health services responsiveness during political unrest in bangkok ijphrd july sept. 2016

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Health Services Responsiveness during Political Unrest in Bangkok, Thailand

Thira Woratanarat1, Patarawan Woratanarat2, Narin Hiransuthikul3,Thanapoom Ratananupong4, Pornchai Sithisarankul5

1Assistant Professor, Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand, 2Associate Professor, Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand, 3Professor, 4Instructor, 5Professor, Department of Preventive and Social

Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand

ABSTRACT

Background: The 2013–14 was a period of political instability in Thailand. Anti-government protests rigorously took place between November 2013 and May 2014 with demonstrators occupying government offi ces, blocking major road intersections and holding mass rallies in Bangkok, a capital city, to call for the Prime Minister (PM)’s resignation and her government. We aimed to share the snapshots of health services responsiveness during recent political unrest in Thailand.

Method: We conducted an observational study to describe the evolution of health services delivery system in all protest areas in Bangkok from 14th December 2014 to 17th January 2015, and health assessment was done during 12-21 March 2014.

Results: Four phases of health services responsiveness were demonstrated: Non-medical staff s, medical staff involvement, team formation, and network system. Eleven health service units were organized to serve 13 satellite rallying locations with accessible range from 10 to 800 meters. 63.6% of health service units had at least one part-time physician. All units were staff ed with nurse, pharmacist, and other non-medical volunteers. Morning and evening were busy hours. Social media and social networks have played a major role in health-related resources pooling, allocation and reallocation. Common health problems were usually accommodated by self tolerance or taking care by health services units in the protest areas.

Conclusion: Political unrest brings about negative impacts to population health. We emphasize the necessity of multi-sectoral collaboration in health services preparedness and proper channels for communication for eff ective responsiveness.

Keywords: Health services, Political unrest, Political instability, Preparedness, Responsiveness.

Corresponding author:Thira Woratanarat, MD MMedScAssistant Professor, Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand, 10330.Tel: 662-252-7864, Fax: 662-256-4292Email: [email protected]

BACKGROUND

The 2013–14 was a critical period of political instability in Thailand. Anti-government protests

rigorously took place between November 2013 and May 2014, mainly organized by the People’s Democratic Reform Commi� ee (PDRC), a political pressure group set up and led by former members from opposition party. Deeply divisive in Thailand, the primary aim of the protests was the removal of former Prime Minister (PM)’s infl uence on Thai politics and the creation of an unelected “people’s council” to oversee reforms of the political system. Protesters viewed former PM as highly corrupt and damaging to Thailand’s democracy, although they

DOI Number: 10.5958/0976-5506.2016.00166.2

254 Indian Journal of Public Health Research & Development, July-September 2016, Vol. 7, No. 3 255

enjoyed strong support in many areas of Thailand, particularly the poorer north, due to his reforming social programs and economic policies. Political parties allied to him have won a majority in every election since 2001. Other issues, such as a rural-urban or north-south divide, social inequality and inequity, over-centralized bureaucracy, and military infl uence in politics and middle-class status have also been seen as factors behind the crisis by analysts and commentators1-2.

Initially, the protests were triggered by a proposed blanket amnesty bill that would pardon several politicians from various charges since 2004. Opposition from across the political spectrum, including the pro-government Red Shirt movement, caused the bill to be rejected unanimously by the Senate of Thailand. Anti-government protests continued, however, with demonstrators occupying government offi ces, blocking major road intersections and holding mass rallies in Bangkok to call for the PM’s resignation and her government. On 8thDecember 2013, all 153 opposition party members resigned, and the PM dissolved the House of Representatives following with her calling for a snap general election on 2ndFebruary. Voting was disrupted in areas of Bangkok and Southern Thailand by PDRC protesters blocking entry to polling stations, leading to an annulment of the result by the Constitutional Court. Sporadic violence, including shootings, bomb a� empts and grenades thrown at protesters, led to 28 deaths and over 800 injuries during the course of the protests. On 21stJanuary, PM’s government declared a state of emergency in Bangkok and the surrounding areas with very li� le eff ects. The protests fi nally resulted in the removal of the incumbent prime minister, a coup d’état and the establishment of a military junta in May 20142.

Since health services provision and political instability have been demonstrated to be an important issue among several countries in the past decades, this study aimed to share the snapshots of health services responsiveness during recent political unrest in Thailand in order to be a lesson-learnt for health authorities to be� er plan for preparedness system future unrest events3.

MATERIAL & METHOD

We conducted an observational study to gather descriptive data regarding the evolution of health services delivery system in all protest areas in Bangkok from 14th December 2014 to 17th January 2015. Subsequently, Health and environmental assessments were done during 12-21 March 2014 at Lumpini park, which was the main protest area in Bangkok during late stage of protest, by using interviewer-administered questionnaire, in-depth interview, and focus group discussion in accordance with convenience and voluntary agreement with the key informants and surroundings.

FINDINGS

During 4-month period of observation, the main area taken by the protesters was Bangkok, a capital city of Thailand. Satellite rallies were organized throughout Bangkok from time to time with permanent stages of the rally speeches near major government agencies.

It was obvious that health services delivery system in response with emerging health problems from political unrest in Bangkok had evolved over time and can be divided into four phases as shown in Figure 1.

November 2013 January 2014 December 2013

Figure 1: Four phases of health services development in protest areas

Phase 1: No medical professional involvement.This stage was noted in early stage of protest in November 2014. Those injured from the a� ack in unrest situation were sent to nearby hospitals by the protester group.


Figure 3: Location of 11 health services units surrounding 2nd main stage (Star: main stage, Number: each health services unit)

Figure 4: Location of 11 health services units surrounding 3rd and 4th main stages(Star: main stage, Number: each health services unit)

Service provision and utilization

The staff in all health service units served all people under non-discrimination policy. There was at least one part-time physician in 63.6% of health service units. All units were staff ed with nurse, pharmacist, and other non-medical volunteers. If the patient needed physician a� ention, those units without physician would refer to another unit or nearby hospital where the physician was on duty. Ambulances were standby in order to promptly transport to appropriate facility within 15-20 minutes. Most stations operated all day long, however, 0600-0900 AM and 0600-0900 PM were usual busy hours. Approximately, each unit served 1,000 visits daily.

Self reliance capacity on human resources and medical supplies

Almost all units exercised similar strategies to acquire their personnel. Successful strategies included social network communication such as Facebook, Line, as well as calling through friend networks and

Phase 2: Beginning of medical professional involvement. 2-3 weeks after phase 1, individual medical professional began participating in health service provision in the fi eld. Basic medicines as well as other medical supplies were still limited and had been donated from those medical professionals in protester group.

Phase 3: Team formation. Since there were satellite protest areas throughout Bangkok, the protesters reconciled and medical team formation was observed during this period, around mid December 2014. Medical team mostly comprised physician, nurse, pharmacist, and non-medical volunteers. Medicines and related supplies were still acquired by donation within each protester group.

Phase 4: Network system. In January 2015, the protesters reshaped their plans with the result of network formation. Individual node from several areas had been working together to eff ectively and effi ciently provide health services, share, and transfer medicines and medical supplies using mobile and social networks. Government and private agencies from various provinces willingly participated in this phase, and took turn to provide health services in protest areas.

Accessibility to healthcare services in protest areas

Eleven health service units were organized to serve 13 satellite stages of the rally speeches (Figure 2-4). Some stages were temporarily organized at specifi c occasions. Four main stages were permanently located with regular activities. The distance between each stage and allocated health service units was in the range of 10-700 meters, whereas the distance from the end of protest area to health service units were 50-800 meters.

Figure 2: Location of 11 health services units surrounding 1st main stages (Star: main stage, Number: each health services unit)


snowball technique. In light of money, medicines, and other medical supplies, most units were independent to each other, and managed their own supplies. Those resources were donated from their own connections which came from friends, private sector, and public donation through mass media campaign except some health service units that were responsible by public hospitals or foundation.

Health assessment in protest area

At later stage of protest, we conducted a rapid health assessment at Lumpini park that was the main protest area during March 2014. Protesters can be categorized into 2 groups: those who stayed all day all night in the park during protest period, and those who travelled back and forth by working during daytime and rallying during evening and night time. 490 people were invited and voluntarily participated in this anonymous 1-week survey during daytime for safety reason and to focus on regular and all-day-long protesters.

Almost 80% of respondents were protesters, 16.7% served as guards, and the remaining included leaders, volunteers, and sponsors. 53.3% were female with average age of 49.19 years (±13.26). Nearly quarter of participants (23.1%) were elderly, i.e., more than 60 years. 73.6% were from Southern region of Thailand. More than half (53.2%) graduated at primary school level, whereas 26.9% at secondary school level and 9.4% at bachelor degree. 52.8% were farmers with average monthly salary more than 20,000 baht (approximately US$700). Only 3.6% indicated that they had no salary and unemployed.

Some interviewees expressed the nature of rallying participation that they took turn with their neighbors in their provinces either monthly or biweekly. Among survey participants, 92.4% continuously stayed in the park for rallying less than two weeks. More than half of respondents have rallied at least 3 stages during 4-month duration (Table 1).

Table 1: Rallying characteristics

Rallying characteristics Number Percentage

Participating rally locations(n=498)

Lumpini 401 80.5

Ladprao 92 18.5

Chaengwa� ana 78 15.7

Silom 92 18.5

Pathumwan 259 52.0

Asoke 88 17.7

Victory monument 131 26.3

Rajaprasong 137 27.5

Chamaimaruchet 52 10.4

Rajadamnearn 333 66.9

Samsen 72 14.5

Urupong 51 10.2

Others 24 4.8

Status in protest (n=496)

Leaders 7 1.4

Guards 83 16.7

Volunteers 10 2.0

Protesters 393 79.2

Sponsors 3 0.6

Rallying duration (n=470)

1-7 108 23.0

8-14 326 69.4

>14 36 7.7

Regarding baseline health status and health-related issues, we found that one-third of the respondents indicated that they had common underlying diseases such as hypertension, diabetes, and hyperlipidemia. Due to quite long period of the protest, we also assessed their perception on their physical activity by comparing between before rallying period and in rallying period. It was interesting that 40% pointed out that their physical activities were more than their routine life as shown in Table 2.


Table 2: Baseline health status and perception on physical activity

Baseline health status and physical activity Number PercentageUnderlying diseases (n=493)

Yes 177 35.9Hypertension 58 32.8Diabetes 28 84.2

Hyperlipidemia 20 11.3

No 316 64.1Perception on physical activity during rallying (n=495)

As usual 126 25.5More than usual 200 40.4Less than usual 169 34.1

We explored common health problems among the protesters and how they dealt with those problems as demonstrated in Table 3. Most health complaints were rarely required healthcare at hospital or clinic due to long distance and high costs. Most people decided to tolerate for a while or go directly to health services units in surrounded areas.

Table 3: Common health problems among the protesters and treatment decision

Chief complaints

Treatment decision (N(%))

Self tolerance Health service units Hospital/clinics

Fever (n=85) 9 (10.6) 72 (84.7) 6 (7.1)Cough(n=142) 26 (18.3) 109 (76.8) 7 (4.9)Sore throat(n=117) 18 (15.4) 93 (79.5) 8 (6.8)Runny nose (n=79) 9 (11.4) 66 (83.5) 5 (6.3)Headache(n=86) 22 (25.6) 60 (69.8) 3 (3.5)Nausea/ vomiting(n=8) 0 (0) 8 (100.0) 0 (0)Abdominal pain (n=18) 3 (16.7) 14 (77.8) 2 (11.1)Diarrhea (n=38) 14 (36.8) 24 (63.2) 0 (0)Dyspepsia (n=30) 18 (60.0) 12 (40.0) 0 (0)Itching(n=86) 47 (54.7) 39 (45.3) 0 (0)Dermatitis (n=7) 5 (71.4) 2 (28.6) 0 (0)Scabies(n=2) 0 (0) 2 (100.0) 0 (0)Tinnitus(n=7) 5 (71.4) 1 (14.3) 1(14.3)Fainting (n=14) 6 (42.9) 8 (57.1) 0 (0)Muscle ache (n=135) 67 (49.6) 64 (47.4) 4 (3.0)Wound (n=8) 0 (0) 8 (100.0) 0 (0)Insomnia(n=79) 66 (83.5) 11 (13.9) 2 (2.5)Loss of appetite (n=32) 27 (84.4) 5 (15.6) 0 (0)Insect bites (n=28) 24 (85.7) 4 (14.3) 0 (0)Conjunctivitis (n=3) 0 (0) 3 (100.0) 0 (0)Others (n=44) 18 (40.9) 23 (52.3) 2 (4.5)

DISCUSSION

From our 4-month observational study of Thailand’s one of the most political unrest situations, it is worth noting that political confl ict has brought

about several phenomena. First of all, as indicated in our fi nding of four phases of health services development in the protest areas, fi rst two phases can be explained by reluctance from most of health professionals whether or not to be careful of their

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manners, and how they should do something to help the people. Since political confl ict is quite sensitive, we observe that there have been many criticisms from both pro-government and anti-government sides before and when health professionals entering the protest areas to help people. Secondly, it is obvious that social media and social networks have played a major role in health-related resources pooling, allocation and reallocation during this political unrest. Although there have been some evidences regarding their roles in various health and non-health situations, there is limited evidence specifi c to political unrest situation4-8. Lastly, most of health services units are quite independent to each other. When they encountered operational problems such as lacks of medicines and medical supplies, most of them tried to solve by asking to borrow or ge� ing from other units by their own hands with limited capacity. Besides the quantity of resources, there have been some speculations on the quality of resources acquired from many sources that might negatively aff ect the health outcomes on consumers. To our perspective and from our research fi ndings, ideal health services preparedness for unrest situation should be collaboratively planned through multi-sectoral stakeholders including governmental agencies, private sector, health and non-health foundation, and civil society representatives. Planned communication channels are essential and should be triggered at proper moment. Since future political confl icts might be unavoidable either at local, national, regional, or global level, both aforementioned recommendations should be taken into account by related authorities so that eff ective responsiveness can be achieved when it comes.

CONCLUSION

Political unrest brings about negative impacts to population health in all dimensions: physical, mental, social, and spiritual. Health services preparedness for such situation should be priory well-planned. Our lessons learnt from political unrest in Thailand point out necessity for multi-sectoral collaboration in health services preparedness, and proper channels for communication to foster eff ective responsiveness when the time comes.

Acknowledgment: We would like to thank our postgraduate students at Department of

Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, and Thirawat Woratanarat for their dedication in fi eld data collection. This research is partly funded by Thai Health Promotion Foundation through Chulalongkorn University and R&D Offi ce for Health Research Translation.

Ethical Consideration: All applicable international, national, and/or institutional guidelines were followed. Ethical clearance was done by Chulalongkorn University.

Confl ict of Interest: None

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