Dr. Amorn Nontasut, the father of the Thai volunteer health system
By Hideki AKIYAMA
NDN Bangkok
Today, June 2nd, marks the anniversary of the passing of Dr. Amorn Nontasut, the father of the volunteer health system. Dr. Amorn passed away on this day last year at the age of 92, just as the health volunteer program was gaining recognition for its contribution to the prevention of coronavirus infection.
Upon his death, Health Minister Anutin tweeted a message of gratitude, stating, "Forty years ago, you created a fundamental system to improve the health of the Thai people." The WHO’s designation of 'Unsung Hero' might be fitting for him—a man who rose to the rank of Undersecretary at the Ministry of Health, yet remained largely unknown to the general public and might have been forgotten if not for the COVID-19 crisis.
I would like to take this opportunity to review some of Dr. Amorn's achievements. The following is from an interview that appeared in Hfocus in July 2013.
In 1953, after graduating from medical school at the age of 25, Dr. Amorn was transferred to Phrae Province in northern Thailand as a doctor for the Ministry of Health. "At that time, I was the only university-educated doctor in the province," Dr. Amorn said in the interview with Hfocus.
"I had to work with staff who were all senior to me. I was worried about how I would manage, but as I went into the forest with them to treat villagers, they gradually began to accept and care for me. Making rounds with them was a valuable experience that allowed me to connect with the villagers. There, I witnessed firsthand the villagers' plight. If they became sick, they had to sell their cows. If they were hospitalized for a serious illness, they would sell their homes and fields. It was not uncommon for them to go bankrupt."
"I couldn't let things continue this way. I was the only doctor, and I couldn’t treat all the patients in the entire province. Then, I remembered that when I was a child, if I became sick, the adults around me would give me medicine, pat my head, and stay by my side. I wondered if that experience could offer a clue."
However, the young doctor was immediately confronted with the widespread problem of goiter, which was rampant in Phrae Province at the time. Dr. Amorn had a special connection to this disease. His nanny, who had cared for him as a child, suffered from goiter, with a large tumor on her neck. Dr. Amorn had grown up stroking that large bump.
With support from UNICEF and the Food and Nutrition Department of the Ministry of Health, Dr. Amorn’s strategy was to promote the use of iodized salt. He established the first salt factory in the province and began selling the product in local markets.
"When the salt arrived from Bangkok, we mixed it with iodine at the factory and sold it in Phrae and the neighboring town of Nan. The results were satisfactory."
The incidence of goiter, which had been 84.8% before the program's introduction, was reduced to 32.6% within three years, and to almost zero after five years.
After returning to Bangkok, Dr. Amorn went to Harvard University to study public health. In 1968, upon returning to Thailand, Dr. Amorn was assigned to Chiang Mai Province in northern Thailand as a public health physician.
At that time, Dr. Somboon Wacharothai and Dr. Kamthong Suwannakit were working on a project to improve public health in rural areas in Wat Bot District, Phitsanulok Province, also in northern Thailand. The Ministry of Health was attempting to establish health centers in every tambon (Thai administrative units between villages and districts), but they were not receiving as much cooperation from the villagers as they had hoped.
After studying abroad, Dr. Amorn, full of confidence and ideas, was inspired by the efforts of the two senior doctors to start his own project in his new location.
"What we had to do was similar to their project, but the way we worked and the underlying concept were different. In Wat Bot's project, the youth were hired for money. I believed that enlisting the help of the area's elders—people who were respected in the village—as volunteers would lead to greater success."
The first thing Dr. Amorn tried to do was create the position of 'health information communicator' in the village to serve as a hub for health and hygiene information.
"There are already information networks in the villages, and they exchange information with each other. The question was, who would help us? I used the Social Metrics method I learned at Harvard. I asked three simple questions, such as, 'Who do you talk to when you get sick?' and asked the villagers to name three people."
"The survey results showed that the names given by the villagers were typically the elders and individuals who held influence in the community. When we looked into who these people were, we found that there was usually one such person for every 15 households."
Dr. Amorn recruited these village elders to work with him in spreading knowledge about health and sanitation throughout the village.
"First, I talked to them. I would tell them, 'The people say that if they have any problems, they will come to you.' These elders felt proud to be appreciated by the villagers, and most of them accepted the position."
Dr. Amorn had noticed that the villagers were already solving their health problems in their own way. However, these methods were based on experience and lacked a scientific foundation. By educating the villagers on basic medical knowledge and treatment methods, he believed health care at the village level could be dramatically improved.
"I was excited by the idea of 'volunteer village health workers' to educate ordinary villagers in basic primary care. However, implementing this from the start was challenging, so I asked the health information communicators if they would be willing to take a course in primary care to provide basic care to the villagers."
They agreed to participate, and they were all unpaid volunteers.
"We didn't pay them. They were all unpaid volunteers—elders who were already respected in the village. Because they weren't paid, they could take pride in what they were doing. Similar projects in other countries have failed to sustain themselves because they tried to motivate people with money. I believe that was fundamentally wrong."
"Some people criticized the project, saying, 'Are you trying to create fake doctors?' The criticism mainly came from my fellow doctors. From their perspective, this was the job of government officials. But as an experienced country doctor, it was clear to me that I could not take care of all the patients by myself."
In 1977, Dr. Amorn, who had been promoted to Deputy Undersecretary of the Ministry of Health, became involved in drafting the Fourth Economic and Social Development Plan (1977-1981). He made primary health care—a focus of his work for many years—one of the main themes of the development plan.
At that time, Dr. Halfdan T. Mahler, Director-General of the World Health Organization (WHO), was advocating for the establishment of primary health care with the participation of local residents under the slogan "Health for All." The 'Barefoot Doctor' system of the Chinese Communist Party, which had significant ideological influence in the Third World, appeared to have considerable sway over UN policy. The Thai government was a signatory to the UN-sponsored Alma Ata Declaration, which outlined the principles of primary health care.
However, Dr. Amorn is somewhat critical of the UN project.
"I agree with the basic idea of involving villagers in health projects because we knew that we couldn't just rely on doctors."
"However, Halfdan made the mistake of making doctors the main actors in the project, as doctors in developing countries at that time tended to be very authoritarian and believed that villagers had no business interfering with their medical care. I think this was the reason why the WHO project did not succeed as well as ours. The villagers should have been the main actors in the project."
After Dr. Amorn was promoted to Undersecretary of the Ministry of Health, he played a key role in introducing new policies in the area of primary health care, including infant vaccination, weight monitoring, and nutrition checks for children.
"I wanted villagers to stand up and take action to protect the health of their families. In traditional thinking, when villagers act independently, officials are often seen as having failed in their duties. Officials were expected to be the givers of everything."
”Because officials were expected to provide government services unilaterally to the people, it was natural for them to intervene only after illnesses occurred, leading to little interest in helping villagers prevent them.”
In 1977, thanks to the efforts of Dr. Amorn and others, the volunteer health system was launched on an experimental basis in 20 of the more than 70 provinces in the country.
n 1997, 20 years later, the number of volunteers reached 680,000, and by 2007, it had grown into a large organization with over 800,000 volunteers. By 2020, 40 years after its establishment, the number of volunteers exceeded one million, and these health volunteers made a significant contribution to the prevention of COVID-19, earning the title of "unsung heroes" from the WHO. Amidst all this, Dr. Amorn passed away on June 2 at the age of 92.
n an interview commemorating the 30th anniversary of the founding of the Health Volunteers, Dr. Amorn spoke about the reasons for the success of the health volunteer system:
"One of the reasons for the success of the Health Volunteers is that we believed the WHO's Health for All initiative would not effectively reach the villagers, so we incorporated our own ideas. We rewrote the slogan to 'Quality of Life for All' and defined the health project as part of a livelihood improvement initiative. I will never forget the angry look on Halfdan's face when I told him about this policy change, but we will see which side was right."
”Cultural factors play a significant role. The volunteers were not people who would do anything for money. Some of them may have been, but most were not. That spirit has been passed down from generation to generation. Most of the people volunteering now are the sons and daughters who grew up watching their parents serve as volunteers.”
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Reference
Hfocus, July 20, 2013
"Thai Ministry of Health reports on the 30th anniversary of the founding of the Health Volunteers.