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Providing Primary / Reproductive Health Services in Asian Urban Areas with Attention to Vulnerable Populations, Especially Women and Girls

Section Two - Nine AUICK Associate City (AAC) Reports

7. Khon Kaen, Thailand


Reproductive Health Status of Khon Kaen Municipality

Reproductive Health Services Provided by Khon Kaen Province

Views of Health Care / Urban Administrators


Dr. Chuanchom Sakondhavat 

Professor, Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University (Resource Person of AUICK First 2005 Workshop) 
Dr. Supat Sinawat 
Associate Professor, Khon Kaen University 
Dr. Chulaporn Sota 
Associate Professor, Khon Kaen University 
Dr. Jitpinan Srijakote 
Associate Professor, Khon Kaen University 
Ms. Wallapa Prangthawat 
Head, Reproductive Health Unit, Khon Kaen Provincial Health Office (Participant of AUICK First 2005 Workshop)

Khon Kaen Map

Khon Kaen Municipality (KKM) is the largest city in Khon Kaen Province, in the northeast region of Thailand, and is located 450 kilometers from Bangkok. The Municipality covers an area of 46 square kilometers, and has a population of 382,156, 186,057 male and 196,099 female (2008), and a hidden population of over 50,000 (42%) in 84 communities. Khon Kaen has been promoted to be the economic center of the northeast as well as the center of education, culture and historical sites. Thus, a lot of people move to the province for business opportunities, resulting in a non-registered population of over 300,000 persons.

1. Reproductive Health Status of Khon Kaen Municipality 

2. Reproductive Health Services Provided by Khon Kaen Province 

3. Views of Health Care / Urban Administrators 


1. Reproductive Health Status of Khon Kaen Municipality

Maternal Health 

As at the national level, Khon Kaen has experienced sustained economic development with increased living standards. Health and family planning services have increased substantially, bringing rapid declines in both mortality and fertility and a general rise in the well being of the population. 

The Maternal Mortality Rate (MMR) was reduced in Khon Kaen Municipality from 20.83 per 100,000 live births in 2007 to 15.53 in 2009. The target for MMR reduction set by the government calls for an MMR of no more than 18 per 100,000 live births. This target was reached, but the MMR has since increased to 22.53 in 2010. 

Khon Kaen Municipality has established a Maternal and Child Health Board, whose Directors include doctors from the Provincial Health Office, Provincial Hospital, District Health Office, Regional Health Promotion Centre, MCH Hospital, Khon Kaen University Hospital, as well as the Head of the Health Promotion Section of Khon Kaen Municipality Office. This is often cited as being one of the reasons for the success in reducing maternal mortality in recent years. Contributing to, but by no means the only reason for this achievement, is that it has for many years adopted and successfully implemented a safe motherhood project, aimed at developing quality maternal and child health services, strengthening health personnel efficiency, and reducing maternal mortality and perinatal mortality. Under this project a number of specific initiatives have been implemented. These include the Hospital Initiative; Action for Safe Motherhood Programme; Thalassemia Prevention and Control project; Reduction of Birth Asphyxia Project; Prevention of Mother to Child Transmission of HIV/AIDS; the Nutrition and Development Corner and Healthy Daycare Center Project; and the Bureau of Health Promotion retrospective study of maternal mortality approach, through the Reproductive Age Mortality Survey. 

Khon Kaen Munnicipality MMRKhon Kaen Municiapity Teenage PregnancyKhon Kaen Municipality Perinatal Mortality Rate

Over 97% of all births in Thailand take place in hospitals or institutions, and are assisted by professionally trained health personnel (doctors / nurses / midwives). In Khon Kaen Province, only five of 19,320 births from 2009-10 are recorded as occurring without professional service. In the case that births occur at home assisted by others, i.e. village health volunteers, traditional birth attendants or family members, a doctor or nurse makes a follow-up visit to check on the health of the woman and the baby. 

Family Planning and the Burden of Unsafe Abortion 

Family planning services are well organized and ensure quality and safety of methods, as well as ensuring that services are available at all levels of the health system at minimum expense. More women than ever are making choices over their birth spacing. The contraceptive prevalence rate (CPR) of married women at the reproductive age (between 15 and 44 years) continues to increase, and was up to 79.2 % in 2006. Despite the accessibility of family planning services and although Thai culture does not support abortion, studies suggest that around 60% of women with unplanned pregnancies seek abortion services from abortionists who are non medical-professionals, to induce abortion through using various techniques. A hospital-based survey in 1999 conducted by MOPH, DOH, found that a total of 45,990 women were admitted for treatment of abortion complications; 71.5% from spontaneous and 28.5% from induced abortion. 41.2% of all such admissions were in the age group 15-24. Regarding specific pregnancy-related conditions, it was found that 30-40% of the population in Thailand carries Thalassemia, 1% have Thalassemia and 5.5% of married couples gave birth to a newborn with severe Thalassemia. During 2008-9, more than 90 % of pregnant women and their partners in KKM have been screened for Thalassemia; five cases were terminated due to congenital anormalies and severe Thalassemia. 

Khon Kaen First ANC Before 12 Weeks of Gestational AgeKhon Kaen Breast Feeding at 6 Months

Prevalence Rate of HIV Infection in Pregnant Women 

The prevalence rate of HIV infections in pregnant women has dramatically decreased. Equally, HIV transmission from mother to child has decreased. The Thai Government policy on prevention of mother to child HIV transmission encourages health care facilities to provide voluntary counseling and confidential HIV testing to all pregnant women, and to provide antiretroviral drugs to HIV positive pregnant women for prevention of mother to child transmission, in addition to replacement feeding for all babies born to HIV infected mothers. The prevalence rate of HIV infections in pregnant women in KKM has decreased from 1.28 % in 1999 to 0.48% in 2009. However, the ratio of infection from adult male to female has increased from 3.9: 1 in 2002 to 2.4: 1 in 2009.

Khon Kaen Number of AIDS Patients

Status of Health of Children Under Five 

The overall indicators show that perinatal and child health is improving (Table 1). In 2007, the Perinatal Mortality Rate had decreased to 6.55 per 1,000 total births, already lower than the national target under the 9th NHDP which was set at 9 per 1,000 total births by the end of 2007. The rate had decreased further to 5.78 by 2010. 

Khon Kaen Birth AsphyxiaKhon Kaen Child Health Indicators

Infant Mortality Rate (IMR) and Under-Five Mortality Rate 

Infant Mortality Rate (IMR) statistics in Khon Kaen are shown on a survey of population change by the Provincial Health Office, which is carried out every 5 years. In 2003-2007, the 2007 Infant Mortality Rate was 12.65 per 1,000 live-births. The national target of the 9th NHDP was 19 per 1,000 live births by the end of 2007. Thai national data showed that the mortality rate of children under five for 2003, from the same report, was 27.39 per 1,000 live-births. By 2010, the rate had decreased to 9.85. 

Nutritional Status 

Malnutrition in Thai children appears to be decreasing, although the increasing rate of overweight children is a cause for concern. From routine health reports, the malnutrition rate in children was 8.71%. The national target of the 9th NHDP was set at lower than 7%. Reports from longitudinal research in 2001 found that nutritional status compared with weight and height, and nutritional indicators. Of children under 3 years of age, 8.9% had a height below the standard height, 8.0% were overweight, while 4.1% were underweight. In terms of breastfeeding, the exclusive breastfeeding rate at six months has increased from 19.98% in 2007, 23.53% in 2008, 46.94% in 2009 to 46.99% in 2010. It was well above the national target of 30% by the end of 2006, set in the 9th NHDP. Regarding child health and development status, the proportion of early age children with normal development increased from 71.69% in 1999 to 79.9% in 2001, on target for the national target of 9th NHDP (80% by the end of 2006). Children in the urban areas have developmental scores higher than children outside municipal areas in all aspects of child development. 

2. Reproductive Health Services Provided by Khon Kaen Province

Much data on reproductive health services are available at the level of Khon Kaen Province, which covers an area of 10,885 square kilometers, and has a population of 175,601 in 2010. 

Health Care Delivery Systems for Maternal, Newborn and Child Health 

There are several sectors other than health which play a major role and provide maternal and child health care. The most important is the Ministry of Education, which has three medical schools (Provincial Hospital and Khon Kaen University Hospital; MCH Hospital) and is responsible for the overall skills and quality of the health providers. Obstetricians and gynecologists, paediatricians, the Perinatal Society of Thailand, and the Paediatric Society of Thailand all play an important role in maternal and child health. The main donors that are interested in supporting maternal and child health programmes in Thailand include UNICEF, UNAIDS, UNFPA, JICA and WHO. 

At present, there are standard guidelines for the provision of maternal and child health services at every level of government health facilities. The majority of maternal and child health services are delivered throughout the country by government agencies at all levels of the health care system. At the village level there are primary health care units, where village health volunteers assist in providing advice and referring cases to health centers. The MCH services system at the community level is complemented by the hospital component, made up of a network of community hospitals at the district level, provincial, as well as regional, MCH and university hospitals. All levels are linked together by an established referral system. Currently 92.2% of pregnant women receive at least four antenatal care visits. The first antenatal care visit before 12 weeks of gestational age was increased from 46.18% of cases in 2008, to 65.36% in 2009 and to 67.56 % in 2010. Most antenatal care is provided in hospitals and/or health centers by medical and health personnel (doctors / nurses / midwives). In government hospitals, antenatal care services are free of charge. Services provided at antenatal clinics include: routine physical examination; voluntary counseling and testing for HIV and Thalassemia; Tetanus Toxoid vaccination; health education; and provision of folic acid and iron supplement. 

All pregnant women are given the MCH Booklet and Pregnancy Pathway at the first antenatal visit. Almost all of the mothers are found to utilize the MCH Booklet to record their antenatal and postpartum care received. Most postpartum mothers are found to receive the complete standard postpartum care; at least two visits by trained medical and health personnel (doctors / nurses / midwives). A slightly higher percentage of infants receive child care from a professionally trained health care provider. The average number of bed-days in hospital for birth is two days for both mother and newborn. If the newborn is sick and requires hospitalization beyond two days, usually the mother is discharged. Some hospitals have tried to set up a place for mothers to stay while their sick babies are being treated, to help promote breastfeeding for sick babies, and to educate mothers about essential newborn care. 

Decreased Human Resources for Maternal, Newborn and Child Health 

As stated above, most care is provided by trained health personnel, doctors, nurses and midwives. In 2003, the ratio of health personnel to population in Thailand was as follows: doctors 1:3,394; dentists 1:15,292; pharmacists 1:10,156, registered nurses (nurse midwives) 1:905 and technical nurses (nurse midwives) 1:1,952. In Thailand there are 70 agencies responsible for health personnel production, of which three are under the Ministry of Education (Nursing College, Northeast Public Health College, Nursing Faculty in Khon Kaen University). A registration mechanism is in place for the accreditation of all doctors, nurses and midwives. However, this does not as yet make periodic updating mandatory. 

Population Growth and Reproductive Health Status / Services in Khon Kaen Province 

Khon Kaen General DataKhon Kaen Motality RatesKhon Kaen Province Health Care Workers, Facilities and ServicesKhon Kaen Care ServiceKhon Kaen Infant Birth Weight


3. Views of Health Care / Urban Administrators

This section will outline the views on current reproductive health care service status in Khon Kaen Municipality of senior health care and urban administrators; namely the City Health Director, the Director of Khon Kaen Municipality and the Director of the Urban Council. 

Overall Reproductive Health Conditions 

City Health Director:
Very good but could be improved 
The targets for the overall reproductive health conditions in Khon Kaen Municipality have been achieved, especially in the female reproductive age group. There are, however, some unsolved reproductive health problems in the city, including teenage (below 20 years of age) pregnancy (14.65%, 16.59%, 17.75% and 17.29% from 2007-2010). The target being set by the Ministry of Public Health is to reduce the percentage of teenage pregnancy to below 10%. The percentage of unplanned teenage pregnancy in our city was 17%, which would lead to further consequences such as low birth weight as well as iodine deficiency of the infants. 

Director of the Urban Council: 
Needs more improvement 

People in Khon Kaen City seem to lack in self–health care, possibly due to their poor economic status. 

Reproductive Health Care Priority

City Health director: 
High 
Khon Kaen gives a very high priority to reproductive health conditions and problems. This is due to the policy being set by the Thai government and such policy also being endorsed by The Royal initiative projects, which aim to provide integrative service and care to all age groups of the Thai population. 

Director, Urban Council: 
Low: the problem is still very serious but priority is low due to other competing demands. 
The low priority of RHC in Khon Kaen city could possibly be a result of: 

1. No organization or specific unit that is directly responsible for providing reproductive health care and lack of public relations services in this aspect; 
2. No adequate monitoring system to assess the progress of the projects involved in RHC; 
3. Budgetary deficit. 

Resources 

City Health Director: 
Quite good 
We feel that our city does have quite adequate amounts of human resources and materials or instruments needed for reproductive health services. However, in the aspect of budget allocation, we think that there are still some disproportions in distributing such fiscal budget to each type of health service. Only 40% of the health budget was allocated to health promotion at the community level. The majority of the budget, in my opinion, was used in the fast growing aspects rather than more sustainable facets. 

Director, Urban Council: 
Woefully deficient 
Most of the governmental budget is allocated to structurally fundamental sectors such as providing more coverage of transportation or electricity to the community. The health care sector obtained a very limited amount of budget. The urban council, however, has provided some budget to support equipment that can be used for health promotions, such as disease-screening set. 

Reproductive Health Issues Addressed

City Health Director: 
1) STDs, especially in people below 20 years of age 
2) HIV/AIDS 
3) Family planning for the health of mothers. In this aspect, the problem we are facing is teenage pregnancy. This problem usually occurs in teenagers coming from other cities for education purposes in Khon Kaen Province. Most of their pregnancies were unplanned. They, therefore, denied to uncover their health problems and rejected antenatal care. 

Director, Urban Council: 
1) Teenage sexual activity resulting in STDs 
2) HIV/AIDS 
3) Unplanned pregnancy 
The major reproductive health problem in Khon Kaen City is premature sexual activity of teenagers which subsequently leads to STDs and unplanned pregnancy. A major contributor to this problem may be the lack of family ties, since in some families the parents have had to migrate to other places for work, so teenagers would have to stay on their own or with their grandparents instead of their parents. 

Specific Needs of the City to Improve its PRHC Services 

City Health Director: 
Less than adequate services, more is needed in: 
Funds 
Political support 
Better co-operation among the organizations involved in this service 
More budgetary and political support is needed for reproductive health services from the government. Better co-operation among the organizations involved in these services is also required in order to provide an integrative service to our people. There is an adequate amount of personnel, equipment and facilities. 

Director, Urban Council: 
Less than adequate services, more is needed in personnel 
The city needs effective personnel who are willing to establish an active move to target people at risk of reproductive health problems. The health promotion projects, especially safe-sex and sex education, should be established from primary school level onwards. 

Special Programs to Increase Services to Slum Dwellers

Director of Khon Kaen Municipality: 
The city has provided several projects for slum dwellers including: 
A. For general slum dwellers:
1. Health promotion and health prevention projects (provision of a total budget of five million baht per year). 
2. A policy was set to transfer decision making and budget from the city municipality to local municipality, so that local health needs would be properly served. 
3. A health awareness project is implemented in slum areas to encourage people to take care of themselves and to set the priorities of their community health problems. 
4. Health promotion projects for disabled people. 

B. For HIV/AIDS cases in slum areas: 
1. A monthly allowance of 500 baht is provided to all cases by the municipality. 
2. Several projects for work training are provided to this special group. 
3. A scholarship is provided for educational purposes to children with HIV. 

RH Services to Immigrants

City Health Director: 
With regards to the migrants, if they have transferred their medical service registration to Khon Kaen City prior to migration, most forms of health service can be provided. The major problem that we usually see is that most migrants do not prepare themselves well enough before migration so they might find difficulty in getting access to some medical services, due to lack of health care registration in the area. 

Director, Urban Council: 
The City sets the priority to provide health services to people who have registered with the health system in the city area. For those who have just migrated into the city without registration to the health system in the city area, difficulties in accessing health care services will be found. 

Budget 

a) Costs covered by city government: THB 1,291,280 
b) Costs covered by national government: THB 112,171,068 
c) Costs covered by other sources (eg. donors etc.): THB 1,750,000

Khon Kaen Objective RH Services Data

Khon Kaen Objective RH Services Data (Continued)

CONTENTS

Top

Foreword

Section One

The New Urban Challenge for Primary and Reproductive Health Care

Executive Summary

1. Background: Urban Growth and Urban Primary / Reproductive Health (RH) Services

2. An AUICK Research Project Report

3. Regional Findings

4. Individual City Findings

5. Summary and Implications

Section Two

Providing Primary / Reproductive Health Services in Asian Urban Areas with Attention to Vulnerable Populations, Especially Women and Girls:

Nine AUICK Associate City (AAC) Reports

6. Kuantan, Malaysia

7. Khon Kaen, Thailand

8. Weihai, China

9. Surabaya, Indonesia

10. Olongapo, Philippines

11. Chennai, India

12. Faisalabad, Pakistan

13. Danang, Vietnam

14. Chittagong, Bangladesh

Annex I.
Research Instrument: AUICK Research Project Outline

Annex II.
AUICK Research Project Participants


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