local level is limited.
According to Thailand National Health Act 2007 (National Health Commission Office 2007), three innovative social tools for participatory public policy process were proposed, i.e., health assembly, health impact assessment (HIA) and health system statute (charter). Obviously, the National Health Assembly (NHA) is both a platform and a process to seek participation of government sector, academia and people sector in the policy process from agenda setting, resolution drafting, stakeholder and public consultation, resolution adoption and implementation to monitoring and evaluation. In practice, population consultation is also required in the process of health impact assessment and national health system statute.
There are many sub-districts or “Tambon” that have their own health system statutes. The preamble part of the first National Health System Statute 2009 (National Health Commission Office 2009) mentions that the local partner networks can prepare their own statutes on a health system for their locality, provided that such statutes are not in conflict or incongruent with the Statute on National Health System. Therefore, this circumstance would be an example of how a mechanism is implemented at the local level for population participation and consultation.
Local Health System Statute
Tambon (sub-district) is a local administrative unit in Thailand, smaller than district and province respectively. It is the third level of the administrative division. Each Tambon consists of 8–10 villages, with the local government unit named Tambon administrative organization (TAO). The TAO council comprises two representatives from each village of the Tambon and one a directly elected president. In 2016, ~500 (out of 7,000) Tambons voluntarily declared their own health statutes.
The first local health statute was introduced in Tambon Cha-lae, province of Songkhla, in 2009. The TAO, health and non-health sectors (e.g., teacher, social developer), community leaders and civil society seemed to be key actors or mechanisms for local health statute. This showed three crucial elements or sectors for policy development, i.e., policy maker, evidence support and society. In Thailand, religion and belief are also accounted for as determinants of health. Therefore, religious leaders, especially Buddhist monks are sometimes involved in drafting health statute and implementation direction (Tambon Mae-thod, province of Lampang). To ensure its effective movement and sustainability, some health statutes can be integrated into the local strategic plan and budget (Tambon Dongmunlek, province of Petchaboon). The contents of the local health statute are wide ranged, including social determinants (economy, forest, natural resources), risks and diseases (food, tobacco, consumer protection, safe sex, non-communicable diseases), life style (observe the Buddhism precepts, alcohol-free, gambling-free, non-violence in local festival and ceremony), health services, health fund, mental and social health (Table 1).
|Table 1. Example of local health statute: Key actors, characteristics and content|
|Year||Tambon, province||Key actor||Characteristics of statute||Content/area interest|
|2009||Cha-lae, Songkhla||TAO and civil society||
||Sufficient economy, food safety, safe sex, non-communicable diseases, participatory local fund|
|2009||Sung-men (District), Phrae||District Health Office||
||Local health centre, community broadcasting, traditional health care, consumer protection, food safety, participatory health fund|
|2010||Mae-thod, Lampang||TAO and civil society||
||Forest and natural conservation, environment, land and mining|
||Traditional medicines, participatory healthcare, fund for health welfare, local fund|
||HiAP, women’s health, breastfeeding, food safety, tobacco|
||Healthy local festival (alcohol-free event), integrated volunteer and traditional health care, consumer protection, food safety, healthy workplace and home, mental health|
|HiAP = Health in All Policies; MOU = memorandum of understanding; TAO = Tambon Administrative Organization.|
From local experience, there are five steps or processes for developing local health statute. The critical first step is searching for local leaders or change agents to facilitate and organize the consultation process. Tambon establishes the local committee which is to take care of this role. Second, they then retrieve and analyze local health problems and related information including processes of sharing concerns and learning among all stakeholders. Third, change agents or local committees organize face-to-face public deliberative platforms for seeking the opinion of the population. Fourth, local committees’ drafting visions, directions and interventions for consultative discussion are documented. At this stage, organizing a local health assembly is an option. Finally, all stakeholders meet and seek a consensus and a common ground for actions. Normally, monitoring plans and updating those statutes are also mentioned. All five steps explained above include considering and undertaking a population consultation.
Consultation for a local health statute is a key success for their engagement. The health statute indicates sharing information or concerns and drawing collective vision of their local health. All activities will be aligned towards health-desirable visions. The process of extensive consultation is crucial for actively seeking the opinions of interest groups, stakeholders and local people. For pooling or consolidating all local resources, e.g., human resources, funding is usually discussed for effective implementation. Importantly, this local public policy using participatory approach and process also promotes the spirit of democracy at the local level.
The local health statute in Thailand is an example of engagement and consultation of the population for health policy. This confirmed that the process of population consultation regarding their needs and expectations can be implemented both at national and local levels. Methods in health statute engagement used both face-to-face dialogue and invited multisectoral stakeholders for a series of consultation meetings. Evidence and information were retrieved from health facilities and academic institutions and by conducting an opinion survey at the local level. This approach can capture wide-ranging contents to promote the Sustainable Development Goals (SDGs) and Universal Health Coverage (UHC).
Local- and national-level engagement is accountable towards population needs, concerns and expectations. However, the citizen dialogue at the local level can beneficially address the challenges to ensure representativity and resource-intensive need of national-level consultation. Such direct involvement leads later to ownership and active engagement of that plan implementation. The methodological design used in local consultation can also be tailored towards the specific characteristics of population and context. There are key success factors from the Thailand experience including 1) having role models and change agents; 2) exposure to a clear learning process; 3) having a wide consultation platform and a scaling-up plan; 4) using effective communication and social media; and 5) providing a clear written plan and steps of implementation.
Furthermore, this participatory local policy formulation and implementation supports the concept of Health in All Policies (HiAP), “approach to public policies across sectors that systematically takes into account of the health and health systems implications of decisions, seeks synergies and avoids harmful health impacts, in order to improve population health and health equity” (Leppo et al. 2013). An HiAP approach in local health statute here emphasizes the concerns and consequences of public policies of all health determinants. In this case study, supporting contexts are governance structures at the local level and conducting intersectoral communication and implementation. This is also the strategy for improving the accountability of policy makers for health impacts at all levels of policy making.
The population consultation obviously included raising social awareness for its own policy. The Tambon health statute could be a social innovative tool for sustainable development. This concept is possibly adopted by other counties. Challenges of the local health statute include mechanism to maintain and ensure engagement and ownership for sustainable implementation. Lastly, is the need for the local government’s continued commitment to provide funding support through the implementation process and the self-assessment framework of implementation.
About the Author(s)
Weerasak Putthasri, DDS, DSc, Deputy Secretary General, National Health Commission Office, Nonthaburi, Thailand
Nanoot Mathurapote, MA, Head of Global Collaboration Unit, National Health Commission Office, Nonthaburi, Thailand
Orapan Srisookwattana, BSc, MA, Deputy Secretary General, National Health Commission Office, Nonthaburi, Thailand
Correspondence may be directed to: Nanoot Mathurapote, National Health Commission Office, Nonthaburi, Thailand; E-mail: email@example.com; tel.: +66-2-832-1924.
Leppo, K., E. Ollila, S. Peña, M. Wismar and S. Cook. 2013. Health in All Policies: Seizing Opportunities, Implementing Policies. Helsinki, FI: Ministry of Social Affairs and Health.
National Health Commission Office (NHCO). 2007. National Health Act Thailand. 3rd published. Nonthaburi, TH: NHCO; September 2010 (Official Thai Version Published in the Government Gazette, Vol. 124, Part 6a, March 19, 2007).
National Health Commission Office (NHCO). 2009. Statute on National Health System Thailand. Nonthaburi, TH: Author.
Rohrer, K. and D. Rajan. 2016. “Population Consultation on Needs and Expectations.” In G. Schmets, D. Rajan and S. Kadandale, eds. Strategizing National Health in the 21st Century: A Handbook. Geneva, CH: World Health Organization.
Rohrer, K., D. Rajan and G. Schmets. 2017. “Population Consultation: A Powerful Means to Ensure that Health Strategies are Oriented Towards Universal Health Coverage.” World Health & Population 17(2): 5–15. doi:10.12927/whp.2017.25157.
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