The rest of the report

Module A: Country Report

Module B: The Position of Women

Module C: Women's Health (Part 1)

References

Authors

Acronyms

Prepared for the World Health Organization, South East Asia Region Office, January 1998

(a) Women in Institutions

As of January 1996 there were 7,199 convicted women and 71,976 convicted men in jail in Thailand. From 1990 to 1994, the ratio of female convicted prisoners to male fell from 1:15 to 1:11, but there has been no research as to the reasons for this change (103; 12). Another group of incarcerated females are those in juvenile detention. In 1995 more than 20,000 boys and girls aged between seven and 18 were sent to juvenile detention centers (208; 4) No detailed breakdown is available on the gender of these juvenile offenders, although general reports indicate that a large majority are male, but what is known is that many of their offenses were either drug offenses or drug-related. In 1995, 291 were found to be infected with HIV (208; 4).

Another incarcerated group of women is those in the Immigration Detention Centre in Bangkok, where both male and female illegal immigrants are (separately) housed before being returned to their home countries. There have been allegations of sexual abuse and other mistreatment in this facility, which have been denied, and it is certainly very crowded, with only limited health facilities. (209; C3)

Health services for both male and female prisons and the IDC are known to suffer from severe under-funding, a problem exacerbated by the rate of HIV/AIDS infection among prisoners. Testing for the virus is not compulsory, and prison doctors report that many prisoners avoid testing because they know or fear they are infected. The rate of infection is believed to be very high (210; 1).

(b) Refugees and displaced persons

The primary group of women now in Thailand who fall within this category are those who have been displaced from neighboring Myanmar. The group among these most easily identified are those living in established camps located along the border, which have a total population of approximately 100,000. These camps are assisted by a loose consortium of NGOs known as the Burmese Border Consortium. They provide generally adequate primary health care in these camps, while more serious medical problems are usually treated in Thai government hospitals in the region. (211; 2).

Many women from Myanmar are however, in Thailand, without being in these camps, often being illegal migrant workers or displaced persons who have no legal status. For obvious reasons there are no reliable statistics on their numbers. Most estimates range from 500,000 to one million illegal Burmese immigrants. Among these males probably outnumber females, but there is no doubt there are still very significant numbers of Burmese women in Thailand (209; C3).

Both their illegal status and the fact that they often speak little or no Thai presents significant health risks. They are unlikely to receive public health information conveyed in the Thai language, the language barrier may prevent them consulting health professionals, or may make such consultations ineffective or misleading, while their illegal status may make them reluctant to approach government institutions such as hospitals or health clinics (211; 4). Many also bring health problems into Thailand, including malaria and elephantiasis (96a; 3). The NCWA in conjunction with World Vision recently began a program in relevant areas to attempt to provide health, family planning and AIDS information to Burmese in Thailand, in an attempt to tackle these problems.

These workers are also particularly at risk from workplace dangers. They are known to work in small-scale industry, sub-contracting, domestic service and construction. They face within these all of the same health risks faced by Thai workers, such as exposure to dangerous chemicals, unhealthy working environments, etcetera,, but are even less likely to be able to assert their rights to protection, and the language barrier may prevent them reading warning notices or receiving other essential information (211; 1996). These women are also at high risk of being trafficked into the commercial sex industry, where they face very considerable health risks, including HIV infection (being in a particularly poor position to negotiate for safer sex), physical abuse, and a range of other problems related to often poor housing, working and dietary conditions. (212).

A further small but seriously disadvantaged group in Thailand is Cambodian women and girls, who usually enter the country illegally. Many chose, or are forced, to work as beggars, working long hours in adverse environmental conditions (such as on road overpasses). There are many girls under the age of ten, even babies, and old women in this group, which is highly vulnerable, both to exploitation and ill health. (213; 22)

(c) Homeless women

No data is available and no detailed studies have been compiled as to the number, health or social background of homeless women in Thailand. Due to the existence of extended family networks, and low levels of unemployment, their numbers are believed to be small, using a strict definition of homelessness.

One group which has attracted attention is homeless girls, commonly described as street children. General accounts indicate that the majority of street children are male, but that some girls are among them. They are mainly found in Bangkok, Pattaya and Chiang Mai often living informally around parks, bus terminals, train stations and markets (214). Both boys and girls in this situation are at high risk of drug abuse, HIV and other sexually-transmitted diseases and a wide range of other health problems, such as skin diseases (often caused or exacerbated by their living conditions). Such girls are also at high risk of becoming victims of sexual assault, as evidenced by one very high profile case in 1996, in which a homeless girl was alleged forced to have intercourse in front of several police officers (215; 1). They are also very likely to be drug abusers, and are at high risk of eventually entering the commercial sex industry (151; 118).

(d) Women and girls with disabilities

Estimates of the number of people with disabilities in Thailand vary. There are 80,000 people with disabilities registered with the Department of Public Welfare, which provides a basic pension and free medical care, but it is acknowledged that many people with disabilities are either unaware of their rights in this regard, or unable to access them. (103; 15) Other estimates range from the National Statistical Bureau's 1.057 million, to the Public Health Foundation of Thailand's estimate of 3.43 million (excluding those with mental disability), made in 1991 (103; 15). The majority live in rural areas.

The broad issues of the well-being of women and girls with disabilities have recently emerged as issues in Thailand. Most debate has centered around issues of access to facilities, and access to education (216). Little information is available on specific health issues for women with disabilities, but it seems likely that access to health services is also a problem, with both physical access issues (such as the lack of ramps, disabled toilets and other basic facilities) and those presented by negative attitudes towards the disabled, a problem. Participants at a seminar on the human rights of disabled women noted that doctors were among the people who tended to be disdainful or uninterested in dealing with disabled clients. Lack of knowledge and general assumptions such as that disabled women would not have relationships or bear children were also discussed (216; 2). There is also concern that disabled girls and women in institutional settings may be particularly at risk of both physical and sexual abuse. (216; 1)

(e) Commercial sex workers

The health risks facing commercial sex workers fall within two groups - firstly those specifically related to their work, including sexually transmitted diseases, and those more broadly related to the lifestyle generally associated with commercial sex work.

With regard to the latter, the morally negative view of commercial sex work held by most sections of Thai society means commercial sex workers usually have a very stressful life. They are subject to the pressure of social sanctions and the fear of arrest at any time. In addition, many are forced to work strictly under a pimp's control, with little or no say in where they go, when they perform even basic acts like eating or sleeping.

Not surprisingly, all of these factors combine to create a generally poor mental health situation. As a result of their lifestyle, commercial sex workers often gamble, use tobacco, alcohol and other drugs and may become drug addicts, something that is often encouraged by pimps and brothel owners as it makes them easier to control. Often they have previously been physically, mentally, or sexually abused or experienced extreme forms of social and physical rejection, which only interacts with the further pressures of the life of a commercial sex worker (96g; 43). See section C3(f) for a discussion of other health issues.

(a) Availability of Health Services for Women's Health Problems

In general, the reproductive health care for women in Thailand is integrated into the existing health service delivery system, described in Module 1. All levels of health facilities available are currently serving both men and women. However, some health services particularly for maternal and child health (MCH) and family planning (FP) are specifically designed to serve women.

As far back as 1942, the MOPH was concerned about maternal mortality and established a Maternal and Child Health Division within its Health Department: this Division was later renamed the Family Health Division. Its main duty was to expand maternal and child health coverage over the entire country. The basic strategy was to train auxiliary midwives to staff a number of midwifery centers, later upgraded to health centers and provide expanded services at tambon level. Therefore, it might be said that the availability of MCH and FP services is close to universal.

(b) Coverage of Maternal Care

Forty years ago, most child delivery and post-natal care was in the hands of TBAs because midwifery centers or health centers were not available in every tambon of the country. Low coverage of maternal health services in rural areas brought about high rates of maternal mortality (MMR) as well as infant mortality (IMR). In the first five-year national health plan, the emphasis was on expanding health facilities, particularly midwifery and health centers in rural areas. The primary purpose was to increase the availability of MCH services and communicable disease control to lower the high rate of maternal mortality and morbidity. The number of health centers has been increasing to cover all the tambons of the country.

Simultaneously, four regional midwifery schools were set up to train auxiliary midwives to be staff at midwifery and health centers, the grassroots level of the peripheral health care delivery system locating nearest to the rural women. At present, MCH services are provided at approximately 9,000 rural health centers, as well as 1,000 government hospitals, all over the country. In addition, all traditional birth attendants have been trained by the MOPH.

(i) Antenatal Care

Ensuring full utilization of antenatal care services remains a problem in Thailand. In 1993 across the Kingdom only 60 per cent of mothers had three antenatal examinations (See Table C.7.1), while 1995 figures report varying rates from 70 to 83.4 per cent (see Table 3).

Other earlier, small-scale studies, have, however, shown better results. In 1988, the study on Health Status and Health Service Utilization of Rural Population (217) indicated that prenatal care was used by 83.5 per cent of pregnant women in rural area of the country. On average, they visited four times (Mean = 4.08) during nine months of pregnancy.

In poor suburban and urban communities of Bangkok, the coverage of antenatal visits is also incomplete. The study of Health and Family Planning in Suburban Bangkok, Thailand (218) revealed that 88.3 per cent of pregnant women used antenatal care services, but 11.7 per cent did not. The government hospitals were the main sources of care where about half of mothers (50.6 per cent) visited for antenatal care. Other important sources were Bangkok municipality health centers, as well as private clinics and hospitals. Only a minority (3.7 per cent) reported to untrained persons, TBAs and local practitioners. Approximately 40 per cent of mothers reported to antenatal care in the second trimester whereas less than one-forth (22.5 per cent) sought care within the first trimester of pregnancy.

In the poor communities of Bangkok, the study on Socio-cultural Determinants of Maternal Health in Urban Poor Communities of Bangkok Metropolis (219) revealed that only three-fourths (74.6 per cent) of the pregnant women had antenatal care. Nearly two-thirds first visited during the first trimester of pregnancy. The government hospital was the most popular place, used by 87 per cent of pregnant women.

As these studies date back to the 80s and the utilization of antenatal services appears to have barely improved, or even deteriorated since that time, it is obvious this is a problem area for the Thai health care system. A substantial minority of women are still not receiving adequate antenatal care.

(ii) Delivery Care

Throughout the past two decades, the proportion of births attended by trained health personnel has been increasing, while home deliveries and those not attended by trained personnel have dropped dramatically. A national survey in 1969-1970 indicated that only 28 per cent of the respondents' most recent births were delivered by trained health personnel, and more than half of them (57 per cent) were delivered by TBAs. During 1983-1987, as many as 66.0 per cent of all births were assisted by trained health personnel, and those who were assisted by TBAs decreased to only about one-fourth of the total births. In 1988, the proportion of delivery attained by trained health personnel in rural Thailand was as high as 70.4 per cent (219). Community hospitals and general hospitals contributed more than half (5

4.7 per cent) of these deliveries. The most recent data indicates that in 1996, nearly 93 percent of deliveries were supervised by a trained attendant, about the same level as 1992. It appears that almost all of these occurred in health facilities. (See Table 3.) The fact that these levels have remained fairly stable, while investment in health care has substantially increased, means that more effort may be needed to reach populations not currently choosing or able to have hospital or supervised deliveries, and to ensure services appropriate to their needs are provided.

(iii) Post-partum Care

Post-natal care has been increasing during the period from 1983 to 1987. According to the MOPH Health Statistic Department Report, the coverage of post-natal care in 1983 was 74.5 per cent of the total post-partum mothers and increased to 98.6 per cent in 1987 (67). More recent data could not be located.

(iv) Regional Differentials in Maternal Care

As Table C.7.1. shows, the utilization of all maternal care services is lowest in the south of Thailand, where in 1993 only 82 per cent of births were attended by a trained attendant, as compared to nearly 90 per cent in the northeast and 93 per cent in the north. Similarly, utilization of antenatal and post-partum care is much lower. There are probably two main reasons for this discrepancy. Firstly, there are problems of physical inaccessibility to the government health services because most of the terrain in the South is mountainous, and other groups live on islands. But perhaps more importantly, a high proportion of the population in the South is Thai Muslim who prefer home delivery by TBA and choose to have had no antenatal care as it may not be felt to be culturally-appropriate (requiring for example examination by a male doctor) (65; 15).

(v) Family Planning Services: Availability and Accessibility

After the declaration of the National Population Policy in 1970, the National Family Planning Program (NFPP) was established and designated as the principal organization to implement the population policy using family planning as the main strategy to reduce the rapid growth of population. The NFPP was first integrated into the Third Five Year National Development Plan. Since then, in line with the specific goal of lowering the population growth rate set in the Development Plan, the NFPP converted the demographic goal into FP target acceptors in each National Development Plan.

Operationally, the Family Health Division which had been responsible for MCH programs, was also assigned responsibility for planning and implementation of the NFPP programs. Family planning services were integrated into the existing MCH services outlets throughout the country. These health facilities encompass four regional MCH centers, provincial and district hospitals, health centers, and all other government health facilities. Approximately, 8,000 government facilities, including 7,000 rural health centers and 1,000 government hospitals, are providing FP services all over the country.

Additionally, in remote rural areas, ethnic minority areas and Thai Muslim areas, the non-government sector is also playing an important role in providing contraceptive services through community-based volunteers. Through this system, family planning services are now available in 17,000 villages in 157 districts and 48 provinces throughout the country (185).

(vii) Sources of Contraception

Sources of contraceptive services were investigated in a nationwide survey, the Demographic and Health Survey of Thailand, in 1987 (91). The results indicated clearly that the government sector was the major sources of FP services for both permanent and temporary methods. The government outlets contributed slightly over four fifths (81.9 per cent) of current users whereas the private outlets accounted for 15.3 per cent. Government hospitals and regional MCH Centers were the major sources of female and male sterilization and IUDs whereas rural health centers were the major sources of injectables and oral pills. In the private sector, drugstores were also the major provider of supply methods, particularly the pill and the condom. As for client's satisfaction with FP services provide at these sources, it was found that a great majority of them were satisfied with FP services received. It is believed this continues to broadly represent the current situation.

(e) Availability of Legal Abortion

As noted above, according to current Thai law, which was drafted in 1956, induced abortion is considered a crime, except induced abortion performed by a medical practitioner in cases of pregnancy resulting from rape or if necessary to protect the women's health (220). In practice, protection of women's health has been restricted to endangerment of the women's life. Accordingly, induced abortions are legally performed only by physicians under the two mentioned circumstances

The existence of such law, however, cannot prevent illegally induced abortion. Consequently, illegal abortion has been performed secretly, often by poorly-qualified practitioners, or by completely untrained persons posing as doctors as well as some trained personnel such as nurses, midwives, and medical doctors. Therefore, the precise extent of induced abortion in Thailand is not known. However, it is believed that prevalence of abortion has been increasing due to changing social mores leading to increased rates of premarital sex, increased acceptance of abortion due to concerns about HIV infection of babies, and the availability of medically supervised safe abortions. Increasing numbers or abortions are apparently being conducted by trained personnel.

In part, however, the perception of increasing abortion rates may be due to increased visibility associated with increased public acceptance. In term of family planning policy, induced abortion has not been included as one of birth control methods in the NFPP due to religious and ethical arguments. Nevertheless, abortion is regarded by many women as a potential birth control method, according to contraceptive surveys (70).

(f) Quality of Care in Health and Family Planning Services

No intensive study on the quality of care in health and family planning services using the Bruce framework has been made, nor has any broad study considering these issues been conducted. Consumer satisfaction, an outcome indicator to evaluate the quality of care provided for women two midwifery centers with significantly different in utilization rate in the northeast of Thailand was investigated (221). It was found that women reported they were satisfied with quality of health and family planning services received from the highly-utilized center in term of midwife's competency and quality of health information. The level of the provider's commitment to work, attitude toward patients and job satisfaction influenced the quality of care that women received.

(g) Other Services for Women

Beyond MCH and family planning services, a variety of other health services of specific relevance to women are currently available. Adolescents and other women of reproductive age can access to premarital and FP counseling and genetic counseling. Infertility treatment is available at 82 MOPH hospitals. Women in menopause can obtain access to health services at government and private clinics and hospitals. The baby-friendly hospital program is being expanded by the MOPH to encourage exclusive breast feeding.

Traditionally in Thai society women, in their role as mothers, wives and daughters, were viewed as the primary providers of health care to family members, an expectation that continues today with particular regard to the care of aging relatives. As health care became professionalized, it is thus not surprising that women become heavily involved, and indeed made up the majority of carers in the professional sector. Thus the situation arose, and continued to the present day, that women were the majority of public (and private) sector health workers

This view is supported by data from the MOPH in which three-fourth of all officials are female (103; 99). By category, about 72 per cent of the medical and public health personnel are female. They are employed mainly as nurses, technical nurses, auxiliary nurses and midwives, as shown in Table C.8.1.

In higher level health care positions, however, the gender ratio is reversed. Thus according to the Physicians Report, women made up 27.2 percent of physicians in 1996 (See Table 3.) An alternative source said that as of April 1996, there were 15,572 male doctors and 5,535 female doctors registered to practice in Thailand. Among specialists, the gender disparity is even more marked, with women representing only 26 per cent of the national total of 21,854 (103; 48). In part this situation has arisen because of women's historically lower access to higher education, and a continuing quota which restricts women to 50 per cent of students entering medical degrees, which is supported by the argument that female doctors cannot work in isolated environments or late at night, so that the number of male doctors must be maintained (103; 48).

Similarly, the number of high level female officials in the health care sector is much lower than that of males. There are only a few female officials with high level positions in the Ministry of Public Health, as shown in Table 3.8.2. This is a reflection of the general position of female public servants in all departments, as discussed above.

Statistics show that, at least for the public sector, there may also be problems in maintaining trained staff. For example, out of the expected number of 53,371 nurses only 25,767 (48.3 per cent) are working for the MOPH. Attempts to increase this number have been thwarted by high levels of resignations, suggesting there may be factors at work discouraging long-term service, or which cause frustration and disillusionment with the profession. One of the reasons for departure from the public sector is higher wages in the public sector. Some reports indicate nurses can earn up to 25.5 times more in the private sector than in the public. (68; 30).

Studies have also shown that many nurses are unhappy and not satisfied with shift work and their nursing responsibilities. Some have complained of poor welfare and compensation (222). Sasithornvejchakul et al. (223) carried out a study among 172 nurses at the Army Hospital. They reported that about 8.8 per cent expressed a high degree of dissatisfaction with work while the remainder expressed "moderate" or "low" dissatisfaction. It was found that younger nurses are more bored with work than older nurses. Other studies have found that nursing is a very stressful occupation (222) with much conflict as to their nursing roles, especially among those working in an unsupportive environment.

As a result, the number of nurses is regarded as inadequate to satisfactorily cater to the health needs of Thailand. The current ratio is 1 nurse per 3,000 people (which can be compared to Malaysia's level of 1 per 740 people. (68; 30).

a. Formal policy statement

The Eighth Five-Year National Health Development Plan (1996-2001) focuses on health issues of relevance to maternal and child health, working-age women and the aged. For the first group, the plans sets a target to increase life expectancy at birth of female to 72.20 years and male to 67.91 years, to reduce the maternal mortality rate to not greater than 20 per 100,000 livebirths; the percentage of HIV-positive pregnant women of age less than 25 years to be not greater than one per cent; and the infant mortality rate of not greater than 21 per 1,000 livebirths. The plan also aims to increase the proportion of women aged between 21 to 35 years who are model mothers to not less than 35 per cent; the number of infants with four months exclusive breastfeeding not less than 30 per cent; and the number of new-born babies weighing under 2500 grams not more than seven per cent (86; 176-177).

For women in the working age group, the plan aims to provide accurate knowledge and behavior related to for women of reproductive age. The plan aims to promote males to participate and take a supporting and responsible role in reproductive health. The plan also encourages women to get pregnant at the age of not less than 20 years. The plan also focuses on providing the correct knowledge and self-care to post-reproductive women (86;182).

The Twenty Year Perspective Plan for Women (1992-2011) was developed by the NCWA and adopted by Cabinet as a suitable guide for other policies and plans. Its health policy is aimed at the reduction of maternal mortality to 0.1/1,000 live births; iron-deficiency anemia in pregnant women to 5 per cent; goiter rate in school girls to less than 5 per cent; light birth weight (LBW) infants to less than 5 per cent; and, infant mortality rate to 20/1,000 live births. Its aim is to reduce general disease mortality and morbidity by half; to reduce deaths due to cervical and breast cancer; to halve the number of newborns suffering thalassemia; to halve the rate of work-related injuries; to discourage smoking among women; and, reduce the rate of family violence and general violence against women. It also sets the ambitious target of reducing by half the rate of sexually-transmitted disease, including HIV/AIDS, among women, and of ending child prostitution (104; 4-9 - 4-15).

The plan also aims to achieve the elimination of infant rubella syndrome, to increase the provision of pap smears for the detection of cervical cancer, to significantly reduce the rate of unwanted pregnancy; out-of wedlock and pregnancy in young girls by ensuring all girls and women have sufficient knowledge of birth control and family life; to eliminate child prostitution, to reform the abortion law with the consideration of women right and social justice.

b. Policies and policy documents which directly or indirectly influence the health of women

(i) Occupation-related diseases

The Eighth Five Year National Development Plan (1996-2001) states that women of working age should be well-informed about issues affecting their health and appropriate behavior to care for their own and their family's health. It states they should have the information to avoid behaviors which would put their health at risk, and be able to participate in health promotion activities in the workplace.

The Eighth National Economic and Social Development Plan also focuses on health issues for disadvantaged groups, particularly women and children in the commercial sex industry. It encourages the setting up of networks in different communities to protect communities from exploiters and prevent women and children from being persuaded or seduced into becoming commercial sex workers. The plan also has provisions for campaigns to change community values so as to discourage involvement in or support for the commercial sex industry. It also provides for steps against violence upon women and children and for inserting family education in every level of school curriculum. (116)

The plan also stresses the importance of the elimination of the discrimination against women according to the United Nations Convention on the Elimination of All Forms of Discrimination against Women, and also application of the Convention on the Rights of the Child. (116)

(ii) Abortion, population and family planning

The Eighth National Plan focuses on the importance of knowledge and strong moral values in reducing the rate of abortions. It states both men and women should have equal rights in making decisions about reproductive health, and in being able to assert their right to safe behaviors (86).

(iii) Nutrition

The Eighth Plan provides for nutrition education to mothers and children, to be administered and provided at the provincial level.

(c) Involvement of women's groups in policy development, program design and program implementation

The Twenty Year Perspective Plan for Women (1992-2011) has been developed by the National Commission on Women's Affairs following intensive consultation with NGOs. The list of organizations and individuals consulted totals over 600, the majority of whom are NGOs. NGOs and grassroots workers were also involved in the development of the Eighth National Development Plan through an extensive, nationwide consultation process (103; 13)

(d) Achievement of goals

The Seventh National Health Plan set the target goals of a maternal mortality rate of 0.3 per 1,000 livebirths; infant mortality at 23 per 1,000 livebirths; contraceptive prevalence rate 77 per cent; child delivery health officers and trained midwives at 80 percent of births and newborn babies weighing less than 2,500 grams at equal or less than 7 per cent of the total. Statistics show these targets were reached or at least closely approached, with 0.23 maternal mortality; 25.9 infant mortality; 75.1 per cent acceptance of birth control (224; 28);.96.4 per cent of deliveries attended by trained helpers; and, 8.1 per cent of newborns weighing less than 2,500 grams (224; 65).

(e) Public debate of women's issues

A number of issues of particular concern in the areas of women's health, or of relevance to them, have recently attracted considerable public and media attention and debate.

(i) Sexual behavior

Over the past few years various issues related to sexual behavior have been actively debated in the national media. Concerns about abortion rates, protective behavior including safer sex and related issues have prompted a debate about the necessity and methods which might be used to improve the level and nature of sex education, including inclusion of moral and emotional issues, as well as biological information (NCWA, 1996; 42). Methods of encouraging condom use by male adolescents, particularly in non-commercial relationships, to prevent pregnancy and HIV/AIDS has been one much-discussed aspect of this issue (Thairat, July 1,1996, p.39).

Abortion, and the possibility of changing the abortion law, has also been a frequent topic of public debate. One view in this debate was expressed by Kabilasil who stated that abortion is considered as direct murder regardless of the reason for doing so, even rape, as it is thought of as violence upon babies (The Manager, January 19,1996, p.10). However, particular in view of the HIV/AIDS epidemic, and concerns about HIV-infected babies and the fate of HIV-orphans, debate on this issue continues. It has been reported MOPH is continue collecting opinions on this matter and is likely to propose further consideration by the profession (Matichon, February 11,1996, p. 10).

(ii) Violence Against Women

In 1992 there was a report of a women raped approximately every three hours while last year the rate increased to one every two hours and twenty minutes, and it is recognized that this figures actually seriously underestimate levels of the crime because many victims are too scared or embarrassed to file a report. (Bangkok Post, July 6, 1996, p.23).

There has been increasing coverage of the issue in the news media, particularly following a number of horrific crimes in which very young girls have been the victims. On July 6, 1996, the front page of the Bangkok Post reported that a five-year-old girl was raped and murdered in the toilet at her school in Bangkok (Bangkok Post, July 6,1996, p.1). Later, a reformed drug addict aged 20 years who was released from prison the previous week was arrested and confessed to the crime.

The level of public concern aroused was demonstrated by the fact that the Prime Minister later visited the school, while the Bangkok governor vowed that security at schools would be tightened and that the toilets should not be isolated from the main building. (Bangkok Post, July 7, 1996,1). Twenty-five government and opposition MPs called on the Prime Minister to push for the death penalty for the suspect in this rape-murder (Bangkok Post, July 11,1996, p.1). In the period after this crime, and explicitly linked to it, it was announced that four hotline centers would be set up in Bangkok to deal with increasing child and woman abuse. (Bangkok Post, July 23, 1996). Reporting of such crimes generally spreads towards wider issues about the perceived moral breakdown, family decline and related issues.

(f) Recent reforms

As noted above, legislation has been recently introduced to provide 90 days paid maternity leave for all female workers who have been employed continuously for more than 180 days. However, many private employers ignore this responsibility.

Other notable recent advances are the new anti-prostitution legislation (also discussed above), which came into effect in December 1996. In broad areas of women's rights, there have been considerably advances in their access to important positions, ranging from general or equivalent rank in the armed forces, to provincial governorships under the Interior Ministry. These and other legislative and administrative changes have allowed Thailand to withdraw all but one of the substantive reservations maintained when it acceded to the Convention on the Elimination of Discrimination Against Women (103, 1996, 7). Broadly it can be said that the legal and administrative framework have improved, but much remains to be done to convert these changes into effective improvements in all aspects of women's position in Thai society, including their health.

A number of major recommendations may be made following consideration of this report.

(a) Information

It is clear from the contents of this report that in many areas of health in Thailand, there is still insufficient information and research findings for example violence against women, induced abortion, adolescent pregnancy, RTI, menopause, reproductive technology etc.

There are also disadvantage groups of people such as women ethnic minority groups, prisoners, hilltribes, homeless, adolescents, migrant workers and factory workers of whom little information is available on the health issues affecting them. This is obviously a very difficult group to identify and study, but further information is needed to address not only their health but also the potential health ramifications of their presence for the rest of the population of Thailand.

A further area of concern is the general lack of monitoring and evaluation of the quality of health care for women. Information systems for collecting and disseminating data for the study of women's health should be established. Finally, with regard to information, it is essential that it should be easily accessible to government officers, NGO workers, researchers, the media, and other interested individuals.

(b) Enforcement

This broad topic covers two main areas - the implementation of government policies and the enforcement of the laws of Thailand to protect women. With regard to the former, it is notable that in many areas there are excellent recommendations and government policies, for example with regard to maternity leave for post-natal health visits, but that such recommendations and policies are not always put into effect.

Secondly, with particular regard to issues raised by the commercial sex industry, and violence against women, it is evident that although Thailand has laws which provide for reasonably strong punishment for offenders in these areas, they are very rarely enforced. With regard to the sex industry, the introduction of new Anti-Prostitution legislation which came into effect in December 1996 offered an excellent opportunity to make a new start in enforcement of the law. With regard to violence against women, it seems that further public education campaigns, and campaigns directed at all elements of the judicial system may be necessary to create a framework in which the law will regard it as an essential responsibility to protect all women against violence, including violence within the family.

There is also an important element of education here which is sorely lacking, for women who are unaware of their legal or other rights will be unable to initiate the procedures which would allow them to utilize existing structures and rules. Thus for example, many women are unaware of the problems created if marital-type unions are not formalized by official registration. If they are abandoned or mistreated, this leaves them with severely circumscribed rights.

(c) Health Policies

It is evident from this report that in research, policy and practice, women's health has often not been considered on an individual basis. Instead, reports, research and services very often speak about "mother and child health". With demographic change meaning older women, women with grown children and single women comprise an increasing percentage of the population, this means the health issues affecting many women fail to be considered or addressed.

(d) Health education

Information in this report indicates that in many ways, women remain ignorant about important health information which would assist them to protect themselves or act appropriately to deal with health problems. It is women's right to know and right to make choice towards medical care information from health care providers. Information about screening for breast and cervical cancer, about appropriate use of medicines, about the importance of exercise and maintaining an appropriate bodyweight are all areas in which it is evident that more information and education is needed.

Furthermore, it is obviously important that the level and appropriateness of sex education be improved to equip girls (and boys) to appropriately protect themselves against the risk of HIV/AIDS and other sexually transmitted diseases. The difficulty of the task of empowering girls in this area is acknowledged, but so is its importance.

Another important area is in consumer education. As women continue to be the main purchasers of household items and food, their awareness of issues such as potential contamination, prepared food which has passed its expiry date and poor quality utensils and containers which may cause health problems are all areas which need to be addressed.

(e) Mental Health

The lack of data on mental health problems has already been noted above, but this topic also requires a further special focus on treatment. It is generally acknowledged that treatment facilities for serious cases of mental illness are already being significantly stretched, and that many people who might have been assisted by counselors and other appropriately-trained professionals to avoid serious mental illness, family problems, suicide and other serious matters have no opportunities to access such services. The NCWA has identified the shortage of services in these areas, and the shortcomings in existing programs to train these workers, and is attempting to alleviate both areas of concern.