Paradigm Conflict: Village Health Volunteers and Public Health in Thailand

Abstract

Reformist doctors in Thailand have combined to create a primary health care system in rural areas in which village health volunteers play a major role. Consistent with the WHO whole-of-society approach, these doctors have envisaged a decentralised system that emphasises volunteers as community oriented, self-reliant agents of change. Our ethnographic research in Chiang Mai, Thailand, reveals that these ideals of village health volunteer empowerment have not been realised. Rather, village health volunteers have become entrapped in a hierarchical, top-down health bureaucracy that affords them limited deliberative agency. We argue that this predicament reveals a conflict of paradigms between, on the one hand, an idealised holistic, spiritual dimension of health with village health volunteers as dedicated, self-sacrificing agents of local communities and, on the other hand, the imperatives of state authoritarian interventions in the avian influenza and COVID-19 pandemics, including rigorous public health protocols and epidemiological methods.

Keywords:

• Village Health Volunteers
• Thailand
• Public Health
• COVID-19
• Communitarianism
• Biomedicine

Introduction

The World Health Organization Alma Ata Declaration in 1978 underlined the importance of community health workers, as part of a health team, to the success of primary health care (PHC).¹ Notably, the Declaration emphasises that primary health care ‘requires and promotes maximum community and individual self-reliance and participation in the planning, organisation, operation and control of primary health care’. The World Health Organization (WHO) ideal of community health worker agency is highlighted by Dr Sanguan Nitayarumphong, of the Health Planning Division of the Ministry of Public Health (MoPH), who considered village health volunteers as crucial to effective community involvement in health care: ‘Volunteers not only assist health personnel in service provision. They are supposed to identify their own problems, determine ways of solving those problems and implement them with financial and technical support from government officers, as well as mobilise their own resources’ (Nitayarumphong 1990, 250, authors’ emphasis).² This is consistent with the earlier directive of the 4th Public Health Plan (1977–1981) that volunteers be trained to be ‘leaders of change’ (WVO 2014, 18).

Thai reformist doctors played a major role in the development of community-based primary health care in Thailand, including the village health volunteer movement. From the early 1970s alternative discourses emerged to contest the dominance of medical elitism. In particular, these counter-hegemonic narratives sought to promote the decentralisation and democratisation of public health in Thailand. The watershed of this opposition to medical elitism was the student uprising of October 1973, which put an end to military dictatorship and fostered parliamentary democracy and civil society organisations. A prominent reformist was Dr Krasae Chanawongse, who formed the New Force Party (Phak Phalang Mai) to contest the parliamentary elections of 1975. In 1982 he became the founding director of the ASEAN Training Centre for Primary Health Care Development. Dr Krasae criticised the ‘medicalisation of Thai society’. Medical knowledge, he argued, needs to be ‘de-mystified, decentralised and democratically distributed to be equitably useful’ (Cohen 1989, 168).

Arguably the most influential reformist doctor in Thailand has been Prawase Wasi. In his voluminous writings, in Thai and English, he has decried the inequitable distribution of health resources—the concentration of hospitals in cities, excessive medical specialisation and reliance on complex medical equipment, the monopolisation of healing by the Thai medical profession and its denigration of traditional medicine and practitioners, and an unethical emphasis on personal gain. During the liberal political period between 1973 and 1976 he founded the Folk Doctor Association and the Buddhist Bareheaded Doctor scheme. In the 1980s he was chairman of the Coordinating Committee for Primary Health Care of Thai NGOs as well as a key figure in establishing the Medical Education for Students in Rural Areas Project in 1974 (Cohen 1995, 162, 172). In 1986 he initiated the Sampran Forum as a meeting place for progressive medical professionals.³

Dr Prawase’s formation of the Bareheaded Doctor scheme (modelled on the Chinese barefoot doctors) reflected his awareness and understanding of the relationship between Buddhism and health as well as the influence of the demythologised and inner-worldly Buddhist thought of the monk Buddhadasa (1906–1993). In the 1970s Buddhadasa had a profound influence on Prawase and other progressive members of the Thai elite and middle class who were concerned with the consequences of unrestrained capitalist growth and were supportive of a ‘Buddhist road to development’. Buddhadasa’s influence included professors (such as Dr Prawase) and students of the prestigious Siriraj Medical School where Buddhadasa lectured in 1961 and 1962, encouraging a ‘discourse on morality among medical intellectuals’ (Puaksom 2014, 186). Prawase himself urged Thais to stop following Western thought and materialism and to rebuild Thai society by promoting a moral community (chumchon thamniyom) (Puaksom 2014, 186–187).

Dr Prawase was also a prominent advocate of the community culture (watthana chumchon) philosophy—an expression of ‘Thai communitarian thought’ (Shigetomi 2013, 1, 22). Prawase’s communitarianism emphasised economic self-reliance and the development of community culture through the promotion of family, the Buddhist temple as the centre of community life, and mutual help (Cohen 1995, 172). Buddhism, he argued, encourages a sense of public service. Consistent with his communitarianism was his call for a diminution of the power of the state bureaucracy with greater authority given to communities, in particular community health workers.

Thailand’s First National Economic and Social Development Plan, 1977–1981, had already foreshadowed the use of community health workers in primary health care as national policy prior to Alma Ata, following the experience of pilot projects in Phitsanulok province, Saraphi and Samoeng districts in Chiang Mai province, and in Lampang province in the 1960s and 1970s that included village health volunteers (Village Health Communicators⁴ and Village Health Volunteers) (WVO 2014, 17; see also Nitayarumphong 1990, 248). Dr Prawase’s Bareheaded Doctor and Folk Doctor schemes also served as precedents. A complementary development that became critical to the effectiveness of the institution of Village Health Volunteers (VHVs) was the introduction and proliferation of community hospitals at the district level. The number increased from 254 in 1977 to 725 in 2003 out of 795 districts (Wibulpolprasert 2005, 323). The growth of district hospitals served to encourage collaboration between local health professionals and village health volunteers (asasamak satharanasuk pracham muban).

Our study focused on the 15 VHVs of Ban Kat town, number 5 ‘village’ (mu.5) of the sub-district, where both authors have previously carried out research. Interviews with the team leader of the Ban Kat village health volunteers were initially conducted in April and May 2020 by phone from Sydney, Australia, due to the difficulty of travelling to Thailand at this stage of the COVID-19 pandemic. When travel to Thailand was possible, we carried out fieldwork between August 2022 and February 2023, with a follow-up field trip in January 2024. This involved interviews with a senior nurse and two epidemiologists (one responsible for the VHVs) at the Mae Wang district hospital with the support of the hospital director, an interview with the head nurse at the local community health centre, attendance at several monthly meetings of the Ban Kat VHVs, and in-depth interviews with each volunteer, some of whom we followed up for further interviews. We also observed and had numerous informal conversations with VHVs, including two team leaders during VHV household visits, and attended several VHV social gatherings. Our interviews were conducted using a combination of central and northern Thai language.

Village Health Volunteers of Ban Kat, Mae Wang District, Chiang Mai

Ban Kat is located about 30 kilometres south-west of Chiang Mai city and is the main market town in the district (amphur) of Mae Wang, with a population of 969 in 2023. Many of the residents are descendants of Shan immigrant traders who settled here in the late nineteenth century. Mae Wang currently has a population of 32,000 in five sub-districts (tambon). The Ministry of Public Health is the largest provider of health services in Thailand, supplying various levels of government health facilities, including regional and provincial hospitals located in provincial capitals, district community hospitals, sub-district health promoting hospitals, and subdistrict-level community health centres which serve several villages. Mae Wang District Hospital was built in 1991 about six kilometres west of Ban Kat, at the edge of the foothills of the western highlands, for the strategic purpose of providing easier hospital access for remote highland villages of Northern Thai, Karen, and Hmong ethnic groups. Mae Wang hospital is a 60-bed hospital and has a close relationship with village health volunteers throughout the district. There is also one 10-bed Sub-District Health Promoting Hospital located in a village adjacent to Ban Kat. In 2022 there were 762 village health volunteers in the district and 131 in the nine villages of Ban Kat sub-district. There are altogether 1.04 million VHVs in Thailand (Narkvichien 2020).

The mean age of the 15 Ban Kat VHVs is 56, with a range from 35 to 77; 11 of the 15 are aged over 50. Only four of the 15 VHVs are male, consistent with the gradual feminisation of the VHV workforce, which had already reached almost 70 per cent nationally by 2006 (Chuengsatiansup & Suksut 2007). More than half (eight out 15) are relatively poor and depend on getting hired for construction or farm labouring, or wood carving, or petty trade. Only one female VHV was considered ‘wealthy’, with her husband the owner of a tractor. This profile is consistent with the age, gender, and occupational distribution of VHVs nationally. Each VHV is responsible for an average of 17.5 households and a range of 15–27.⁵ To facilitate the work of the VHVs, the Ban Kat population has been organised into neighbourhood blocks of contiguous houses along the main road and lanes. The VHVs are allocated to neighbourhoods they reside in or nearby. The current team leader showed us an impressive, colour-coded diagram with the (first) names and house numbers of each household (including those of the VHVs). For the VHVs, these neighbourhood blocks and kinship and neighbourhood bonds have facilitated access, communication, trust, and surveillance.

Interviews with each of the Ban Kat VHVs revealed that the most common reasons given for volunteering as a VHV were to make Buddhist merit (tham bun), personal friendships (based on kinship, neighbourhood, or schooling), or to help community members (‘helping people in the community’ [chuailue khon nai chumchon], ‘helping villagers’ [chuai chao ban], and ‘sharing’ [suan ruam]). More self-interested motivation may be at play, such as respect and prestige in the community which may translate into local political influence. For the poorer VHVs, the guaranteed welfare benefits (sithi sawatikan) are likely to encourage volunteers. These benefits include special hospital rooms and food, award of honours (kiatkhun) for outstanding volunteers such as royal insignia, eligibility for them and their children to study at Ministry of Public Health institutions on a quota basis, and monthly allowances (sithi rap khapuaikan). During the COVID-19 pandemic, many volunteers also received small cash donations from families hosting events such as housewarmings or funerals where volunteers were engaged to screen guests for symptoms prior to entry.

Regulations of the Ministry of Public Health stipulate that VHVs must be at least 18 years of age, have a household registration card or have resided permanently in the community for at least five months, are literate in Thai, are in good health, have a willingness to assist in carrying out public health work, are of good character and have the trust and respect of the people (prachachon), etc.

The VHVs of Ban Kat have their own meeting hall where they meet monthly. They are required to submit individual reports via an App (Smart Or Sor Mor)⁶ to the district hospital before the end of each month. If late, they can submit hard-copy reports via the team leader within five days. This is overseen and checked by the epidemiologist, Mor (Doctor) Boy, from Mae Wang District Hospital, who is responsible for all of the 131 VHVs in the Ban Kat sub-district. His key role involves delivering information to VHVs on changing ministerial health policies and ensuring adherence to MoPH rules and regulations. A notice board in the meeting hall lists the division of health responsibilities for the Ban Kat VHVs into 12 categories: animals; non-communicable diseases (e.g. hypertension, diabetes, cancer); health promotion; mental health (e.g. alcoholism, suicide); local wisdom (e.g. traditional herbal medicine); environment (e.g. water, garbage); consumer health protection; health security of VHVs (e.g. rights, certificates); prevention and treatment of illicit drugs; prevention and treatment of AIDS; maternal and child health; and oral and dental health. Either one or two VHVs were appointed by the team leader (prathan) to take responsibility for these health issues and, if problems arise, to report to the nurse of the local Ban Kat Sub-District Community Health Centre. For example, if a VHV is unable to decide whether to refer an ill person to the local health centre or district hospital they may consult the local health centre nurse to assist with making an assessment via a video call. All the VHVs received an initial training of five days by PHC staff at the Mae Wang District Hospital. Three have been selected for another 70 hours of specialised training as caregivers to help the disabled and bedridden. Their work has been assisted by the opening of a Rehabilitation Centre for the Elderly and Bedridden by the municipal office in November 2022, which includes a full-time nurse and regular visits from the hospital physiotherapist.

The notice board is obviously rather dated as there is no mention of the coronavirus. In fact, the COVID-19 pandemic from 2020 to 2022 added significantly to the responsibilities and workload of the Ban Kat VHVs. This included encouraging vaccination,⁷ enforcing the wearing of facial masks, hand washing and use of sanitisers (especially at social functions such as housewarmings, funerals, and at the two local markets), checking body temperatures at group gatherings of more than 20 people, administering RAT tests⁸ for those exhibiting COVID symptoms, policing quarantine requirements for those who contracted the disease and for outsiders who came to reside in the town, and assisting in providing food for those quarantined.

Epidemiology and the Surveillance Role of Village Health Volunteers in Pandemics in Thailand

Epidemiology emerged in the eighteenth century in response to epidemics, in particular smallpox, which, according to Michel Foucault, was a ‘widely endemic phenomenon with a very high mortality rate’ and subject to ‘very intense epidemic outbursts’ (Foucault 2009, 58). The response to the smallpox epidemic was inoculation (or variolisation) and, later, vaccination, both foreign to medical practice at the time. Foucault compares this response to different epidemics of former times—leprosy in the Middle Ages, which was based on exclusion and the binary division between those who were lepers and those who were not, and the plague of the sixteenth and seventeenth century with the imposition of quarantine based on spatial ‘partitioning grids’ (Foucault 2009, 9,10). Inoculation and vaccination as ‘mechanisms of security’ were no longer concerned with territory but with quantitative and calculable health traits of populations (such as statistical risk of morbidity and mortality)—the genesis of the new science of epidemiology, accompanied by the ‘surplus of power’ of doctors as public health officials (Foucault 1984, 121).

In Thailand, epidemiology was central to the state response to avian influenza and COVID-19 pandemics of the twenty-first century, and village health volunteers played a major role in this response. In 2007 the World Health Organization announced that the VHV program in Thailand for the avian flu pandemic of 2004–2006 was ‘a success story for community-based surveillance’. The role of village health volunteers (numbering 773,000 in 2005) was to serve as an ‘early warning active surveillance mechanism’ for any unusual poultry illness or deaths and influenza-like illness in the community (WHO 2007, 7). In addition, they served as risk communicators and health educators (equipped with government-issued posters, leaflets, and booklets). They played a key role in the so-called ‘X-ray’ campaigns conducted twice a year between 2004 and 2006. The purpose of these campaigns was to get a single, cross-sectional view for the whole of the country of avian influenza in poultry and among humans (WHO 2007, 8). Although VHV involvement was periodic, it was very intensive and time-demanding over periods of several weeks when every household in every village in the country was assessed for poultry illness and death, and human illness, combined with the sampling of sick poultry. This required daily reporting and twice a day if there was an outbreak (WHO 2007, 10).

According to Kaweenuttayanon et al. (2021, 393), the ‘exhaustive surveillance’ conducted by VHVs was ‘the most significant contribution’ to the containment of the COVID-19 virus in Thailand. In response to the first wave of the pandemic (March to April 2020) the Thai government proclaimed a State of Emergency Decree (on 26 March 2020) and ordered the closure of public and business areas (restaurants, markets, cinemas, massage parlours, pubs and bars, gyms, etc.), triggering the mass movement of unemployed workers from Bangkok and from abroad to their homes in the provinces (numbering up to 80,000 per day) (Nayawadee et al. 2021, 394) and mandating 14 days’ quarantine upon return. The government declared and enforced curfews between 10 pm and 4 am on 2 April 2020. The government also advocated a ‘stay home’ policy for the whole of April 2020, cancelled national holidays to prevent massive social gatherings and domestic travel, and ordered school closures. All international flights were suspended from 4 April 2020, with only emergency or authorised flights permitted (Nattadhanai et al. 2021, 4). This is an example of Shelia Jassanoff’s concept of ‘public health sovereignty’ whereby ‘people are required to observe potentially severe restraints on liberty in the name of the common good and are governed by the disciplinary mechanisms of biopower described by Michel Foucault’ (Jasanoff 2020, 125). Of course, public health sovereignty is not possible without a bureaucratic sub-structure to support it. In Thailand, VHVs combined with sub-district health centres to support rapid response health teams stationed at provincial health offices and district hospitals and acted as critical medical police in a top-down public health bureaucracy.⁹

The emergency decree was accompanied by intensified surveillance by VHVs. This included the use of a web-based COVID-19 database (Smart Or Sor Mor) to register all returnees, returnees who developed symptoms, close contacts of confirmed cases, and groups considered at high risk (Kaweenuttayanon et al. 2021, 394).¹⁰ From March to April 2020, VHVs visited more than 14 million households, monitored 809,911 returnees and 64,552 people at high risk, and referred 3,346 symptomatic patients to hospitals by July 2020 (Kaweenuttayanon et al. 2021, 394). As noted, the ‘labour-intensive role’ of VHVs also included disseminating information about COVID-19; distributing facial masks and sanitising gel and enforcing their use; and checking body temperature, mask wearing, and social distancing at social gatherings¹¹ and local markets. In Ban Kat sub-district this was reinforced by the municipal office’s (thesaban) twice-weekly advisory announcements on town loudspeakers on hand washing, use of sanitisers, and the wearing of masks. However, according to Ni, the former team leader of the VHVs of Ban Kat, the success in controlling COVID during this first wave was due to strict community surveillance:

Health volunteers are keeping an eye on everyone and making sure they wear masks and no one has an excuse not to wear one because everyone has been given one. But it’s not just because of us—the villagers are keeping an eye on each other . . . I keep an eye on people coming from different places (other provinces) and make sure that they self-isolate for 14 days. The headman also pays a visit to remind them not to leave the house during self-isolation. The health volunteer reports to the doctor if they find people visiting from outside the village. I have to ensure they stay put until the doctor is free to check on them. If the doctor can come quickly and all is okay, they can leave, but they can’t leave until the doctor has seen them.

From February to April 2020, Ni only had to oversee three people who were forced to self-isolate for 14 days, during which time she tested their temperature daily. This included a woman from Bangkok who had travelled to Ban Kat with plans to visit family for only a few days. While she showed no signs of illness, she was required to stay and self-isolate for 14 days. Ni also followed the policy in Ban Kat that mandated infected persons to isolate in bedrooms with food left outside the bedroom door by other householders.

It is noteworthy that the role of VHVs in controlling the COVID-19 pandemic in Thailand has followed the standard epidemiological methods of public health surveillance, which are, according to Chanpong Rojanaworarit of Mahidol University: (a) systematic data collection, (b) data assembly and analysis, and (c) dissemination of pertinent information to key personnel through descriptive epidemiological reports as a basis for public health action (Rojanaworarit 2015, 70–71). The surveillance role of VHVs is confined to data collection, the ‘most critical phase of surveillance’ (Rojanaworarit 2015, 75). Data collection includes those in the community who exhibit COVID risk behaviour, those who show symptoms of COVID, and the regular monitoring of those individuals who have contracted the disease. In collecting data, VHVs are required to strictly adhere to protocols set down by the Ministry of Public Health as a means to obtain standardised quality information. This also applies to data collection for other diseases such as diabetes and dengue fever. Surveillance for dengue is meticulous and time-consuming. Ban Kat VHVs visit each of their assigned households once a week and check and record the number of water containers and any container that has mosquito larvae. If larvae are found, they report it to the municipal office for spraying. They also carry out monthly testing for diabetes using a glucose meter test and routine blood pressure checks using a blood pressure monitor. This rigorous top-down surveillance system is reinforced by MoPH regulations for VHVs (Rabiab krasuang satharanasuk wa duai asasamak pracham muban 2554 [2011]), which leave little scope for bottom-up initiative and agency of VHVs.

Ministry of Public Health Regulations in a Top-Down System

The MoPH regulations, a copy of which was held by the current Ban Kat VHV team leader, were often cited by the epidemiologist Mor Boy at VHV meetings. The 11-page document includes selection criteria for VHVs, training procedures, role, responsibilities and rights of VHVs, the composition of various committees established to promote and support VHVs, and expected VHV etiquette. These regulations clearly underline the top-down, hierarchical, and bureaucratic character of the VHV movement. The regulations include pronouncements such as:

1. It is appropriate that the VHV regulations should assist VHVs to protect, improve and support cooperation in caring for community health according to the PHC principles (lakkan) of the Ministry of Health.

2. The district heath administration should train (obrom) VHVs according to the curriculum established in 2554 [2011].

3. The training and development of the VHVs means that it is a state unit (nuaingan khong rat) that has been approved by the Central Committee to carry out training and development of VHVs by instructors.

4. The Central Committee has the authority to advise the Minister of Public Health concerning announcements in relation to the work of VHVs, formulate and evaluate the curriculum for VHVs in accordance with the proclamations of the central committee … 

5. The role and responsibilities of VHVs include acting in accordance with the policies (nayobai) of the Ministry of Public Health, disseminate information about public health, assist public health of the people according to the rules (rabiab) of the Ministry of Public Health or according to other articles of the law (bodbanyat) … 

Notably, the last three pages of these regulations are devoted, in text and illustrations, to uniform requirements for male and female VHVs. Grey is the prescribed colour, but style differs for work and ceremonial occasions. In Ban Kat sub-district, the colours are more varied. Green t-shirts are worn when VHVs assist the municipal office, such as administering rabies injections. Purple is for meetings. Pink is worn for housewarmings, weddings, and other celebratory occasions, as well as for aerobic and sporting events. At the annual training camp for all the VHVs of Ban Kat sub-district on 4 and 5 February 2023, the volunteers were required, on the first day, to wear purple uniforms in the morning and pink in the afternoon and evening. Only grey uniforms were worn on the second day. These uniform prescriptions give the VHV organisation a quasi-military character which it shares with other state-controlled volunteer bodies, in particular the yellow-uniformed royalist Village Scouts (Luk Suea Chao Ban) and the Volunteer Spirit 904 (Chit Asa 904) created in 2018 by the current Thai King Vajiralongkorn.¹² Five of the fifteen VHVs of Ban Kat are registered members of Chit Asa 904, highlighting some overlap between the two volunteer organisations and, also, in the case of VHVs, the merging of loyalties to local community and to nation. The VHVs are required to purchase mandatory uniforms with their own money, of which a few VHVs expressed slight resentment. Yet they bought and wore them as required.

Furthermore, there is a marked emphasis in this MoPH document on VHVs maintaining appropriate etiquette (canya). They are entreated to behave with diligence, endurance, satisfaction, determination, confidence, faith, sacrifice, honesty; to have firm belief in morality (khunnatham) and loving-kindness (mettatham) in carrying out voluntary work; to fulfil their role in accordance with the law and humanitarianism (khwam pen manut); and to act as role models of good health behaviour to others. For instance, although not compulsory, many VHVs in Ban Kat chose to be vaccinated to set an example to the community, which served to allay vaccination resistance in the town. One of the younger VHVs, Jip, noted that during the height of the COVID pandemic her family urged her to quit in fear that she would contract COVID, but she refused out of a sense of duty and sacrifice to her community.

Conflicting Health Paradigms

One suspects the influence of Prawase Wasi’s Buddhist communitarianism on the required VHVs etiquette outlined above with his extolling of the moral code of ‘goodness’ and ‘doing good deeds’. In his speech in July 2006 on King Bhumipol’s ‘self-sufficient economy’ (sethatkhit phor phiang), which the King proclaimed in 1997 in response to the economic crisis of that year, Prawase contrasts the King’s ‘new paradigm’ with the ‘Western development code’ encompassing scientific (external) knowledge and a ‘culture of materialism and consumerism’. The latter code (KPM: Knowledge, Power, Money) leads to a widening gap between poor and rich, environmental destruction, cultural and spiritual decline, and social crises (as, he notes, was predicted by Buddhadasa). By contrast, the King’s self-sufficient economy is a new development code that values Goodness, Community, and (internal) Knowledge (GCK). ‘Goodness’ includes the moral virtues of self-reliance, frugality, honesty, loving-kindness to others, environmental preservation, cultural preservation, and spiritual learning (which entails wisdom [panya] and ‘doing good deeds’). In the speech, Prawase urged ‘grassroots community’ and ‘horizontal’ rather than vertical, top-down organisation (Wasi 2009, 42–52). Loving-kindness, doing good deeds, and horizontal organisation are among the idealised moral virtues of village health volunteers.

Prawase Wasi’s moralistic communitarianism is reflected in the writings of another younger reformist doctor (and Harvard-educated Thai anthropologist) Komatra Chuengsathiansup. He is a former head of the Health Systems Research Institute (MoPH) (2003–2004) and director of The Society and Health Institute (MoPH) (2004–2019).¹³ In an article on spirituality and health, Dr Komatra contrasts the two paradigms of ‘biomedical model of health’ (that has dominated the Thai health system) with the holistic paradigm of spiritual health. In this comparison he notes that biomedicine is based on ‘mainstream scientific thought characterized by its reductionist and materialistic worldview’, concluding that spirituality ‘belongs to a different paradigm with entirely different ontological and epistemological assumptions’ (Chuengsatiansup 2003, 3). Echoing Dr Prawase’s communitarian thinking, he asserts that spiritual health is realised in communities and is destroyed by materialism and consumerism (Chuengsatiansup 2003, 3–4). Komatra concludes by urging a process of continuing dialogue between the two paradigms (Chuengsatiansup 2003, 14). Yet, the limited scope for VHV autonomy and innovation in the MoPH regulations suggests that a biomedical model in a top-down health bureaucracy prevails. This vertical system is highlighted elsewhere by Komatra in an evaluation of the village health volunteer movement in the 1980s and 1990s as ‘implementation without deliberation’. Commenting on VHVs in this period, Komatra writes:

They had a very limited role in the decision-making process to determine both what was to be done and how implementation should be carried out. Rather, they participated in prearranged activities based on a universally standardized primary health care handbook. . . Participation, however, was permitted only insofar as it did not hinder policy decision-making. In other words, it was participation in the implementation processes rather than in the political processes of deliberating and determining how to improve health. (Chuengsatiansup 2008, 48)

Much later research suggests that there has been little empowerment over time of VHVs in this respect. A study of a semi-urban community in central Thailand (Kowitt et al. 2015, 784) found that ‘the emphasis on specific protocols and required activities decreased the flexibility with which they were able to provide support in accordance with their understanding of community needs’. Here, one VHV stated: ‘Sometimes the commands [from the government] are not suitable for the community. It is not the role of the VHV. We receive commands that do not match needs’. The authors add that increased reliance on protocols ‘impeded VHVs’ ability to tailor information to community members’. Contemporaneous research on VHVs, also in central Thailand, repeats these criticisms, observing that ‘fixed operational methods which are inflexible and impractical for some community contexts … ’ (Jewjinda & Chalermnirundorn 2018, 330) and that ‘community members were not involved in any participatory process in finding solutions to the problems in the community’ (Jewjinda & Chalermnirundorn 2018, 334). A recent comparative study of community health workers’ (CHWs) response to the COVID-19 pandemic in Kenya and Thailand concluded that the CHWs in Kenya were ‘more likely to conform to the “citizen agent” tradition, choosing to act pre-emptively to find preventive measures on their own’ compared to the more centralised public health system in Thailand where CHWs followed a ‘state agent tradition’ that ‘emphasized the chain of command and government guidelines’ (Sudhipongpracha & Poocharoen 2021, 242, 245). In Ban Kat, the VHV meetings we attended primarily involved the epidemiologist, Mor Boy, announcing new programs and policies without any dissension from the VHVs. Numerous VHVs noted that the rules and regulations continue to increase, which was confirmed by the Ban Kat Sub-District Community Health Centre nurse who stated that ‘there are just too many rules’.

The impetus for the ministerial policing of VHVs in Thailand came from public health officials who emphasised the importance of increased oversight as a means to standardise VHV support and control the quality of information provided (Kowitt et al. 2015, 784). Experience from the earlier avian influenza pandemic possibly influenced this policy. Many of these disciplinary changes were decreed not long after the introduction of the 600-baht allowance in 2009 for VHVs ‘which has caused many VHVs to associate the allowance with increased governmental oversight’. One volunteer from northeast Thailand stated in the early 1990s that he ‘derived satisfaction from knowing that he is in “royal service” as a volunteer and suggested that one good thing about not having a wage is that no one can criticise him for not working’ (Whittaker 1996, 76). Regarding the 600-baht payment, a VHV from a central Thailand community commented, ‘The allowance controls us and makes us do specific functional duties. Previously, we did whatever we wanted to do’ (Kowitt et al. 2015, 784). Similarly, a VHV in Ban Kat spoke of increased responsibilities accompanying the monthly allowance and less flexibility: ‘Before we were paid 600 baht we could take turns in attending meetings. We could no longer do that once we were paid’. One longstanding VHV in Ban Kat of 25 years made a similar remark concerning the new regulatory impositions. In the early days, he said, there were only five to six VHVs and supervision was not as strict (khemnguat) as it is today. The monthly allowance was increased to 1,000 baht in 2019, but some VHVs in Ban Kat said this amount barely covered transport and food costs, forcing them at times to rely on local donations. The announced increase in March 2023 to 2,000 baht may serve as an incentive to volunteer but at the cost of maintaining ministerial control. The current Ban Kat VHV team leader proclaimed that VHVs ‘must carry out the policies of the Ministry of Public Health’ (tong patibat nayobai khong krasuang sathanasuk). Similarly, the former VHV leader stated: ‘since we are now paid, we must follow the rules and do as we are told!’. She added that they must also attend training sessions (obrom) if ordered by doctors; if they do not they may be dismissed (tat sit). They may also be dismissed if they fail on three occasions to send in their monthly reports.

Within this regulated top-down system there is, nevertheless, some limited scope for initiative and innovation. As noted above, VHVs are eligible to receive honours, including royal insignia. The Ministry of Public Health regulations specify that such awards are for ‘outstanding work’ (patibat ngan di den). While the wording refers only to excellence of work, according to epidemiologist, Mor Boy, this includes significant innovations. He referred to a VHV from another Mae Wang sub-district who had won an inter-district competition for her innovatory work on traditional herbal medicine. Another VHV recently won a competition in another sub-district in Mae Wang by introducing and organising a mini marathon for the district’s annual sports day. These competitions are organised on a district, provincial, regional, and national level. Mor Boy claimed that innovations of this kind are encouraged but hastened to add that they should not conflict with MoPH policies, rules, and protocols.

Conclusion

Reformist doctors have played a crucial role in Thailand in the village health volunteer movement. Inspired by Buddhist moral values and WHO advocacy of holistic medicine, they envisaged the role of village health volunteers as community oriented, self-reliant, and innovative. However, our research in Mae Wang district, Chiang Mai, and research elsewhere in Thailand, reveals that village health volunteers have become enmeshed in a centralised, hierarchical, and top-down system rigorously controlled by the Ministry of Public Health. Volunteers have been effective state agents for a range of health problems, but with limited autonomy and agency, in a system of implementation without deliberation. The competitive award system does provide some scope for innovation but freedom to innovate is still circumscribed by the prescription to adhere to ministerial regulations.

We have also argued that the early ideal of empowering village health volunteers has been confronted by the reality of epidemics which have, historically, elicited authoritarian interventions by the state of varying forms, and in Thailand no less so than in the cases of the avian influenza and COVID-19 pandemics. We view epidemiology as the handmaiden of state authoritarian intervention in these health emergencies and the imperative of rigorous surveillance to gain standardised quality data nationwide with village health volunteers as disciplined agents of this surveillance. In this political environment there has been little scope for the ‘cross-paradigm dialogue’ so earnestly proposed by reformist Dr Komatra two decades ago.

Acknowledgements

We would like to thank the director of the Mae Wang District Hospital, the Mae Wang municipal mayor, the Ban Kat village health volunteers, especially the two team leaders, and the epidemiologist responsible for the village health volunteers for their generous assistance with our project during our fieldwork in Chiang Mai. We would also like to thank the expert reviewers who helped to significantly improve the manuscript.

Additional information

Funding

The authors appreciate and acknowledge funding support from the School of Social and Political Sciences, Faculty of Arts, University of Sydney.

Notes

1 The Alma-Ata International Conference on Primary Health Care that took place in September 1978 is a landmark event in the history of global public health. It was attended by approximately 3000 representatives from 134 countries and 67 international organisations (Basilico et al. 2013).

2 Dr Sanguan later played a major role in the universal health care coverage (UHC) legislated in early 2002.

3 Joseph Harris characterises the Sampran Forum as an example of ‘epistemic communities’ and ‘autonomous political networks’ that share principles, ideas, or values and operate across different formal organisations. The Forum has been effective in influencing health legislation and the establishment of many health organisations (Harris 2015, 7, 10, 15).

4 Village Health Communicators were upgraded to Village Health Volunteers in 1994 (WVO 2014, 420).

5 The number recommended by the Ministry of Public Health is 10–15 households per VHV.

6 Or Sor Mor is an acronym for asasamak muban (‘village volunteers’).

7 VHVs were given priority for vaccination.

8 Those who tested positive were sent to the Mae Wang district hospital for a PCR test.

9 Kwanchewan Buadaeng argues that the emergency decree was disproportional to the scale of the pandemic and was instituted mainly to suppress the opposition movement (Buadaeng 2022, 2). This movement was centred on student-led protests in Bangkok that demanded reform of the political system (including the role of the monarchy, the dissolution of parliament, and the rewriting of the constitution).

10 This data could be reported on printed forms and later uploaded by local health officers.

11 In Ban Kat, social gatherings (such as funerals) of more than 20 persons required VHV attendance to check attendees’ temperature and mask wearing.

12 The Chit Asa 904 organisation is under the authority and control of a division of the Ratchawallop Police Retainers, King’s Guard 904. The number 904 is the police code word assigned to King Vajiralongkorn when he was Crown Prince.

13 Komatra Chuengsathiansup is now the director of the Princess Maha Chakri Sirindhorn Anthropology Centre in Bangkok, Thailand.