Women’s Health in Thailand

Women’s Health and Development: Country Profile, Thailand
Prepared for the World Health Organization, South East Asia Region Office, January 1998

A.1. Physical features

Thailand is situated in the heart of Southeast Asia and is the gateway to Indochina. It borders the Lao People’s Democratic Republic in the North and Northeast; the Union of Myanmar in the North and West; the Andaman Sea in the West; Cambodia and the Gulf of Thailand in the East; and Malaysia in the South. The Kingdom has a total land area of 513,115 square kilometers (100; 2), stretching 1,640 kilometers from North to South and 780 kilometers from East to West at its widest point (101; 1).

The climate is tropical with long hours of bright sunshine and high humidity. There are three seasons; hot (from March to June), rainy from July to October) and cool (from November to February). The temperature ranges from an average low of 23.7o C to an average high of 32.5o C (100; 4). The geographic and climate conditions are suitable for the cultivation of a wide range of tropical and semi-tropical agricultural crops. Earthquakes are rare and mild, but typhoons regularly threaten during the rainy season, and severe floods occur every few years.

Thailand is divided into four regions; the North, the Central Plain, the Northeast and the South (100; 3-4). The North consists primarily of mountainous and hilly terrain, with many natural forests. The Central Plain, often described as the Chao Phraya River Basin, is the richest and most extensive rice-producing area. The capital city of Bangkok is located in this region. The Northeast region is characterized by undulating hills with harsh climatic conditions resulting in frequent floods and droughts. The Southern region is partly hilly with thick forests and rich deposits of minerals and ores and also features many islands.

A.2 History and political structure

By the 13th century Thais had become a distinct cultural and political entity, and a force to be reckoned within mainland Southeast Asia. Thai princes ruled over states as far apart as Lanna (in modern Northern Thailand) and Nakhon Si Thammarat (in the modern south). However, the Thai historical imagination has been most stirred by the Kingdom of Sukhothai (13-15th centuries) and that has been viewed as the predecessor of the modern Kingdom of Thailand (100; 15).

After the decline of Sukothai, and the rise and fall of the kingdom centered on Ayudhaya, the national capital moved to Bangkok. The nation remained an absolute monarchy until the establishment of a constitutional monarchy in 1932. King Bhumibol Adulyadej last year (1996) celebrated his 50th year on the throne. Due to the great respect in which the monarchy is held, it is common for the monarch to offer informal guidance on the political development of the nation (103; 5).

The parliament is bi-cameral, consisting of the House of Representatives and the Senate. Members of the House are elected in multi-member electorates, typically with three members per electorate, and the maximum term of parliament is four years. All citizens over the age of 18 years are eligible to vote. (This was lowered from 20 in 1995.) Members of the Senate are appointed to four-year terms by the Monarch, who is advised at the sole discretion of the Prime Minister. The Senate has the power to block or amend any legislation, although substantial amendments must then be referred back to the House of Representatives for approval.

Thailand has a multi-party system and there are a large number of parties represented in the House of Representatives. Traditionally the leader of the largest party becomes Prime Minister, provided he or she can form a coalition government and gain the confidence of the house (103; 5). However, over the past 60 years Thailand’s government has most frequently consisted of military-dominated administrations, often established after army coups. Since 1992, however, there have been three elections and four elected administrations. A new democratic constitution is now being implemented, designed to reduce or eliminate vote-buying and improve democratic participation.

Administration is conducted on two levels – national and local, with the latter being divided into progressively smaller units termed provinces, districts, sub-districts, tambons and villages. The chief executive of each province is a governor, appointed by the Ministry of the Interior. District and sub-district officers are also appointed. Village heads are elected, with those taking office before 1992 serving until the retirement age of 60, while those elected after that date serve five-year terms. In 1995 the first elections for sub-district government bodies were held, as part of a plan to decentralize decision making (103, 6).

A.3 Demographic features

The Thai population was estimated as 60.44 million on July 1, 1997. In 1995, urban areas were home to 18.856 million people while 40.853 million lived in rural areas. Of the former, 7.486 million lived in Metropolitan Bangkok (106, 1-2).

During the past 30 years, the population density has doubled, from 51 persons per square kilometre (p/sq. km) in 1960 to 115.2 in 1995 (73). The Bangkok Metropolis has the highest population density of about 3,758 p/sq. km in 1990 (107). In the same year the Central and Northeast Regions had a higher population density than average, at 118 and 113 p/sq. km respectively. Population density in the South was 99 p/sq. km and the North had the lowest population density of 62 p/sq. km (107).

The 15.7 million young people aged under 15 years accounted for 29.2 per cent of the country’s population in 1990, down from 38.5 per cent in 1960 (72). The working age group (15-59 years) increased from 56.9 per cent in 1960 to 34.8 million persons or 63.4 per cent in 1990. About 3.97 million persons or 7.4 per cent were aged 60 year and over (72). The Northeast had the highest proportion of the young people, while Bangkok Metropolis had the lowest. The highest proportion of the senior citizens was in the North and the Northeast.

The age dependency ratio, the ratio of persons in the dependent ages (under 15 years and 60 years of age and over) to those in the working age (15-59 years), was 56.5 in 1990 (72). In other words, there were about 57 dependents for every 100 persons of working age, much reduced from recent decades, when the figure was well over 100 (72). If the age dependency ratio is divided into child dependency and old age dependency, it is found that the child dependency ratio was 45.1, reduced from 90.3 in 1960, and the old age dependency ratio increased from 10.0 in 1960 to 11.4 in 1990 (72).

The number of single people over 13 years of age (the statistic selected by the NSO, although it would be expected there would be very few married people under 16, due to legal restrictions) increased between 1960 and 1980 and reduced in 1990 (72). There were 17,710,300 persons aged 13 years and over were single or 36.3 per cent in that age group. The proportion of single males was greater than that of single females (36.8 and 30.4 per cent respectively).

Those who currently exhibited marital dissolution consisted of 5.8 per cent widowed, and 2.1 per cent divorced and separated. The proportions of marital dissolution were remarkably different between males and females (3.5 and 12.1 per cent respectively). The proportion of single individuals was much higher in municipal areas than non-municipal (42.8 and 31.2 per cent respectively).

By region, the Bangkok Metropolis had the highest proportion of single individuals (45.3 per cent), while the North had the lowest proportion (29.1 per cent). The proportion of marital dissolution was similar for all regions (around 8 per cent), although the Bangkok Metropolis had the lowest proportion of individuals whose marriages had ended, at 6.7 per cent.

Among ever-married women aged 15 years and over, the fertility rate showed an average of 2.9 live births, with the average number of living children of 2.7. These figures were lower in municipal areas than in non-municipal areas.

The crude birth rate had been reduced from 44.2/1,000 people in 1965 to 17.14/1,000 in 1995 (73). In 1994, the highest crude birth rate was in the South (25.8/1,000) while the second highest level was in the Northeast (22.8/1,000). The North and the Central had similar crude birth rates of 17.8 and 17.6 respectively. The lowest rate was in Bangkok Metropolis (14.7/1,000 population) (107).

The country’s crude death rate has been reduced from 10.9/1,000 population in 1965 to 6.1 in 1995. The North had the highest rate through out 1994-1995. The South had the second highest rate of 6.6/1,000 population in 1991. The Northeast and The Central had crude death rate of 6.3 and 5.6 respectively and Bangkok Metropolis had the lowest of 3.3/1,000 population (107).

The difference between the crude birth rate and the crude death rate has had an impact on the population growth rate. The highest annual population growth rate was 1.9 per cent in the South. The Northeastern rate was in the second (1.6 per cent). The Central rate was 1.2 per cent. Bangkok Metropolis and the North had about the same rate of 1.1 per cent population growth (107).

A.4 Social features

Buddhism is the state religion. About 95 per cent of population are Buddhists with an almost equal proportion between males and females (72). Under the constitution, the Monarch must be a Buddhist, but is also the upholder of all religions, with freedom of religion guaranteed. Muslims are the largest religious minority and are concentrated in the south of Thailand. According to the 1990 Census they comprised 4.1 per cent of the population. Christianity, the second largest minority religion, is followed by 0.53 per cent of the population (100; 151). Others are Hindu, Sikhs, Brahmins and Confucians, under the classifications applied by the census.

Although Buddhism is the main influence in the Thai society, it is by no means the only one. Underlying this national religion are a host of other faiths and beliefs that are often so intertwined, including beliefs in various forms of the supernatural such as ritual charms, potions and amulets that are believed to provide the wearer with strength, protection, or a general well-being.

Thai is the national and official language and is spoken and understood by nearly all of the population. In addition regional dialects are spoken, particularly in the south and the north-east, where the people have strong cultural and kinship ties with the citizens of neighboring Lao. In the mountainous regions of the north and along the western border with Burma there are minority groups known as hill tribes, which have distinct linguistic and cultural identities. (100)

In addition, Thailand has on its soil a large number of undocumented migrant workers, with the National Security Council estimating between 700,000 to two million foreign laborers in Thailand (130; 1). Attempts have been made to develop measures to regularize their status, but none have yet achieved widespread acceptance and following the economic downturn, moves are being made to expel many of them.

The proportion of the poor among the total population dropped from 26.3 per cent in 1986 to 13.7 per cent in 1992. But this has been accompanied by an increase in income disparities, with the gap between the income of the top and bottom 20 per cent of households rising from 12.2 times in 1988 to 15.8 times in 1993 (101; 4). Expressed in other terms, the top-earning 20 per cent of households now collect 60 per cent of the total income, while the lowest-income 20 per cent of households earn only 4.5 per cent of the total (101; 4).

Regionally, the north-east’s average income was 10.2 times lower than that in Bangkok in 1991 and this gap widened to 11.9 times in 1994 (101;4). The difference in social and economic status among regions has induced significant internal migration, chiefly from rural to urban areas (particularly Bangkok and surrounding areas). A study covering the period from 1983 to 1988 found migrants were predominately young adults who actively participated in the labor market, implying that their major reason for migration was employment, a situation which continues. In 1992, about 7.3 million people migrated (97, 1992). Among these, about 75 per cent or 5.6 million, had been living in rural areas. Male migrants slightly outnumbered their female counterparts.

An interesting characteristic of the Thai pattern of migration is, however, its relatively temporary nature. The 1992 National Migration Survey found 1.5 million people had moved back to rural areas after spending an average of five years in urban areas – mostly Bangkok (102, 99). The reason giving by the returning migrants themselves was mostly the unpleasant nature of city life, including pollution, traffic jams and poor infrastructure, although researchers concluded that being discarded for younger or better-qualified workers was also a factor in some cases.

A.5 Education

In 1996, the national budget allowed for expenditure of 171,914.1 million baht on education, 20.4 per cent of the total budget and 3.54 per cent of GDP, as shown in Table 1. This reflects a substantial increase in spending over recent years. Social services and national security were the second and third categories, with 117,705.1 and 108,015.6 million baht or 14 and 12.8 per cent respectively (108; 1996).

Primary school facilities are available to almost the entire population. In 1994, the proportion of students in the school-aged population was 94 per cent. The literacy rate was 91 per cent in 1985. It rose to 94 per cent in 1992 (109). It would appear this statistic relies on census data, augmented by graduation records, with the assumption being made that each person who has graduated from school is literate. Problems with later loss of literacy, or schooled illiteracy, have not been investigated.

Education in Thailand starts from three years of pre-school for children aged 3-6 years, although this is not compulsory. Six years of primary education, for children generally aged from 6-11 years, is compulsory. Secondary education is divided into two parts; three years for lower secondary level and another three years for upper secondary.

In the past few years there have been significant efforts to increase pre-primary education, particularly among disadvantaged sectors of the population. In 1996, 200,000 pupils were enrolled in Ministry of Education-funded pre-school centers, up from 20,000 in 1993. They attended 3,474 centers concentrated in the poorer northern and north-eastern regions (101; 36).

The enrollment of students in lower secondary schools has historically been low. It rose from 29 per cent of the population aged 13-15 years in 1980, to 35 in 1985, 40 per cent in 1990 and 64.5 percent in 1994 (108). This is low compared to other South-East and East Asian countries, with comparable figures in 1988 being 48 per cent in Indonesia, 57 per cent in Malaysia, and 87 per cent in the Republic of Korea (110). The government is now moving to make lower secondary education compulsory for all Thai students. The transition rate of students from the final year of primary school to the first year of lower secondary school rose from only 40 per cent in 1988 to 85 per cent in 1994 (108).

The enrollment in upper secondary school was 34.2 per cent of the relevant age groups in 1994. It rose from 21.6 and 24.3 per cent in 1982 and 1987 respectively. University enrollments are also increasing. They rose from 5 per cent of the relevant age group in 1982 to 15.7 per cent in 1994 (108).

In 1993, 80.3 per cent of total work force in Thailand had only primary education or lower attainment. It was estimated that by the year 2000, more than 70 per cent of country workforce will still have only primary education. It is clear that future demand will be for an educated workforce to produce high technology products for exports (109), but this demand will be very difficult to meet.

Although the provision of education in Thailand has improved in terms of the amount of students’ attainment, very significant educational inequalities still exist, with huge regional disparity and differential access based on socio-economic status. The majority of students in universities are from business or professional families (110).

A.6 Economy

Over the past decade the driving force for change in Thai society has been economic growth, with the nation recording the world’s fastest rate of economic growth between 1985 and 1994, an average of 8.2 per cent. Per capita income rose to a forecasted $US3,139 in 1995 (111). In the last year, however, there has been asignificant economic downturn, the impact of which will certainly be significant, although as yet this is difficult to assess.

A long-term trend has seen the importance of agriculture declining and industrial production and services increasing as a proportion of GDP has also accelerated. Agricultural production contributed 38 per cent of GDP in 1960, but only 11 per cent in 1995 (111). Manufacturing production rose from 13 per cent of GDP in 1960 to 30 per cent in 1994 (111). Bangkok and surrounding regions have been the primary contributors to the growth of the manufacturing and service sectors. In 1993, the share of GDP at 1988 constant prices of Bangkok and vicinity was 56 per cent of the national total (111). Thailand’s manufacturing sector was originally based on value-adding to primary products. Initially growth in manufacturing was in low-tech industries such as clothing and footwear production, but since around 1990 investment has increasingly swung towards medium-tech industries producing goods such as electronics, computers, petrochemicals, machinery and motor vehicles (102, 36).

Tourism has also been important in economic development. Since 1987 (Visit Thailand Year), it has outstripped other sectors as a source of foreign exchange. Tourist arrivals topped 5.4 million in 1995, a 13 per cent increase from 1993, and they provided an estimated 170 billion baht in national income (103; 3).

The proportion of people employed in the agriculture declined from 84 per cent in 1960 to 51 per cent in 1992 (113). This was balanced by a rise in industrial employment, from 4 per cent in 1960 to 15 per cent in 1992. With this employment concentrated in Bangkok and surrounds, this has led to significant migration, with 1.1 million people in the 15-30 age group leaving the poorest north-eastern region from 1980 to 1990, most moving to Bangkok (103; 99).

Overall, unemployment has usually been low, although with the current economic problems is again becoming a problem. The latest available study found that 375,100 people were unemployed (1.1 per cent of the labor force), of whom 55 per cent were female. The majority of both males and females in this group had only primary education or less. Shortages of some skilled and unskilled workers are experienced frequently in various regions and economic sectors, although there is believed to be significant underemployment in rural areas. Various estimates suggest that in the near future between one and two million people will be unemployed.

The rapid growth of exports and imports indicates the increased openness of the Thai economy. The share of merchandised exports (fob) plus merchandised imports (cif) to GDP (at current prices) increased from 26 per cent in 1970 to 67.9 per cent in 1994 (112). However, in 1995, exports grew at the rate of 22.5 per cent while the imports grew at the higher rate of 27.6 per cent, leading to a trade deficit amounting to 8.3 per cent of GDP (112). The composition of imports has moved increasingly away from consumer goods towards capital, intermediate and raw material goods. The import of capital goods alone has grown from 25 per cent of total imports in 1960 to 55 per cent in 1994 (112). Inflation has been moderate, at around 5-6 per cent, (114), but is expected to rise significantly in 1997-8..

The Thai government has sustained a budget surplus since the 1988 fiscal year. In 1995, the surplus was $US5.6 billion. However, external debt as at September 1995 was $US 63,884 million (39 per cent of GDP), made up of public sector debt of $182 million and private sector debt $47,536 million (101; 3). This problem has been made more serious, and the ratio of debt to GDP significantly worsened by the recent devaluation of the Thai currency.

The high rate of economic growth and rapid structural change in the Thai economy have created some significant problems. Infrastructure bottlenecks are a serious problem, mainly due to the concentration of growth in Bangkok and other large cities. The average speed of vehicles in Bangkok is 10km/h (114; 14). Pollution levels have been rising in waterways and in the urban atmosphere.

Since 1961, government development measures have operated within the framework of successive five-year plans, most of which have focused almost solely on encouraging growth in the gross domestic product, with the assumption that benefits of such growth would eventually “trickle down” to disadvantaged areas and society sectors (115, 299). The focus of the eighth such plan, which came into effect on October 1, 1996, is, however, somewhat different. It aims for a slightly lower annual growth rate of 8 per cent, with an increased stress on human development and social improvement, rather than simply on increasing the GDP (116, 23). Attempting to address the increasing disparities in income distribution discussed above, the plan states agricultural workers’ average wages should not fall below 1/13 of that of workers in the non-agriculture sector.

The plan sets a target for the reduction of the percentage of people classified as poor from the 1992 level of 13.7 to 10 per cent in 2001. The plan also focuses on dispersion of property ownership through fiscal and monetary policy, upgrading quality of life of rural people, carrying out agricultural restructuring and dispersion of industries and services to regions, developing regional centers, and occupational development and upgrading of the quality of life of the urban poor (116, 16).

A.7 Environment

Environmental problems can be broadly divided into two groups – those which primarily affect rural areas, and those which predominate in urban areas. The latter are mainly found in the Bangkok region. Bangkok alone accounted for 51 per cent of country’s energy consumption for local transport (118; 15).

Lead pollution has been one major problem. Throughout the early 1990s lead levels in congested areas of Bangkok consisted exceeded the standard set by the National Environment Board. (117; 25). An associated problem is lead levels in food (which is often stored, cooked and consumed at road-side stalls). This problem, however, appears to be being brought under control with the introduction of unleaded gasoline in 1992 and its increasing use (118, 1993; 15).

Concern has been growing, however, about the dangers presented by dust and other airborne pollutants. Tests in mid-1996 indicated that in many areas of Bangkok the level of dust particles smaller than 100 microns was 11 to 58 per cent above the safety standard. Levels of particles under 10 microns exceeded the standard by up to 100 per cent. This is believed to be a major contributing factor to respiratory problems, with an estimated 1 million residents of the capital suffering from problems created by the dust. A Chulalongkhorn University study found families of students attending a selection of Bangkok schools were on average spending 1,500 baht a month on treatment for respiratory illnesses (131).

The hazardous waste problem associated with industry (which affects both urban and rural areas) has also dramatically worsened in recent years. It is estimated that Thailand will produce 2.8 million tons of hazardous waste per year by the year 2000. Disposal facilities are limited. (119) Water quality is being significantly affected by industrial waste, affecting both domestic supplies, agriculture and the natural environment (120; 13).

Industrial chemicals are also having an increasing negative impact on the health of workers. The Ministry of Public Health reported a substantial increase in incidence of occupational health problems from 2 per 100,000 population to 9 between 1978 and 1987. One of the most important occupational ailments is lead poisoning. A MOPH study in 1987 showed that more than 14 per cent of cases of occupational exposure to recorded lead-in-blood levels exceeding 60 mg per 100 milliliters, with 0.5 per cent of the sample reaching the critical risk level of more than 100 mg per 100 milliliters. Twenty per cent of the sampled workers in lead-associated plants registered above-normal concentration levels.

In rural areas, forest depletion is the major environmental problem. In Thailand, the percentage of land covered by forest has been depleted from 53.3 per cent in 1961 to 26.6 per cent in 1991. From 1976 to 1982 the average rate of loss was 3.8 per cent per year, one of the highest among the tropical countries (121; 19). Forest loss is a major cause of CO2 emissions into the atmosphere, contributes to increasing severity of floods due to increased run-off and is believed to be a contributing factor to the increasing frequency and severity of droughts, particularly in the north-east region.(121; 19).

Another environmental problem in rural areas is contamination through the increased use of chemicals in agro-industries. An Agriculture Toxicology Division survey in 1982-1985 found that 90 per cent of rice and cereal specimens on the market contained organo-chlorines, which can cause cancer in the human body. Exposure of workers to these chemicals, often without appropriate safety equipment and education, is also a serious problem.

Thailand also faces a number of problems in what might be regarded as the social environment. The abuse of illicit drugs, particularly amphetamines, has been identified as a major health and social problem, one which has spread widely through society. The number of drug addicts seeking medical attention increased from 53.7 per 100,000 people in 1981 to 102.4 per 100,000 in 1985, and is believed to have continued to increase since then (96; 10).

A TDRI survey in 1993 found that there were 247,965 registered amphetamine addicts in 1993-4, but this figure did not include unregistered addicts, and it is believed that since this time the level has risen further. Concern about the problem has led the government to increase penalties for dealing in and supplying amphetamines to equal those for heroin, reflecting the level of concern about the problem (132; 2).

Changing social structures, including the breakdown of the extended family, increased rate of marriage breakdown and separation of families for long periods due to inter or intra-national migration for work, has also significantly changed the social environment. An increasing number of broken families has exposed many children to high risk of adopting drug use, or of becoming homeless or delinquent.

Particular concern has been expressed about increasing suicide rates, believed to be related both to increasing mental health problems and general problems in society. The number of cases reported to the Police Department rose from 1,029 in 1990 to 1,451 in 1994. Department of Health figures show that from October 1993 to September 1994, 1,909 people committed suicide, a rate of 48.67/100,000 people. This increase has been generally attributed to an increase in social, economic and personal pressures related to “modernization” (103). Its extent may not be fully recorded in the above figures, due to the social stigma attached to it and the resultant desire to avoid classification of deaths as suicide whenever possible..

A.8 Health

(a) Organization of the health care system

Provision of health services is the responsibility of the central government. Free health care is available in State hospitals to those who cannot afford to pay for treatment. Individuals earning less than 2,000 baht per month and couples earning less than 2,800 baht per month are eligible for a social welfare card that provides free treatment in government hospitals. Senior citizens (over 60 years of age) and children under 12 automatically receive free treatment and welfare schemes run by individual hospitals provide for care for those who had do fall within these groups, but cannot afford to pay (103; 48).

In addition, free services are provided to government workers, many factories and enterprises have social security schemes, and there is a health card system for workers in the informal sector (of agriculture). Free treatment schemes cover doctor’s fees, medication, in-patient accommodation, surgical fees and necessary medical equipment. However, there is greater demand than supply for these services, public wards are often overcrowded, and patients may wait months or years for treatments such as joint replacements or organ transplants (103; 48).

The Ministry of Public Health (MOPH) is the principal government organization responsible for organizing health care facilities. Additionally, there are some other government agencies contributing their health-related activities to improve the health status of specific groups of the population that they serve. These government organizations are the Ministry of Interior, the Ministry of Defense, the Ministry of University Affairs, and so on. Health care services provided by government organizations encompass preventive and promotional, curative, and rehabilitative services.

MOPH has eight major departments (98): the Office of the Secretary to the Minister; the Office of the Permanent Secretary for Public Health; the Department of Medical Services; the Department of Health; the Department of Communicable Disease Control; the Department of Medical Sciences; the Office of Food and Drug Administration; and, the Department of Mental Health. These organizations are responsible for planning, supporting monitoring and evaluation of public health services provided mostly at provincial level. MOPH provides medical and health services through peripheral health facilities located at provincial, district and village levels. In order to launch the policy of “Health for All”, at household level, the MOPH trained village health volunteers (VHVs) and village health communicators (VHCs) to serve every household with primary health care all over the country.

The primary purpose of health service outlets organized by MOPH is to serve a majority of the population outside Bangkok. These encompass regional hospitals and general hospitals at provincial level, community hospitals at district level, and health centers and community health service stations at tambon and village level. The services provided by the hospitals are predominantly curative, with a certain amount of preventive promotion, and rehabilitation services. Preventive and promotion health services, predominantly MCH and FP services, and basic curative services are available at rural health centers. The rural health centers, the grassroots health facilities located nearest to the rural communities, serve as referral units at the primary level of the government health care delivery system.

In addition, community health service stations (CHSSs) are the smallest health facilities providing basic health services in politically sensitive areas, some remote rural areas with scattered populations along the border of the country or in ethnic minority villages. Beyond the government sector, many NGOs are also providing health care services to some segments of population. These NGOs are mostly non-profit or charitable organizations. In Bangkok and other urban areas, private hospitals, private clinics, and private drugstores are playing a significant role in health promotion and curative activities. In rural areas of the countries, most of the prevailing private health facilities are local shops where basic drugs are available for sale, local healers such as Buddhist monks, injectionists, herbalists, traditional doctors, traditional birth attendants (TBAs), as well as spirit doctors. MOPH licenses and trains producers of herbal medicine. In 1995, there were 381 herbal medical health facilities and 2,313 herbal drug stores. There has however been a policy to discourage the use of traditional healing in unsupervised circumstances due to the dangers of misuse and mistreatment.

The private sector is playing an increasing role in providing health services in Thailand, due to increasing prosperity and government support through Board of Investment policy. Under this policy, private hospitals are taxed at a low rate during the first three to five years after establishment. According to the Bureau of Health Policy and Planning Division, the number of private hospital increased from 164 in 1982 to 122 specialized and 209 general service hospitals in 1991 (63).

(b) Investment in the health sector

In 1992, per capita health expenditure in Thailand was $US101, up from $US55.5 in 1988. Average household expenditure on health per annum in 1992 was $US120 (122).

In 1995, the national budget for the MOPH was 46,412.2 million baht (6.31 per cent of the total national budget and 1.1 per cent of GDP). This increased from 20,568.6 million baht in 1990 (4.84 per cent of total national budget and 0.9 per cent of GDP), or 125 per cent within five years. In term of budget expenditure classified by sector, public health consumed 44,335 million baht in 1994. It increased to 52,596.9 million baht in 1995.

In 1994, there was a total of 1,127 hospitals with 93,540 beds in Thailand. Of those beds 22,404 were located in Bangkok and 71,136 in the provinces. The ratio of population to beds in Bangkok was thus 1:249, as compared to 1:628 in provincial areas. The national average was 1:747. (63, 1994; 146)

In 1994 there was one physician per 4,165 people (63, 1994; 153), although also in 1994 the Medical Council Association of Thailand calculated the ratio was 1:3,012 for both public and private sectors. The numbers of other health workers are still considered to be very low and they are concentrated in Bangkok.

(c) Nutritional and Health Status Indicators

The 1993 National Food and Drug Committee Report showed the Thai people had an average calorie intake equal to 2,443 Kcl/day, 126 per cent of the Recommended Dietary Allowance of 1,936.3KcL, calculated in 1986 (RDA). However, malnutrition remains a problem, especially among pre-school children, although the problem has decreased with increasing average incomes.

In line with increasing levels of general prosperity and increased health services, there have been significant changes in the causes of morbidity and mortality, which have seen Thailand go through what has been described as a “demographic transition”. This has seen a decrease in the importance of infectious diseases and those related to undernutrition and sanitation problems, but an increase in chronic health problems associated with industrialization and lifestyle and traffic and work accidents.

Overall there has however been significant decreases in crude death rates (as discussed above), which are demonstrated in increased average life expectancies, which are currently 71.7 years for women and 66.6 years for men. Life expectancy at 60 (additional years) is 22 years for women and 18.8 years for men (103, 2).

Death rates have significantly declined over the past two decades, from 9.5 per 1,000 in males and 7.9 in females (in 1976), to 6.3 and 4.1 in 1994. The major causes of death during 1987-1992 were heart disease (56.0 per 100,000 people), accidents (48.5), and malignancies (43.5). The rates for hypertension and cerebrovascular disease, liver and pancreatic disease and tuberculosis were 16.4, 13.0 and 6.1 respectively (67).

From 1987-1991, diarrhea was recorded as the most significant infectious disease (1,435.7 per 100,000 population in 1991) (63). Others were dysentery (156.3), food poisoning (106.3), measles (47.4) and hepatitis (31.6). The reported rate of cholera, 9.9 per 100,000 in 1987, had dropped to zero in 1991, while reported diphtheria rates had also dropped to zero.

Not included in the above statistics, but of major importance in considering health issues in Thailand, is HIV/AIDS. Its rapid spread is discussed in Module C.

The ten leading causes of death in rural and urban areas accounted for greater than 90 per cent of all deaths. While cancer was responsible for 50 per cent of the urban deaths, respiratory diseases were the principal killer in rural areas, accounting for 25 per cent of deaths. The rural population was proportionally more likely to die from injuries and poisoning, infectious diseases, and neonatal complications than their urban counterparts, who were more likely to die from heart diseases and cancer. In both rural and urban areas, males were more likely to die from cancer, injury and poisoning, digestive system diseases and infectious diseases than females, who were more likely to die from respiratory and heart diseases.

The rate of many other communicable diseases has also been reduced through an expanded program of immunization (EPI), with the total number of tetanus cases between 1990 and 1993 falling from 813 to 502. Over the same period the cases of diphtheria fell from 58 to 28, and measles fell from 29,463 cases to 17,851 (99). The EPI program aims to immunize every newborn baby and to ensure all children under five have received appropriate courses of BCG, DTP, polio and measles vaccines. In 1991 the rate of immunization of school children had reached 98.42 per cent, while the figure including pre-school children exceeded 90 per cent (103, 51).

Mother and Child Health and Family Planning (MCH/FP) programs have also been successfully implemented. Different calculations of the rate of infant mortality are presented (see Module C for further discussion). In 1993 the North had highest infant mortality rate, of 42.4 per 1,000 live births and Bangkok had lowest (22.5 per 1,000 live births). (63) The causes of these deaths are widely scattered across congenital and infectious diseases, and no obvious patterns are evident, except that the rate of death across all categories is declining. Considering regional mortality rates, they were lowest in the Bangkock Metropolis (22.5) and highest in the north (42.2)

ntroduction

A comprehensive analysis of the health situation of Thai women requires an understanding of women’s standing in society, the economy and politics. To this end, this module provides an overview of women’s status in Thailand.

Inequality between Thai women and men still exists in Thai society in several areas, however the former gaps in access to resources and opportunities have narrowed considerably over the last few decades. Thai women have maintained by far, one of the highest economic participation rates in Asia, working to help to support the family from a young age. With the rapid industrialization of the country, women have increasingly left the agricultural sector to work in industry and services, and today predominate in the former.

Regarding education, there have been marked improvements in opportunities for women over the past three decades and few significant inequalities exist in education today between Thai women and men. Enrollment at all levels of education are virtually equal however, traditional gender biases still prevail in fields of study. In leadership and influential positions, however, women still lag far behind men from the household to the political level. The trend has improved steadily albeit slowly.

B.1 National Policies for the Advancement of Women

(a) Laws and constitutional provisions

In 1995, following a long campaign by the women’s movement, a provision specifically providing for equality between men and women was re-incorporated in the Thai constitution. First introduced in the 1974 constitution, the equality clause was then removed in the subsequent constitution of 1976, promulgated following a military coup in that year. The efforts of two female senators to enshrine women’s rights in the Constitution of 1976, received insufficient support at that time. (124; 4) Section 24 of the 1995 Constitution now states: “All persons shall enjoy rights and liberties subject to the provisions of the constitution. Men and women shall enjoy equal rights. The restriction of such rights and liberties in violation of the spirit of the provisions of the Constitution shall not be imposed” (123; 23).

The inclusion of this provision is seen as having considerable moral impact in pushing government organizations towards non-discriminatory treatment for women. Any bill presented to either house of parliament can be referred by one-fifth of the House’s members to the Constitutional Tribunal, and if found inconsistent with, or contrary to, the constitution, it will lapse. Cases before other courts may also be referred to the Constitutional Tribunal for consideration and decision. Its decision will be binding on all further cases relating to the same law. The legal appeal process has, however, been very rarely used, and the persuasive effect of the amendment will probably be more important (103; 12).

(i) Inheritance

There is no discrimination in Thai law regarding inheritance for females and males.

(ii) Land ownership

Broadly, Thai women enjoy equal rights to land ownership with men. In northern Thailand inheritance of assets, including land, was traditionally through the female line. There is, however, a particular problem within the law for Thai women with alien husbands.

Article 86 of the Land Law of 1954 states that only aliens of the nations which have mutual treaties with Thailand are allowed to own land. So far Thailand does not have a mutual treaty with any country. Article 74 gives power to the land officer to deny registration of any land ownership if the officer deems that such transactions are for the benefits of the aliens, which includes any foreign spouse (104; 12-12). Theoretically, this applies to both Thai men and women married to aliens. However, since Thai women are legally obliged to change their title and family name upon marriage, land officers can easily see they are married to aliens. Thai men, on the other hand, can claim that they are single and it is highly unlikely that any evidence to the contrary will be unearthed (103; 34).

(iii) Credit

There is no discrimination against women in access to bank loans, mortgages and other financial instruments. Traditionally, women have been responsible for family funds, so they are generally believed to be more responsible than men and hence may enjoy a small bias in their favor. Women with family responsibilities, particularly those who have been divorced or widowed, may however have difficulties in convincing lenders of their ability to meet both family and financial responsibilities (103; 52).

Under Thai law, both men and women must have their spouse co-sign any loan agreement. Both parties are then responsible for the debt.

The chief impediment for obtaining credit is the same for both men and women: poverty. Commercial institutions are unlikely to consider loans of less than 50,000 baht, and there are few other lenders except for “informal credit sources” such as pawnbrokers and local lenders, which charge very high rates of interest (103; 52).

(iv) Marriage and divorce situation

There are some important inequalities in Thai family law. Article 1445 of the Family Law states that sexual relations between an betrothed woman and another man gives her fiancee the right to terminate the engagement and to claim civil compensation from the third party. Women do not have the same right (104; 12-1).

A similar inequality is seen in divorce law. The Family Law provides two channels for divorce. For a consent divorce, the couple can register the divorce in any registry office. A judicial divorce, however, involves the filing of a lawsuit based on the grounds of divorce provided in Article 1516. There are ten grounds of divorce, nine of them applying equally to husbands and wives. The first ground clearly reflects unequal socio-legal expectations and unequal treatment. Under this provision, a husband can sue his wife on the grounds of adultery while a woman cannot use these grounds against her husband. She must prove that her husband has provided maintenance or honored another woman as his wife. (This provision was only added in 1974. Before that time women had no rights in this area.)

A further important inequality affects women’s right to control their body and sexuality. Article 276 of the Criminal Code does not recognize a husband forcing his wife to have sexual intercourse as rape. It is considered as an ordinary assault, which carries a lighter penalty (103; 59).

Another continuing problem for women in Thailand concerns bigamy. In an attempt to transform from a polygamous to monogamous society, Thailand adopted civil marriage registration in 1935. The Family Law since then has required that marriage must be registered with the state registry office in any district throughout the Kingdom. The parties entering marriage must testify to registry officers that they are single before a marriage license is issued. Since the central marriage registration system has just recently been established, there is still no effective way to check people’s marital status and double or multiple registrations of marriage are widely practiced by men. The law does not regard this act (bigamy) as a serious crime. There is only the petty crime of perjury to a registry officer (103; 62).

The Name Act of 1982 obliges women to register a change in title from Nang Sau (Miss) to Nang (Mrs.) and she must take the husband’s surname. If she divorces she can go back to her maiden name but the title must remain as Mrs. (21; 37). A man’s title only changes at the age of 15 from from Dek Chai (a boy child) to Nai (Mr). The title Nai does not indicate whether a man is single or married and thus men can easily conceal other registered marriages.

These issues impose extra and unequal burdens on women. Upon marriage, a woman must change all her personal records, particularly her house registration and identity card. If she fails to do this, it is considered a petty crime. Although this law is rarely enforced, fear of enforcement remains, and if a woman has not made the change she may be fined 200 baht every time she enters into a legal transaction. Alternatively, officials may refuse to carry out the transaction. This law has moreover, reinforced and perpetuated a traditional attitude that only sons can uphold and preserve the family’s name and identity (21; 37).

Thailand’s Nationality Act of 1965 was based on the traditional concept that recognized the man as the head of the family. This concept has made Thai women who marry aliens second-class citizens. They possess lesser constitutional protection than men, as well as presenting the land ownership difficulties discussed above. A Thai woman married to an alien does not have the right to automatically confer Thai nationality on her alien spouse. In order to become a Thai national, the husband must go through the whole complex process of naturalization and abandon his original nationality. In contrast, alien women married to Thai men can simply apply to the Ministry of Interior to obtain Thai nationality. No specific qualifications are required and they need not abandon their original nationality (104; 12-12).

(b) International Instruments

Thailand acceded to the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) in 1985, with reservations to five articles, namely Articles 9, 11, 15, 16 and 29. In 1990, the government withdrew its reservations on Article 11 concerning equal opportunities in employment and Article 15, concerning the equality of men and women before the law. In 1992, the reservation on Article 9 was withdrawn, following changes to the law determining the nationality of children of a Thai mother and alien father. Processes within Thailand to remove two further reservations have been completed: on Article 7 concerning the role of women in political and public life, and on Article 10 concerning educational opportunities (103; 6).

Two reservations remain. One is on Article 16 which concerns the elimination of discrimination in matters relating to marriage and family life. In mid-1996, the Cabinet approved changes which would have made the necessary amendments to the law to allow Thailand to withdraw this final substantive reservation, but this decision lapsed following the calling of elections. The other remaining reservation is on Article 29 which specifies that international disputes concerning CEDAW be submitted to the International Court of Justice, a reservation likely to be maintained by Thailand, as by many other countries (103; 7).

Thailand acceded to the Convention on the Rights of the Child in 1992. There are three reservations on Article 7, concerning names, Article 22, concerning child refugees, and Article 29, concerning education. None of these reservations are specifically related to gender issues.

B.2 National Machinery for the Advancement of Women

In 1989, Thailand established a permanent national machinery for the advancement of women, in the form of the National Commission on Woman’s Affairs (NCWA). The mandate of the NCWA is to spearhead the advancement of women in Thailand. It is a young organization, having assumed independent legal status as a state agency with its own budget allocation and secretariat on 24 March, 1989. Prior to this, similar organizations existed in a variety of institutional forms (103; 8).

The main objectives/functions of the NCWA are:

– To submit policies and master plan for the promotion of women’s activities, roles and status to the Council of Ministers for approval.

– To recommend guidelines for implementing plans and policies in accordance with the National Economic and Social Development Plan, as well as to coordinate and monitor implementation.

– To support and assist women’s development efforts conducted by government agencies, state organizations, state enterprises and private organizations.

– To give comments and recommendations to the Prime Minister on the need for new or amended laws or regulations to promote women’s activities, roles and status.

– To report to the Council of Ministers on the situation of Thai women at least twice a year (104; 13-3 to 5).

The NCWA has 30 members. Eighteen of these are representatives of government organizations, such as relevant ministries or departments, two represent umbrella non-government organizations and ten individuals are appointed for their personal skills and experience. Many of the members in the latter group are also active in NGOs. The NCWA meets three or four times a year and at these meetings considers primarily recommendations and reports from its subcommittees and it secretariat, the Office of the National Commission on Women’s Affairs (103; 8).

The sub-committee structure of the NCWA is central to its work. Some committees are created on an ad-hoc basis, to deal with particular issues and events, but most are standing committees. These consider functional areas such as health, labor, education, family development and commercial sex issues, or are sometimes formed for a fixed term for a particular purpose, such as the committee that prepared Thailand’s Report to the Fourth World Conference on Women.

As the NCWA has the responsibility for coordinating the national women’s development effort, there are no specific focal points for the advancement of women in technical ministries. Instead, the NCWA works, particularly through its sub-committees, so for example, the NCWA Sub-Committee on Women’s Health will liaise with relevant individuals and organizations within the Ministry of Public Health with regard to issues of particular concern.

The ONCWA, the Commission’s secretariat, operates as a division within the Office of the Permanent Secretary of the Prime Minister. It has developed significantly since its creation. Beginning with a staff of only ten, and a 1990 budget of 1,796,700 baht, it has grown to a staff of 43 (as of March 1996), with a 1996 budget of 20,626,800 baht (103; 9).

Approval has been granted to raise the status of the ONCWA from a division to a department, which will lead to a significant increase in the rating of the position of Head of the Office. Overall, the change is expected to give the Office a stronger voice within the government and heightened public profile. Significant staff increases are not expected due to current restrictions which apply across the civil service (103; 9).

Together, the NCWA and ONCWA have conducted many activities over the past six years. Among their particular successes have been the opening to women of many official positions in which they were previously barred such as District Chief and General in the Armed Forces. The first female District Chief was appointed in February 1996 and six female officers from the three armed forces were promoted to the rank of General in April of the same year (124; 8)

Other achievements include major campaigns organized around the International Year of the Family which focused on the importance of fathers, and the removal of many of the reservations initially imposed on Thailand’s acceptance of the Convention on the Elimination of Discrimination Against Women (103, 7). Other major programs have included the promotion of women’s involvement in economic and political leadership, particularly at a local level; legal training of grassroots women; and promotion of fair and non-discriminatory media treatment of women (103; 8).

They have also been responsible for promoting the collection and dissemination of gender-sensitive statistics, and for ensuring effective networking and communication among GOs and NGOs working in women’s development. To this end, the ONCWA produces a tri-annual newsletter (Sarn Satri), directories of organizations and individuals working in women’s development, many reports of seminars as studies, and translations of important documents such as the Beijing Declaration and Platform for Action.

B.3 The Women’s Movement in Thailand

During the economic boom in Thailand during the 1960s and early 1970s, a number of professional women’s associations were formed, including those of female physicians, businesswomen and secretaries. These operated within fairly narrow limits to attempt to improve the position of women. More broad-ranging groups, the so-called ‘progressive feminist groups’ emerged in Thailand following the overthrow of the military dictatorship in Thailand in 1973. Students had an influential role in ousting the military dictators, particularly through ‘the October 14th’ incident. It was from this students’ movement that university women’s groups came into view.

Following their involvement in the national political arena, student groups became more diversified and specialized. Women’s groups in universities shifted their focus from campaigning for justice for all to voicing women’s problems. In 1972 a group of concerned women and men worked set up a ‘semi-progressive’ organization called the Group for the Promotion of the Status of Women (now registered as an association). The International Women’s Year (1975) played an essential part in shaping the direction of this and other similar groups (125; 29).

Two significant women’s groups, Friends of Women and the Women’s Information Center (the latter is now called ‘Foundation for Women’), were formed during the early 1980s in Bangkok. These were among the first Thai groups influenced by the world-wide feminist movement. Subsequently, other small action-oriented groups made their emergence. For example, the Hotline Center, with its focus on phone counseling and self-defense courses for women, was founded in 1985. Another group called EMPOWER was founded in 1986, with the aim of providing education for women working in red-light areas (125; 30-31).

Activities of non-government organizations vary by their objectives and organizational structures. There are groups whose aims are to promote women’s status and protect women’s human rights such as Foundation for Women and Friends of Women Foundation. Some, for example the Hotline Center Foundation and ACCESS, provide women with counseling on family and health problems, including HIV/AIDS problems. Others, such as the Women Lawyers’ Association of Thailand, provide legal advice and aid to women with family-related legal problems. There are also a few places like the Emergency Home for Women and Children run by the Association for the Promotion of the Status of Women which provide temporary shelter for abused women and pregnant women without family support. A few groups like EMPOWER work to provide informal education and training for women in the sex industry. There are also organizations such as the Gender and Development Research Institute (GDRI) which focus on action research on gender issues particularly in the fields of politics, administration and democratic development as well as publishing sex disaggregated data as a tool to effectuate policy changes.

Women’s studies began in Thailand in the early 1980s, with support from Canadian funding agencies. Thammasat and Chiang Mai Universities were the first institutions to set up women’s studies projects at the higher education level. Since then, interest in women’s studies has expanded considerably. Currently, seven universities have women’s studies projects or centers: two in Bangkok and five in the provinces (104; 47-48). However, much more needs to be accomplished in bringing these women’s studies projects and centers into active operation. The concentration thus far has been on introducing a gender perspective to general courses. Work is also in progress at all these women’s studies centers to initiate women’s studies courses. No specific degree has yet been granted in the field of women’s studies in any university in Thailand (103: 38). Many books and publications have been produced by the NCWA for use in various courses offered at Thai universities.

The women’s movement in Thailand has been characterized by close cooperation between NGOs and government workers. Together, they have campaigned and achieved some progress in the eradication of legal discrimination against women. Progress has been made possible mainly due to the pressure from local women’s organizations and the international influence of the UN Convention on the Elimination of All Forms of Discrimination Against Women (123; 22).

The push to incorporate an anti-discrimination provision in the constitution was another major focus, which succeeded in February, 1995. Spearheading the initiative were the GDRI, the Gender Watch Group, and the NCWA. They organized signature campaigns, the sending of postcards to Members of Parliament and organized meetings and discussions with key change agents. (124)

B.4 WOMEN’S STATUS IN FAMILY AND SOCIETY

In the past, most rural Thai families were of the extended type. At present, due to social change and development, new Thai families tend to be nuclear. The 1990 population census showed that nuclear families made up 67.6 per cent of the total, with extended families comprising 26.2 per cent of extended families. In Bangkok 66.9 percent of families were nuclear and 21.0 percent were extended (72).

The change in family structure, combined with decreasing fertility rates, has contributed to reductions in the average size of households. In 1987, the average household size was 5.6 whereas in 1995 it was 4.5 (72). It is predicted this will fall to 3.7 by 2005 (103; 5).

(i) Son preference

The most recent and comprehensive study on this issue found that parents were not concerned about the sex of their children (167). A large survey in Bangkok showed that the majority of respondents were indifferent with regard to their child’s sex (69.4 per cent). Parents desiring a son slightly outnumbered those wanting a daughter. Another study found that in all except the central region, more women expressed the desire for a daughter.

Historically, however, the situation was different. Suwanatas (171) studied low income groups in urban areas and found that in the past, every family, regardless of its social status, preferred sons to daughters. The main reason for son preference was that a son had more opportunities to participate in religious activities. But the study found that the strength of the sex preference has declined. Parents in middle class families expect their children, both sons and daughters, to support them in their old age through psychological and behavioral practice rather than financial support. Parents in low income families expect their children to assist them economically from a young age, and also hope they will continue the family heritage.

Among the Muslim minority in the southern Thailand, however, there is evidence of a slightly stronger son preference. Pongpaiboon (166) noted that due to Muslim laws of inheritance, in a family without a son, when the male head of household dies, the property passes on to more distant relatives. Having daughters has also led parents to fear possible gossip about their sexual behavior. The study found, however, that as in the rest of Thai society, acceptance of gender equality was increasing.

(ii) Female infanticide

Female infanticide and selective abortion of female fetuses are not known to occur in Thailand.

(iii) Social attitudes towards girl children

Studies have shown significant differences in child-rearing practices for sons and daughters, both historically and in the present, but these differences relate primarily to socialisation rather than access to food, health care and other expenses, as will be discussed below when the health of girl children is considered. The socialisation practices, however, vary significantly by region, due to differing social histories.

Santasombat (168) studied the treatment of daughters in northern farming families. In these communities, women were the producers and centers of the family. After marriage, men stayed with their wives’ families. The girls were thus raised to be diligent, to be responsible for household chores, to work on the farm, to take care of the family budget, to follow their own traditions, and to obey and show gratitude towards their parents. Parents expected sons to become monks to make religious merit for their parents and to contribute significantly to farm labor until marriage.

Other studies have found a similar emphasis on training girls in household management and childcare. Frequently this means that all of girls’ time outside school is taken up by such tasks, while their brothers have more opportunities to study, play and move around the community freely. It also means, however, that girls are prepared from an early age to assume responsibility and develop management and organisation skills, which their brothers may not. (104; 3-7)

(iv) Seclusion and segregation

In modern Thai society, seclusion and segregation of women is not practiced.

(v) Polygamy and Early Marriage

In Thailand, the legal marriage age is 17 years, although marriage between individuals under 20 years of age still requires the consent of their parents. Individuals aged between 15 and 17 may marry with the consent of a parent or guardian and the court. Section 277 of the Offenses Relating to Sexuality in the Criminal Code also states that if a man has sexual intercourse with a girl aged between 13 and 15 years of age, with the girl’s consent, the Court may grant the couple the right to marry and the man will not be punished. (103; 63) Cases involving this provision are, however, extremely rare.

In fact the minimum age of marriage as provided by law is of little relevance, as most Thai women are considerably older than this before marriage. Women’s Singulate Mean Age at Marriage (SMAM) in 1970, 1980, and 1990 was 20, 22.8, and 23.5 years, respectively. Men traditionally have married somewhat later, with the SMAM in 1990 being 25.9 years. Rural women tend to marry at a younger age than their urban counterparts (26.5 vs. 22.6 years), while Bangkok women have the highest SMAM (27.2 years) and northeastern women the lowest (22 years) (72).

Historically, male polygamy was socially well accepted, while women were expected not only be monogamous, but also totally faithful to their husbands. Despite the fact that polygamy is now illegal, as noted above, sanctions within the law are not strong and many men continue to practice polygamy, both openly and secretly, causing considerable family disruption (158; 146). In cases of bigamy, second and subsequent wives are not entitled to any of their husband’s property, and may suffer from effective loss of joint property, because the union is illegal (103; 62).

(vi) Status of widowed, divorced or separated women

The rate of divorce in Thailand has been rising in recent years, from 4.4 per 100 marriages in 1960 to 8.1 in 1980 and 9.6 in 1993. The highest rate of divorce is within Bangkok, 24.7 per 100 marriages, but there are also considerable differences between rural areas, with the rate in the north (10.6/100) being considerable higher than in the northeast (5.4/100) (103, 5)

Widowed women make up 7.2 per cent of women in municipal areas, lower than in non-municipal areas at 9.9 per cent. The divorce and separation rates in the municipal area were 1.1 and 2.5 per cent respectively and 0.9 and 1.8 per cent in non-municipal areas. These rates were fairly uniform across regions, although Bangkok had a lower percentage of widowed women (72, 22).

The percentages of widowed, divorced or separated women were two to three times higher than that of men. Widows formed 9.4 per cent of the population, but widowers only 2.8. The divorce rate for women was 0.9 and for men 0.5, while the percentage of separated women was 1.9, compared to 0.9 for men. It appears thus, that men are more likely to re-marry after marriage dissolution.

Widowed women do not suffer any stigma in Thai society. Those whose marriages have ended in divorce or separation may suffer some social penalties, in that traditionally, Thai society has regarded it as the woman’s responsibility to hold a marriage together. However, most studies have shown that divorced women (there is little information on separations) do not suffer significant social stigma, although they may encounter financial difficulties and problems in adequately caring for their children.

Hongmanee (158) studied the impact of divorces using Registrar Office data. The sample consisted of 463 divorced women and 926 married women from nine representative provinces. This study found that more than half of divorced women gained a better social standing after being divorced. Twenty per cent of them indicated that they were disgraced. Those who worked for the private sector, self-employed, employees and unemployed, indicated that there was no change after divorce. Sixty two percent of divorced women working in the government sector indicated dramatically improved relationships with their relatives, although 67 per cent of them showed that their relationships with ex-husbands’ relatives worsened. Eighty one percent of these women said they had more freedom and half of them felt more secure financially. Only 33 per cent of divorced women indicated that their psychological condition had worsened.

However, the study did find that women of low economic status tended to suffer financial hardship after divorce. Those who belonged to a high social class were least affected. (Most divorced women were middle class and poor, 55.9 per cent and 28.4 per cent respectively). Most divorced women did not have sufficient savings upon which to build a future. Thirty six percent of these women received half of the family assets. Only 5.8 per cent of women were given their full entitlement. Most (82 per cent) did not get any financial support from their ex-husbands. Financial difficulties were exacerbated by responsibility for bringing up children. Sixty seven percent of divorced women had to take care of the children and 22 per cent of them shared responsibilities with ex-husbands.

(vii) Access to household property and participation in household decision making

As in many countries, the proportion of households headed by women has increased significantly in recent years, as a result of migration by male household heads, increased rate of marriage breakdown, and other social changes. The Social and Economic Status of Households Study in 1992 (172) showed that out of 16,000 households randomly sampled from four regions and Bangkok, 20.2 per cent were headed by women, whose major sources of incomes were from labor and salaries (37.8 per cent), followed by profit from their own businesses, including agriculture. In the rural areas, agriculture was the most important source of income for the majority of these households.

Even in households which have traditionally been considered male-headed, women have an important role in decision-making, particularly economic decision-making. Limmanond (161) in a large sample study from Bangkok found that women would individually make small economic decisions about daily expenses and child care. However, both husband and wife would share responsibility for major decisions such as a new investment, the number of children they should have, and the children’s education. (As already noted, the law requires the assent of both husband and wife in the taking of mortgages, land purchases, and so on.) These findings reflect the historical reality that Thai women traditionally played significant roles in household decision-making, even during old age (104; 7-3). Entry into the labor market has strengthened this power.

(viii) Policy Measures

Concern about increasing rates of family breakdown, juvenile delinquency, and related problems have led to a significant government policy focus on families. Rather than concentrating on women’s position, most of these policies and campaigns have focused on encouraging men to take a more responsible role within the family. Among the campaigns have been those discouraging the following: polygamy, the taking of minor wives and the use of commercial sex services. Slogans used included “One Man, One Wife”. Campaigns have also concentrated on enhancing the role of fathers in bringing up their children. (103; 9) Both of these campaigns have used a wide range of mediums, from bumper stickers and pamphlets to radio and television spots to attempt to reach a broad cross section of the population. The government declared April 14, during the traditionally family-orientated Songkran (New Year) Festival, as Family Day, as a continuing focus for such programs.

Government policies and programs to enhance women’s status in society through the work of the NCWA are outlined above, while more information on promotion of women’s role in public life is included in section 3.7.

(ix) NGO Campaigns

Non-governmental women’s organizations have worked together with the government in the efforts outlined above, conducting supplementary and complementary campaigns.

B.5 Women and Education

Historically, women had fewer educational opportunities than men, due to the fact that most pupils were schooled by temple monks, who were not allowed to be close to women. Therefore, most women only received training in household chores, handicrafts and occasionally in other occupations, normally from a senior member of their family. Increasingly from the 1860s onwards, girls from higher class families did have opportunities to attend secondary school and sometimes university. From 1932 onwards, the national education policy emphasized equal access to primary education for both sexes. (104; 47-9)

(i) Illiteracy Rates

Thailand has succeeded in significantly reducing illiteracy rates among both women and men over the past few decades. The rate of illiteracy, among females aged 15 and above in 1995 was 8.4 per cent (56). The rate of illiteracy for men in the same year was 4.0 per cent. Although women still comprised 62 per cent of the total illiterate population aged 6 years and above in 1990, the gap has been reduced, with the current statistics reflecting historical inequalities in access to primary education, rather than the present situation.

(ii) Enrollment Rates

Recent statistics and indicators on education, such as the numbers of students enrolled at various educational levels, indicate that the present generation of women and girls has almost equal access to education with the same conditions and curricula as men and boys (153). In 1993, the gross primary school enrollment rate for girls was 97 per cent while that for boys was 98 per cent (110). At the secondary school level, the enrollment rates for young women and men were equal at 49 per cent (101). Schools in Thailand are mostly co-educational, and the few single-sex schools in Bangkok are fairly balanced in terms of numbers of schools and students.

At the tertiary level, the situation of near equality in overall participation remains. In 1993 women comprised 53.9 per cent of bachelor degree graduates at public universities. In postgraduate studies women were still in the minority, comprising 46.8 per cent of masters graduates and 44.2 per cent of doctoral graduates (103; 38). In vocational education, male enrollment accounts for 63 per cent of total enrollment due to the importance of such qualifications in such traditionally male areas as mechanics and engineering. (101; 39) The high degree of gender stereotyping in subjects studied at the tertiary level is discussed below.

(iii) Drop-out rates

As the above data indicates, girls and boys have approximately equal opportunities to complete each level of education, although opportunities for boys remain marginally higher at all levels. As noted above, concern remains about the relatively low level of continuation between primary and lower secondary levels. As recently as 1992, only 49.96 per cent of girls and 51.22 per cent of boys graduating from primary school went on to lower secondary school. Secondary school gross enrollment levels were 30 per cent for boys and 28 per cent for girls in 1980 and these rates had risen to 49 per cent in both cases in 1994. (153) Sex disaggregated statistics for 1996 are not yet available, although it is believed the overall progression rate to lower secondary has risen to around 60 per cent.

The reasons for this low rate of progression for both boys and girls are largely economic, with families needing the labor or income of their younger members, or being unable to support the cost of their continuing education. A 1991 study also revealed that, at all school levels, girls are more likely to drop out of further education if there is a pre-school age child in the household. Demand factors may also have some impact, particularly as noted above, with strong dem

and for the labor of adolescent girls in manufacturing and service industries. Several studies on educational investment (155; 157) have also found that agricultural households are far less likely to make a significant investment in the education of their children. These studies also showed that in families with limited resources, parents prefer that sons undergo further education rather than daughters, although as the above figures indicate, these attitudes do not appear to have a significant impact on actual retention rates. They may however have a significant impact on certain groups in society, such as hilltribes, where female educational opportunities remain significantly below those of males.

(iv) Opportunities for Further Education

Continuing education, which involves a wide variety of courses offered by the Department of Non-Formal Education, is an important part of the national policy to increase the overall level of education of the population. It provides the opportunity for women and men who may have in the past been denied formal education opportunities to expand their education and possibly prepare for further formal education (153).

The Department has recognized the particular importance of its programs to women, and has formulated a framework for providing lifelong educational for women which is relevant to target groups and supportive to inter-organization networking and coordination. It seeks to develop a combination of local wisdom and modern technology. To implement this program, the department has established four regional centers for the promotion of lifelong education for women to serve each major region of the country. Figures from the department (for 1992) indicate, somewhat surprisingly, that women formed only 46 per cent of the students enrolled in functional literacy courses, despite their predominance among the illiterate population, as discussed above. Overall women dominate most classifications of non-formal courses, being 56.7 per cent of vocational certificate graduates, 60.9 per cent of vocation course graduates, and 50.4 per cent of distance education graduates. Only in classroom adult continuing education courses are they under represented (39.8 per cent), reflecting most probably the difficulties they find in meeting attendance requirements for this type of course in view of other, particularly family, responsibilities.

(v) Promotion Policies

As noted above, the Thai government is directing considerable resources into increasing retention rates, particularly for lower secondary education, for both girls and boys.

(vi) Successful Projects

A large number of projects are being conducted by both the government and NGOs in northern Thailand, particularly targeting girls who are at risk of entering the commercial sex industry. These projects typically offer scholarships to fund the cost of secondary and vocational education for girls judged to be at risk because of family circumstances (e.g. broken families, other members of the family in the sex industry), poverty, or other factors. In the government projects, although significant funds have been made available, there have been some difficulties in ensuring effective and timely distribution of money.

Some NGO projects have concentrated on offering not only financial support, but also counseling and other services, sometimes including accommodation, designed to ensure that girls are fully supported and as far as possible protected from agents and pimps. These projects are generally recognized as being successful in protecting the girls in the program and keeping them within the education system (154).

(vii) Gender Stereotyping

In recent years there has been increasing realization about the degree of gender stereotyping within the national education system, both in terms of the subjects studied, and the images of male and female roles presented to students. Considering the latter, recent studies by the Thai National Focal Points and NGOs have focused on stereotypes about the role of male and female at all levels of Thai education system.

In a major NCWA project, Xuto (156) showed that significant stereotyping exists in the textbooks used in all primary schools. In those textbooks, male characters appeared twice as frequently as female characters. Overall, men and women were presented in different and unequal roles, with women being less important and supplementary to men. In pictures and text, men appear as the head of the family and breadwinner whereas women were generally presented as housewives, cooking, cleaning and caring for children, and as supplementary income earners in low-income families.

At present, the Department of Curriculum and Instruction Development, Ministry of Education together with the NCWA are reviewing the situation and hoping to work with preparation teams, writers and advisors. It is hoped this program will increase their awareness of gender issues and improve the depiction of women and men in all new text books.

Considering how the presence of gender stereotyping influences the choice of study area, while there is no information on subject choice in secondary schools level, there is bountiful evidence of such stereotyping in all parts of the tertiary education system. In formal vocational and technical programs, in 1992, women comprised only 3 per cent of the students in industrial mechanics programs, and 20 per cent of the students in agricultural courses. In contrast, they constituted 97 per cent of the home economics students and 90 per cent of students the commerce courses. (101; 39) (Commerce, accounting and related areas are seen as traditionally female area of study and work in Thailand.)

Undergraduate statistics reveal similar divisions. Female students dominate in humanities, social science and health-related courses. Men, in contrast, heavily dominate law, engineering and agricultural and related courses. (101; 41)

In most cases, the choice of courses by female and male students is based on the stereotyped views of students themselves and of students’ parents ideas about the most appropriate courses for their sons and daughters. A seminar conducted by the NCWA among young women confirmed the importance of parental attitude, as did a related seminar of career and vocational guidance counselors. Its participants indicated that families were usually a conservative influence, tending to direct girls and boys towards traditional gender-stereotyped areas of work or study. (103; 38)

B.6 Women and Work

(a) Labor Force Participation

Thai women have played an essential role in the development of the country through their participation in the labor force. Chongsathityoo (140) concluded that Thai women have had a greater role in economic development than women in any other Asian country. This is the result of the nation’s economic, social, and cultural characteristics. Historically, women were seen as important contributors to the family income, particularly through their agricultural labor and small-scale trading. The demand for their labor in the new industrial economy thus easily fit to the social system. These factors paved the way for women to participate in many different sectors of the labor force including agriculture, industry, and services.

(i) Labor Force Participation Rates

As noted earlier, over the past decade Thailand has enjoyed an annual growth rate of over 8 per cent. This growth was based on the expansion of the manufacturing, service and tourist sectors, in which female labor is predominant. In each of the five leading export industries – electrical machinery and parts, textiles and ready-made clothing, chilled frozen and canned food, precious stones and jewelry and footwear, women comprise not less than 75 per cent of the workforce, a figure which rises to almost 90 per cent in the food sector (126; 7).

According to the data collected by the NSO in 1991 female workers accounted for about half of the total of 29 million workers in the country and the participation of female workers was higher in non-municipal areas than in municipal areas. In 1995, women formed a higher proportion of the unemployed population at 55.4 per cent (142).

Figures from the National Statistical Office indicate that 61.2 per cent of all Thai women aged 13 years and above were economically active in 1995. Women’s economic participation rate remains lower than men’s for all age groups (104; 19) with the exception of women aged 13 to 19 working in urban areas. In 1992, the number of women aged 13 to 14 working in urban areas was almost double that of men in the same age range due to high rural to urban migration rates among young women (124; 55). The demand for female domestic workers, factory workers and service workers has created many opportunities for women to begin work, often at a younger age than their male counterparts (103; 37).

(ii) Formal and Informal Sectors

The fact that the informal sector is defined in different ways by different researchers presents some difficulties in considering women’s involvement within it. It can, however, be broadly said that the informal sector includes micro-enterprises, sub-contracting, homeworking, unstructured agricultural employment and other small industries to which regulations about minimum wages and conditions either do not apply or are not commonly applied. Whatever the definition used, authors generally agree that women make up the majority of workers in the informal sector in Thailand.

Sirisambhand (143) concluded that in 1991 there were about 1.5 million women employed in Bangkok. About 65 per cent of these workers, or almost one million women, were employed in the informal sector, including sales workers, craftspeople and service workers. More than half of this number were employed as private employees in craft and production processes and services. A further large percentage were unpaid family workers (about 300,000 women).

A major part of the informal sector includes self-employed workers such as street vendors, recycling collectors and workers in similar areas. When involving more than one worker, these are termed micro-enterprises. One study of over 400 such enterprises in Bangkok found that two thirds were headed by women, and nearly half of these women were the main income earners for their families (144). They faced many risks created by the informal nature of the employment, with no security nets in case of sickness or injury, and no legal structures ensuring continuing employment or availability of facilities such as vending space (144).

Over the past decade the availability of employment in the form of work completed in the home (or sometimes in communal spaces), on an unstructured basis has grown significantly. In part this has been due to the shortage of labor prepared to work in the factory environment, and also because of its advantages to manufacturers, who can often avoid controls such as minimum wage rates, holidays and sick pay, as well as having a workforce which is fragmented and easily controlled.

A broad study in the late 1980s by Lazo (145) found that in almost all of the major homeworking industries – including clothing, artificial-flower production, wood carving, gem cutting, umbrella making and wickerware, women predominated. Knife-making, which has been traditionally viewed as a male trade, was the only industry in which men outnumbered women. Homeworking is attractive to many women because of its flexibility, and their ability to continue it in conjunction with childcare and other domestic responsibilities. Homeworkers are mostly rural residents, commonly in the 31-40 age bracket, with little or no education and training. They are supplied with raw materials or partially-finished items, and paid on a piecework basis. Formal contracts between workers and suppliers are rare, so there may be considerable difficulties in enforcing fair payment for work completed, a situation further complicated by ties of obligation or patronage which may bind the two parties. Due to the piecework nature of the work, no employment regulations, such as minimum pay or sick leave, are involved, and workers tend to labor for long hours in an attempt to make as much money as possible (145). Another study showed there are particular difficulties for migrant women to manage micro-enterprises, due to their lack of funding, experience and contacts or support networks (143; 17).

(iii) Categories of Female Workers

Female workers can be divided into five categories; employers, government employees, private sector employees, self-employed workers or family-employed workers. Women accounted for only 17.91 per cent of employers in the 1995 Labor Force Survey, but 69.22 per cent of unpaid family workers. (124). When employment status was broken down by occupation, the proportion of female workers was higher than male in trading and services, but were lower in administration, transportation and communication, agriculture, and skilled labor. The proportion of female and male workers in professional and clerical occupations were similar. (101)

(iv) Distribution of female labor

The Thai labor force is significantly segregated by sex, with women being concentrated in certain sectors and occupational groups, and almost absent from others. Thus, as noted above, women comprise more than 90 per cent of workers in food processing, related to traditional female labor, but there are very few female mechanics and engineers.

Within the civil service, the MOPH has the highest proportion of female workers, 75 per cent, followed by the Ministry of University Affairs whose female workers account for 74 per cent of the total staff. The Ministry of Agriculture and Cooperatives has the lowest proportion of female workers, 28 per cent, followed by the Interior Ministry, 33 per cent (101).

Among professional workers, physicians and nurses have the highest proportions of female workers, 72.6 per cent, followed by social workers, social welfare workers, behavior modification and control workers, and community development workers, 66 per cent; workers in the financial, economic, trading and industrial sectors, 61 per cent; general administrators, statisticians, legal service personnel, and international affairs personnel, 55 per cent; while only 4 per cent of engineers, architects, and mechanics are female.

(v) Managerial and Administrative Positions

In 1993, there were 345,553 civil servants, of whom 54.8 per cent were female, but they remain concentrated in the lower ranks. They comprised 60 per cent of workers at the lowest levels of 1 to 3. At the middle administrative rank of level 8 they comprised 20 per cent and at level 10 only 6 per cent. There were no female civil servants at the highest level (101). Since then, there have been increases in the percentage of women at higher levels, up to 11.92 per cent of level 10 and 4.0 per cent at level 11 in 1997. The percentage of female government officers at higher levels is gradually increasing, due to greater entry numbers, selection on merit rather than purely seniority-based systems and the fact that men are more likely to seek the higher salaries available in the private sector.

Women are also significantly under-represented in managerial and senior administrative levels in the private sector. Statistics for a major commercial bank for 1995 showed that there were 442 male executives, but only 190 female. There were 329 male branch managers and only 34 women in this position. At the level of assistant manager, there were 207 women compared to 149 men. As is the case in the civil service, however, the position is improving slowly, with the percentage of female executives rising from 22 in 1991 to 30 per cent in 1995 (104; 44-5).

Limited access to training is one major factor preventing women’s promotion. Research has shown that, in factories for example, perceptions that men are more able to handle machinery and supervisory roles may give them access to better jobs. Social attitudes about what is “appropriate” for women may deny women these opportunities. The tendency to appoint men to manage or supervise extends right through society, and has been described by one author as the “teak ceiling”. (102; 114)

Women’s historically lower access to education has supplemented and contributed to their lack of training and promotion opportunities. Most working women in all occupations have completed primary education but only 10 percent hold bachelor degrees. This pattern is the same for workers in government sectors, where the proportion of female workers (compared to males) who earned certificates in basic and advanced vocations is more than 50 per cent, but, those with masters and doctoral degrees account for only 40 and 23 per cent of the total workers respectively.

(vi) Unemployment and Under-employment

Unemployment levels in Thailand, as noted above, are generally very low. Data collection, however, classifies anyone who has worked at least one hour in the past week as “employed”, so these figures may hide considerable underemployment, particularly in rural areas, where farm work may be a more than full-time occupation at some times of the year, but be very light at others. Lack of choice may also force workers to accept low-paid or unpleasant employment (103; 41).

An issue which has gained prominence in the last few years is the problems faced by older female workers in the industrial sector. Increasing automation and the drive to increase productivity in the face of strong international competition has led to the introduction of higher levels of technology. As a result, many older female workers, generally with only four or six years of primary education, but 20 or more years’ experience in industry, have been laid off. (146; 3) Sometimes this has been used as an excuse, rather than a reason, for the lay-off of such workers, with employers preferring lower-paid younger workers, who they believe will be more productive (103; 46).

Those women laid-off because of technological change are not being re-trained, but instead replaced by younger workers, often males with secondary or technical training, because of employers’ assumptions that males are more capable of operating complex machines. The laid off female workers often return to their home village and take up homeworking, or other informal employment such as vending or food selling, but this is often not their preferred life choice.

(b) Working Conditions

(i) Income

The minimum wage in Thailand, set at near-annual intervals, with differing levels for Bangkok and its surroundings, and the rest of the country (a recognition of differences in living costs) is the same for both men and women. There is also an equal pay statute stating that male and females should be paid equally. No law suit has ever been placed before the courts and the law appears at present to be unenforceable (103; 47).

In reality, there are significant pay differentials between male and female workers, in part because women are more likely to be employed in low-level positions. Furthermore, while women may be doing the same or similar work as men, they are often employed under a different title or classification. Also women are more likely to be homeworkers or involved in the informal sector of the economy where the minimum-wage rates are not applied (103; 45).

The 1995 Labor Force Survey categorized the salary levels of workers into three groups: low (less than 2,000 baht monthly), middle (2,001-19,999 baht monthly), and high (more than 20,000 baht monthly). Women were disproportionately represented in the low income group in all sectors, and significantly under-represented in the high income group. In municipal areas, women comprised 62 per cent of workers in the low income group. In contrast, they formed only 29 per cent of the high income group. The proportion of women and men among lowly-paid non-municipal workers was almost equal at 51 per cent and 49 per cent respectively, but there was a significant difference among the high income non-municipal group, in which women comprised a mere 18 per cent (142)

(ii) Working Hours

Standard working hours in Thailand are eight hours per day, but many workers are known to spend far more time than this in their occupation. One study found that women in the agricultural sector who comprise more than half of the total of female workers, worked more than 50 hours per week (104; 4-2). Another study found that women in rural areas of Thailand worked, on average, 11 to 15 hours daily, and this did not include the time they spent nurturing their children. Furthermore, most of this labor was unpaid because it was done for a family business, in which the women must participate (104; 4-2). Another study found that women working in brothels (the sector of the sex industry with the worst working conditions), on average, served six clients in a 12 hour day (148).

(iii) Transport and Housing Allowances

As noted above, the minimum wage in Bangkok and surrounding areas is set at a higher level than in the rest of Thailand. This is designed to recognize the fact that housing, food, transport and other expenses are more costly in this region. Outside this region, Thai workers, at least in lower-level occupations, are not normally paid transport or housing allowances, although accommodation is not infrequently supplied. Free or heavily-subsidized accommodation is available for many civil servants, particularly teachers, military and police, and workers in remote areas.

Construction workers most frequently live on the site where they are working, in rudimentary accommodation built by themselves with material supplied by the employer. Factory workers are frequently provided with dormitories. In one study, 71 per cent of women working in the factories lived in the factories’ dormitory. Most of these workers lived in poor conditions with insufficient bathroom and toilet facilities (148).

Women’s Time Use Patterns

Information on working hours, as given above, comprises the bulk of data available on how women in Thailand spend their time. There was however one study which found that among workers in rural areas, men spent 2,294 hours per year working on agricultural production and women 1644 hours. But housework took the women’s work burden total to 3894 hours per year, while the men made no contribution to household labor. Another study showed that men regarded housework as a “light” and boring job, that was the sole responsibility of women (104; 3-4).

The latter finding confirms general beliefs that Thai men take little or no role in most household chores. More affluent women rely on domestic employees and their extended family network to assist with household chores and child care, but these resources are being eroded by the breakdown of the extended family and the shortage of domestic labor which is being lured instead into factories and service industries (21; 19).

The lack of support from their spouse, and/or unavailability of child care facilities, means many women working in municipal areas after migrating from rural villages are forced to leave their children behind, usually in the care of grandparents or other relatives. Alternatively, they may use highly informal arrangements with neighbors and friends, or with unregistered local child-minders. There are concerns that either choice can lead to increased rates of family breakdown, juvenile delinquency and psychological problems, as well as being very stressful for the female workers concerned.

(d) Female Child Labor

(i) Extent and Activities

In 1993, out of the total female population of 3,059,200 in Thailand, 1,798,200 aged 15-19 were entering the labor market, and 1,730,300 of them had a job. There were 15,200 employed girls aged under 15 years (142). The proportion of girls aged 13-14 years entering employment was higher than that of boys. Thirteen percent of girls under 15 living in municipal areas were working, while 24 per cent of those living in non-municipal areas were employed. These proportions were the same for the 15 to 19 years group (142), reflecting higher secondary education rates in municipal areas. These girls became unskilled laborers in the industrial sector or worked in non-formal industries, family industries and small-scale industries with fewer than 20 employees. Labor Department inspections in 1994 showed that of 27,066 premises throughout the country, 1,399,176 workers were screened. Of these, 719,971 were women (18 and over) and 8,976 were children. Of the latter, 230 were younger than 13 years of age, 1,184 were aged 13 to 15 and 7,562 were aged 15 to 18. It is not considered that these figures reflect the full rate of participation of children in employment, since child laborers are believed to be over-represented in the informal system and are not protected under the labor laws.

Demand for child labor has been increasing in recent years because some work is considered more appropriate for children than adults (for example that handling small objects for which smaller hands are an advantage). Furthermore, children are believed to be more obedient to supervisors, and they can be paid less than adults. Girls are more in demand than boys because of lower payment. Most of this employment is non-skilled industrial work, particularly in textile and canned food industries and with both open and disguised sex businesses (21; 19).

(ii) Child Labor Eradication Measures

Child laborers are defined in Thailand as workers aged between 13 and 18 years where employment of children aged 13 and above is accepted. This definition differs from that of the International Labor Organization, which defines child workers as those aged 15 years and under. To bring Thailand in line with international norms, the Labor Department is now trying to amend the child labor law, changing the minimum age for children to begin work from 13 to 15 years. In order to correspond to new child labor laws, the government has extended compulsory education from six to nine years, allowing children who have finished grade six to have a chance to continue their education until 15 years of age. This system is now on a trial run.

(iii) Child Labor Protection Acts

Both male and female child workers (those aged 13-15 years) are covered by special provisions of the labor law. Under the law, child workers are not allowed to do work that will inhibit their growth and development, they must not be employed in work hazardous to health or in a potentially dangerous environment (this provision covers workers up to 18 years), and they are not allowed to work overtime or on weekends. They are entitled to training leave with pay. Any premises with more than 10 child workers must provide them with informal education. The law also states that recreation areas must be made available for children and they must be given their full and fair wage, with no deductions or payment to other people.

Having been passed by the House of Representatives and the Senate, a new law which will raise the minimum age of employment to 15 years is now undergoing final examination before being put into effect. The law also tightens restrictions on working hours for children aged from 15 to 18. (149)

(e) Policies and Laws

(i) Maternity benefits

The legal and practical position of female workers with regard to maternity leave has improved considerably over recent years, as the result of a prolonged campaign by unions and women’s groups. The law now provides for 90 days of paid maternity leave for all workers who have been continuously employed for more than 180 days. In the public sector, these funds are provided by the employing agency, while private sector employers are obliged to provide 45 days’ pay, with the remaining money being provided from a social security fund (103; 47).

It is generally recognized, however, that in the private sector women may be unaware of their rights or may find it difficult to obtain their entitlements. Many employers either simply ignore their responsibilities, or operate employment systems that allow them to skirt the provisions of the law. For example, a survey of major factories around Bangkok found that around one in four workers was employed as a casual or temporary employee, and therefore not eligible for the benefit (102; 103). Additionally, while the law does make dismissal on the grounds of maternity illegal, no case has ever been brought against an employer for such a dismissal (103; 47).

It might also be noted here that there is no provision within Thai law forbidding employers from specifying employees must remain single. To give just one example, bus conductors (mostly female) must be single. This may create particular problems when such workers form families, but do not register their marriage, leaving their own and their children’s status uncertain (103; 47).

(ii) Child Care Support

There is no formal, government system to provide child care support. Many large employers, including the civil service, provide funds to assist with the cost of schooling for workers’ children and there are limited examples of individual workplaces providing limited services.

(iii) Protective Legislation

Legislation designed to protect female workers, governing such matters as night work, lifting heavy weights and similar matters exists, but is not enforced.

(iv) Other Social Support

There do not appear to be any relevant government programs which might be included under this category.

(v) Employment Guarantees

As unemployment has not been a problem in Thailand for a considerable time, there are no specific government programs designed to address it.

(vi) Unemployment Support and (vii) Social Security Benefits

A contributory social security scheme was established in 1990, for the first time providing access for the majority of workers to limited sick pay, long-term disability payments, and funds for families affected by work-related deaths. It is planned that in the future, unemployment and retirement benefits will also be provided, but at present most citizens still depend on family support in such circumstances, and the family overall remains the most important foundation of individuals’ social security. A limited number of relatively high-level employees of both the public and private sector have enjoyed retirement benefits and disability/death insurance schemes for many years, but only a relatively small number of women have been in a position to benefit directly from these schemes (103; 52).

The Thai population aged 60 years and over is expected to rise from 4 million in 1990 to 8.4 million in 2015. With this expected rise, increased attention has been paid to the issues of old-age pensions, and to the question as to whether families will be able to continue to care for older members, as they have in the past. These issues of particular concern to women due to their considerably greater average life-span (150; viii).

(viii) Anti-Discrimination Provisions

There are no legal provisions in Thailand forbidding discrimination against women in employment. This has meant women have been clearly discriminated against by employers without any means of redress. In many cases, women are forced to retire earlier than men, such as the factory workers who may be forced into retirement in their late 40s, as discussed above. Another obvious case is that of the Thai Airlines stewardesses, who were forced to retire at the age of 45, while their male counterparts did not have to retire until the standard age of 60. The company has now announced its intention to change this policy (103; 46).

Similarly, there is no legislation which prevents the advertisements of jobs specifying the sex of candidates required and such advertising is extremely common. By gender stereotyping work, and preventing women from even applying for many positions, such advertisements serve to perpetuate the unequal position of Thai women in the national workforce (103; 46).

(f) Women’s Participation in Labor Unions

From the re-imposition of military control in 1976, labor unions had only an extremely limited place within the Thai industrial system. They began to re-emerge in the early 1990s, (101; 103) but the majority of leadership roles have been taken up by men. Nevertheless, a few prominent individual women have emerged and taken the lead on issues such as maternity leave and discrimination in forced retirements. In general though the predominantly male leadership of unions has meant that the needs of female workers have not been considered and their rights have not been protected (147; 16).

(g) Women and the Commercial Sex Industry

The NCWA estimates that there are 150,000 to 200,000 commercial sex workers in Thailand, of which 15 to 20 per cent are children under the age of 18 (151; 118). NGO estimates have put the number close to one million (103; 25). There are also large numbers of Thai women working in foreign countries as commercial sex workers, with estimates of more than 2,000 such women in Japan, 7,000-8,000 in Germany and large numbers in Malaysia, Taiwan, Brunei and the Middle East (96g; 43).

Traditionally, poverty was regarded as the chief cause of prostitution, but research has shown that a more complex mix of factors has pushed girls and women into the commercial sex industry. Women have traditionally been seen as the conserving the institutions of the family and village, and through their remittances to their families, many commercial sex workers have continued to do this (152; 891). Furthermore, the strong sense of gratitude which requires children to “pay back the breast milk” also puts pressure on women to find a well-paid job, and often commercial sex work is the only such job available (151; 118). Increasing materialism and producing demand for items such as cars, televisions and “modern” houses, has also led many women to feel obliged to choose commercial sex work as the only area in which they can earn sufficient money to satisfy these desires (96g; 42).

These “push” factors interact with a strong demand for commercial sex services produced by traditional attitudes which condoned or even encouraged sexual adventure for men, both before and after marriage. A variety of studies have shown that many Thai men visit prostitutes regularly, with one such study indicating that 90 per cent of Thai men have been to a commercial sex worker at some time in their lives (96g; 43) and 48 per cent having their first sexual experience with a commercial sex worker (103; 23). The recent spread of HIV/AIDS has had some effect in reducing the demand for such services, but recent studies have shown it remains high (103; 23). In December 1996 a new anti-prostitution law, the final result of 10 years of campaigning by women’s activists, came into effect, replacing a 1960 law which had a number of negative aspects. Among the changes introduced in the new law are a move from stressing the commercial sex workers as the criminal to instead focusing on pimps, brothel-owners, traffickers and others who profit from the commercial sex business. It also explicitly allows for the prosecution of parents who sell their children into prostitution, or connive at their entry to it (127; 15).

The bill also widens the definition of sex business to cover establishments used for contact between commercial sex workers and clients, reducing legal loopholes which have previously prevented prosecutions (127; 27). It further provides for heavy penalties for clients of under-age commercial sex workers (under 18, with heavier penalties for under 15 year olds) (127; 13).

The new law also provides for significant changes in the services available to women and girls who have been victims of the commercial sex industry. It seeks to increase the formal level of NGO involvement in providing services for their care and rehabilitation, to decentralize this care to a provincial level, and set in place a full range of appropriate services (104; 7-9). Also included in the National Policy and Plan of Action for the Prevention and Eradication of the Commercial Sexual Exploitation of Children (adopted by the Council of Ministers in conjunction with the new law) are a series of preventative measures which aims to provide education, vocational training and other services to assist girls and women avoiding the clutches of the industry, and public education campaigns focusing on moral values and the horrors of the commercial sex industry (104; 3-4).

The effectiveness of these new measures has yet to be tested. Concern remains about difficulties in enforcing the law, including the problem of bribery and corruption within the judicial system (151; 119). It will also be important to ensure that sufficient funding and official support is received to make the new rehabilitation services effective.

2.7: Women’s Political and Public Participation

Thai politics has been dominated by men throughout history. From as early as the Ayuthaya period (15th – 18th century), Thai women only figured in political mattered “as a medium of exchange used to foster political alliance or attributes or offering to the male leaders in power” (173). Women in Thailand, particularly outside the high class society, had an important economic role, working in the fields and trading, but men were responsible for controlling politics and administration.

(i) Representation of Women

When, in 1932, Thailand’s governing system became a constitutional monarchy, male and female citizens were granted the right to vote and stand for election on an equal basis. It was not until 1949, however, that Thailand’s first female Member of Parliament, Mrs. Orapin Chaiyakarn, was elected to office in a by-election (123; 7). In the period from 1932 to October 1996, a total of 124 women were elected to parliament making up 2.9 percent of all elected representatives to that date (123; 8). The parliament elected to power in July 1995, had 391 Members of Parliament of whom 24 were women, representing the highest number of women ever elected to a single Parliament in Thailand (123; 8). A further election was held in November 1996 and led to the reduction of the number of female MPs to 22. Currently, women hold 5.6 per cent of parliamentary seats.

The Senate consists of 260 members appointed by the King on the advice of the prime minister. Women comprise 8.1 per cent of the current body, appointed in 1995, a total of 21 members. This represents by far the highest-ever representation of women in the Senate. Throughout the 1980s, the level of female representation was around 2 per cent, (73; 73) and since 1932, a mere 58 women have been appointed to the Upper House, making up less than 2 per cent of the total number of appointed senators (103; 67).

A similar slow if significant increase in female representation is seen in provincial government. In the Provincial Administration Organization elections of December 24, 1995, 135 women were elected out of total of 2,148 positions, representing 6.3 per cent, according to the Department of Local Administration in the Ministry of Interior. This is the highest percentage of female representation to date at the provincial level.

The local Administration Act of 1914 barred women from running for election at the local level until 1982, when the act was amended. This, combined with the provision that allows all Village Heads and Sub-district Heads elected before 1992 to retain their position until the age of 60 (123) has made the progress of women in this area difficult. At present, women constitute less than 2 per cent of Village Heads and Sub-district heads, according to the Department of Local Administration.

In March 1995, the Subdistrict Council (SC) and Subdistrict Administrative Organization (SAO) Act came into effect, as part of a decentralization drive. Following the first SAO elections, held in May of that year, women occupy 1,212 out of 18,553 positions (175). At the municipal level, the most recent elections were held on November 18 and December 17, 1995. The results showed that 152 women were elected out a total of 1,860 positions or 8.2 per cent (Figures supplied by the Department of Local Administration).

(ii) Decision-making in Government

The government from 1995-6 had two female ministers, including a deputy interior minister. Only one previous administration, that of Prime Minister Chuan Leekpai, had two female ministers. Traditionally, most administrations have had one female minister, usually given a ministry judged as relevant to “female” concerns. The Cabinet, formed in November 1996 had no female members while the latest Cabinet as of 15 November 1997 again has one female minister as Minister to the Prime Minister’s Office.

(iii) Leadership of Political Parties

Political parties in Thailand have had a history of male leadership. In 1995, Mrs. Sudarat Keyurapan was elected Secretary-General of the Palang Dharma Party, the first and only woman to have ever held this position in a political party. No women has ever led a political party.

Leadership aside, women’s concerns have never been a priority area of political parties. Of the 12 political parties which participated in the July 2, 1995 election, only two parties had any mention of women’s concerns in their policies (123; 24).

(iv) Business and Professional Women

Thai women have been much more prominent in business than in politics. The upper echelons of business and banking are still male-dominated, but some individual women have managed to reach the highest levels, some of whom will be highlighted below.

Khunying Chanut Piyaoui, beginning in 1949 with a 60-room hotel, is now the Chairperson and Managing Director of the Dusit Thani Company which holds major shares in the Royal Princess and the Thani hotel chains. She is also a member of the supervisory board of the Kempinski Hotel chain. Together the four chains have hotels in 30 provinces of Thailand as well as in 20 countries throughout the world (174).

Ms. Patara Sila-on, owner and founder of the S&P restaurant chain, began a small ice-cream parlor and restaurant 23 years ago. Today, her business has expanded to include 35 branches in Bangkok, Chiang Mai and Ayuthaya; 40 bakeries in Bangkok; and three restaurants in London and Singapore (174). Khunying Niramol Suriyasat is the Chairwoman of Toshiba Thailand and Managing Director of Bamgkagi Industrial Park. Leader in the male-dominated Japanese business world, she supervises over 2,000 employees (174).

Outstanding women in banking include Ms. Chinda Charung-chareonvejj, Executive Vice-President of the Bangkok Bank; and Ms. Nopporn Ruangskul, Strategic Advisor to the Managerial Board of the Thai Dhanu Bank (174).

(v) Reservations and Quota Systems

Thailand has never instituted reservations or a quota system to promote women’s participation in politics and administration. Nationally, efforts have been made by organizations such as the GDRI and the Gender Watch Group to encourage political parties to adopt quotas for women but thus far, to no avail. Concurrently, the GDRI, in collaboration with the Civil Service Commission, has been working to introduce an affirmative action program in the civil service, to increase the proportion of women at decision-making levels (GDRI).

At the local level, prior to the promulgation of the Subdistrict Council and Subdistrict Administration Organization Act in 1995, several women’s organizations lobbied for the inclusion of quotas for the Subdistrict Administration Organization elections. As each village elects two representatives to this council, women’s groups called for the act to stipulate the election of one woman and one man. However, this demand went unmet (123).

(vi) Women as Voters

Over and above campaigning and lobbying for changes in discriminatory legislation, women have also played an active role as voters. In 1992, when the sex of voters was noted for the first time, 300,000 more women were recorded to have cast their ballot than men (123; 8). Women’s interest in politics was further substantiated by an activity coordinated by the GDRI in collaboration with three national newspapers a day before the September 1992 election. Readers were asked to predict which political parties would have their female candidates elected the following day and who the elected female MPs would be. More women sent in correct answers than men although both participated equally (123; 9).

B.8: Women and Religion

Approximately 95 per cent of Thai people profess Buddhism. There are also other two important minorities, namely, Islam and Christianity.

In Buddhist doctrine, followers are divided into four groups, namely, the monks (pra), the nuns (mae-ji), laymen, and laywomen. In the Thai tradition, only men are ordained as monks, although in other traditions women can also be monks. The role of a nun (mae-ji) is far more circumscribed. They shave their heads, wear white robes and observe five or eight precepts, compared to 227 precepts for monks. Nuns (mae-ji) cannot be fully ordained (176; 36).

This fact has been very important to the social position of women. As they are unable to make merit for their parents by becoming a monk, they have instead been allocated the role of finding financial support for their parents, which has in modern life exposed them to many dangers.

The social perception of nuns is that they play the role of the monks’ servant, cooking and cleaning for them and performing other tasks around the temple. Nuns were traditionally from poorer families with little education and low social status. A study in 1980 (103; 54) found that over 85 per cent of nuns were from the rural areas and they had only completed four years of compulsory primary education.

In general, the position of mae-ji is not highly regarded and is much lower than that of a monk (177;178). This causes a real problem for Thai women who want to lead a religious life in a community and do not want to be nuns due to the lower recognition by the public. This situation does seem to be improving since a number of highly-educated and high profile women have become nuns. They are active and are trying to improve the public perception of nuns. Several institutions for nuns have recently been established (103; 54). These institutions are active in offering education to nuns and other disadvantaged women aiming to prepare them to work in educational, development or religious teaching jobs after completing the courses.

A survey (103; 53) conducted by the Religious Affairs Department in 1994 indicated that there are approximately 16,000 nuns (mae-ji) in Thailand, compared to 278,960 monks. Only about one-third of these nuns are registered with Thai Nun’s Institute. Nuns have no special religious status and the Department of Religious Affairs assumes no responsibility for them. Only monks are eligible to have tax exemption, to get free use of public transport, and to enter Buddhist universities to which the government allocated funding of about 93,400,000 baht in 1996 (103; 54). Nuns, as well as monks, do not have right to vote in elections. Nuns thus, suffer many of the legal restrictions applied by religious life, without gaining any of the corresponding benefits.

As many monks are only ordained for a short traditional period during the post-harvest season, male civil servants and workers in big companies, male soldiers and male employees of some large companies are entitled to a three-month leave period with full pay to be ordained as a monk, whereas there is no such eligibility for women (103,;54).

Despite discussion of the introduction of female monks, such a plan is likely to produce considerable resistance, due both to doctrinal matters and the traditional male dominance of religious institutions. Thailand has only a male Sangha (Buddhist order), and all work dealing with Sangha is always performed by men (176). Women are generally excluded even from such layperson’s religious duties as asking for the observance of the precepts, or announcing a sermon (178; 74).

The main minority religion in Thailand is Islam and Muslims consist of approximately 3 per cent of the total population. Thai Muslims live primarily in southern Thailand and about 99 per cent of them are Sunnis. Government Muslim employees are allowed leave from work for important Muslim festivals and are entitled to work half-days on the Muslim holy day (Friday). Both male and female Muslim employees working for the government are granted one four-month leave with full pay to make the Hajj, the pilgrimage to Mecca (103; 55).

In terms of exercising some human rights, women in the Muslim community seem to face some obstacles particularly in roles as leaders in community, public and political circles. These are due to strict interpretation of Islamic doctrine and public attitudes related to the religion which often tend to restrict women’s access to public space and ability to speak out in public environments.

Attitudes towards women vary between the different Christian churches and are a source of controversy worldwide. In the Roman Catholic church, women can become nuns in religious orders. As nuns they dedicate their lives to their religion and perform many valuable social, medical, educational and other services. They cannot, however, be ordained as priests and are thus excluded from those duties.

Some of the Protestant churches have a different attitude towards women. In the Church of Christ in Thailand (CCT), women can serve as Deaconesses and Elders. The seminaries train students without regard to sex, so in principle women can be ordained. However, it seems that Thai culture, rather than religious principle, causes discrimination against women holding these positions.

B.9 Women and Sport

Traditionally, Thai women’s participation in sport was severely restricted. They were excluded from sports such as boxing, boat racing and takraew (the traditional Thai sport something like volleyball, except that the feet and body is used to keep the ball in the air, instead of the hands), but were allowed to pursue limited, low-contact self-defense sports such as archery and fencing. Girls, in particular, also took part in traditional folk sports usually practiced at festivals, focused on movement skills (181).

The introduction of a Western-style education system provided girls and women with increased sporting opportunities, with the inclusion of physical education at all levels of the curriculum (183). A study by Juipan (180) revealed that 89.7 per cent of female students in secondary schools in Bangkok enjoyed exercising or playing sport. One of the most favored sports was badminton, followed by volleyball. Another study (179) found female teachers expressed the desire to regularly practice calisthenics.

Women’s involvement in grassroots sport has recently begun to flow through to higher levels of competition, with the proportion of Thai female participants increasing from 33 per cent at the 14th South East Asian (SEA) Games in 1987 to 39 per cent at the 18th Games in 1995. Women are however, severely under-represented in sporting administration, being only 18 per cent of officials, whereas the proportions in Indonesia, Singapore and the Philippines are above 20 per cent (183).

The Physical Education Department (182) reported Thai women were interested in football, swimming, badminton and volleyball, but that they only had time for jogging, bicycling or aerobic-style workouts. This study found most allocated about one hour at the end of the day, once or twice a week for sports activities, the primary purpose of which was health promotion. Lack of time and equipment were stated as reasons for not participating in sporting activities.

Although these are important factors preventing women from playing sport, but there are also important social factors which discourage women’s participation. Traditional beliefs have suggested that a woman participating in sport will become masculine, and be looked unfavorably upon as they expose themselves in public (as required by many sporting uniforms). Additionally, perceptions about women’s weakness and fears about sports effects on menstruation and pregnancy, have had a discouraging role.

A 1987 study by the NSO in Bangkok in 1987 found that overall, a greater percentage of men played sport than women in all age groups, except the 15-19 age group, in which women slightly outnumbered men (48.57 to 46.14). In total, only a very small percentage of adults participated in sport, with only 12 per cent of men between 20 and 60 playing sport and 6.3 per cent of women (21; 106). A survey in provincial areas would probably find even lower levels of participation due to a shortage of facilities and lower income levels (103; 55).

Although no detailed studies have been done, it is obvious also that media coverage of sporting events is dominated by male sport. It generally concentrates on exclusively-male sports such as football, kick-boxing (Muay-Thai), boxing and snooker, although female competitors attract more attention during international events such as the SEA Games (103; 56).

Module C: Women’s Health (Part 1)

Introduction

This module examines the health status of women in Thailand. It seeks to identify areas in which progress has been made in improving women’s health, areas in which significant problems remain and newly-emerging problems. Further it seeks to identify the structural framework in which progress has occurred, the reasons for success or failure in various areas, and the ways in which women’s health is linked to their social, family, economic and political position within Thai society.

C1: Morbidity and Mortality

(a) Causes of Morbidity and Mortality

(i) Mortality

The trend mortality in Thailand has been decreasing in the past four decades. Simultaneously, life expectancy at birth of both gender has been increasing in the same periods (70). During the past three decades, infant mortality rates per 1,000 live births (IMR) for both gender also decreased over three times, from 84.3 in 1964-65 (73; 24) to 26.1 in 1995-96 (70) Among children in the 1-4 years age group, child mortality was as low as 1.1 per 1,000 in 1994 (67; 44).

Data on major causes of mortality is available to allow consideration of gender differentials for the ten leading causes of death in 1996 Death rates for most causes are higher among men than women reflecting women’s 7 year longer life expectancy, on the average, in all previous national surveys of population changes.

The first ten leading causes of mortality per 100,000 population by gender as ICD mortality tabulation list (10th revision) in 1996 encompassed the followings.

Mortality / 100,000 Population

Female Male

1. Diseases of the circulatory system 82.1 134.8

2. External causes of mortality 31.1 78.8

3. Neoplasms 40.6 62.8

4. Diseases of the respiratory system 21.2 46.9

5. Certain infections and parasitic diseases 21.7 40.5

6. Diseases of the nervous system 15.2 28.8

7. Diseases of the digestive system 10.5 25.2

8. Diseases of the blood and blood-forming organ and certain disorders involving the immune mechanism 5.6

20.2 9. Endocrine, nutritional and metabolic diseases 12.0 8.0

10. Diseases of the genitourinary system 8.0 9.3

It is interesting to note that when gender differentials of the above ten leading causes of death are taken into accounted, all rates of female, but endocrine, nutritional and metabolism diseases (cause group number 9), are lower than male in 1996 (67).

(ii) Morbidity

A nationwide survey of health status conducted in 1991-92 (68) using interviews and physical check ups found that of the 41.9 percent of individuals having an acute morbidity during the two weeks prior to the interview, females reported slightly more illnesses than males in every region, in the ratio of 1.2:1.0. Of illnesses identified, 45.1 per cent of females and 38.1 per cent of males were able to report their illness, suggesting a greater awareness of health issues and their own bodies among women (68; 38). In both genders and in almost all age groups urban dwellers had higher acute morbidity rates than rural residents, except in the northeast and south. (68; 39) Housewives were the occupational group with the highest morbidity rate of 50.1 percent (68; 40).

(b) Mental health issues

Although there have been few studies examining issues of women’s mental health, or of mental health in Thai society generally, it is broadly agreed that mental health problems are an increasing concern (as discussed in Module A). It would appear that women, who often carry the burden of both income earning, household management and emotional management of family life are particularly at risk (97; 6-7). One extensive survey by Wongpanich (not specifically looking at mental health) found that workers in textile factories suffered a significant range of symptoms which appear to relate to mental health, ranging from bad dreams and hallucinations to suicidal feelings (96h; 65).

As discussed in Module A, suicide rates generally are increasing. They remain considerably higher for males than females, which public opinion generally relates to women being more aware of continuing to try to meet responsibilities, particularly family responsibilities, no matter what the difficulties.

The theory that women try to continue living a normal life despite mental health problems is supported by recently-collected data on the rate of treatment for mental health problems in public hospitals. The number of female inpatients is approximately half that of males, although the number of each gender treated as outpatients is approximately equal (See Table C.1.9.). The fact that over a five-year period these figures show no significant increase in the number of patients treated may be a reflection on the resource limits of the institutions, rather than the level of mental health problems.

(c) Morbidity from certain causes

Malaria remains a significant threat and a major concern of public health programs, although in historical terms, the significance of the problem has been greatly reduced. The reason for ineffective malaria control in Thailand mostly due to internal occupational migration engaged in forest-related activities such as gem-mining along Thailand and Cambodia border, lumbering and rubber-tapping in the East and the South, is a high-risk group. Moreover, it was supplemented by cross-border migration of workers from neighboring countries. Recently, malaria outbreaks have taken place along the Thai-Myanmar border in the western and in the south of Thailand due to the influx of cross-border migrant workers. Adult males in general are at much greater risk of acquiring malaria than adult female. In 1997, the proportion between female to male patients was 1.0:2.0 (229; 1-10). However, in these intense transmission areas infants, young children and pregnant women are also considered as high risk groups and high death rates are observed.

In line with the HIV/AIDS epidemic, tuberculosis become a public health problem in 1990, after years of steady decline (65;20). The death rate from tuberculosis is substantially higher for men than women, with 1994 figures showing rates of 10.0 per 100,000 for males in both the north and north east and 12.1 per 100,000 population in the central region comparing to female rates of less than 5 per 100,000 population in these regions. The rate in the south is considerably lower (7.2/100,000 for males and 2.3 per 100,000 for females). In 1995 the sex ratio of tuberculosis cases between female and male patients was 1.0:2.2 (91).

Leprosy is still a health problem in Thailand with 396 new cases in 1994 (0.67/100,000 population). This rate is however far lower than in the past, and the goal of total eradication of the disease remains in sight. The proportion of female to male cases was 1.0 to 2.0

Regarding non-communicable diseases among population 15 years and older, the prevalence of many diseases was higher in female than of male. For instance, hypertension is 5.6 percent for female and 5.2 percent for male and high blood cholesterol was 13.0 for female and 9.1 for male. Similarly, diabetes in female was 2.7 and 1.9 in male in every region, and anemia was 25.0 percent in female and 17.3 percent in male. Among population ages 30 years and over the prevalence of ischemic heart disease was slighter higher in male than female, 10.7 for the former and 10.4 for the latter.

C2: Nutritional Status

(a,b) Discrimination in food allocation

With regards to socio-cultural factors affecting nutrition among children, no studies differentiating between girls and boys have been conducted concerning the consumption of nutrient and micronutrient rich foods, including breast milk (96h). Studies in other countries have shown that excessive mortality of female children might be caused by discrimination in food allocation and health care provision for young girls within the household.

A national survey in 1987 noted that girls were slightly more malnourished than boys in the north and northeast (68; 49), but statistics on morbidity and mortality for children throughout Thailand show no evidence of any discrimination, as shown in Table 3. As expected biologically, death rates among young boys are higher than those for girls (96h, 54). A national study on morbidity and mortality in 1985/6 showed no definite patterns of sex difference for infectious diseases among under-fives, with rates of diarrheal diseases, which might demonstrate any discrimination, being almost the same for boys and girls (96h, 55). This is consistent with the low level of sex-preference expressed by parents, as discussed in Module B.

Breastfeeding is an important issue in Thailand, however, with the high level of women’s employment outside the home impacting negatively on rates of exclusive breastfeeding during infants’ first 4 months. In 1995, the MOPH Nutrition Division of Department of Health (76; 24-25) conducted the assessment on feeding pattern of children 0-24 months of age by interviewing mothers in 10 provinces in 1995 indicated that the percentage of infants exclusively breastfed at 6 weeks was 26.2. However at four months of age the percentage of infant exclusively breastfed significantly dropped to 3.6. The percentage of infant breastfed along with supplementary food at six months was 70.8 at the same period. Data on gender differentials in breast feeding and data on infants breastfed along with supplementary foods at one year of age are not available.

In 1996, a nationwide survey of fertility in Thailand (94) reported that 95.7 percent of ever-married women whose children were under two years of age breastfed their children. Only 4.3 percent of mothers who never breastfed their children. In urban areas, mothers who never breast fed was higher than those in rural areas (7.9 and 3.5 percent, respectively). Interestingly, no regional differentials in breast feeding did exist.. In every region, over 90.0 percent of mothers breast fed their children. In consideration of duration of breast feeding, mothers breastfed for 7.8 months on the average. Mothers in the Northeast breast fed their babies for 9.3 months, longer than any mothers in other regions whereas mothers who lived in Bangkok breastfed for a shorter period of 5.6 months. Urban mothers breastfed in the shorter period than the rural ones, 5.8 months for the former and 9.4 months for the latter (94; 19-20).

The three major reasons for mothers who did not breastfeed were mothers’ working (31.5 percent), inadequate breast milk (29.6 percent) and mothers’ health problems (18.4 percent). It is worth noting that as high as 41.6 percent of non-breast fed mothers living in Bangkok reported the reason as employment (94; 20). The relatively high rate of supplemented breastfeeding at six months (70.8 percent)(76; 24-25) does indicate, however, that education and promotion programs have encourage mothers to maintain at least some breastfeeding.

(c) Prevalence of underweight children and adolescents

Two National Nutrition Surveys of Thailand in 1986 and 1996 suggested a rapid decline of children under five years who are malnourished in both gender. As assessment by anthropometric measurement using Gomez’s classification as a local standard (weight- for- age), the percentage of female malnourished decreased from 43.1 percent in 1986 (92; 87) to 31.6 percent in 1995 (92; 34-36). The percentages of children in the same age group who were underweight were slightly different between the two gender. In 1986, it was 43.1 percent for female and 40.3 for male, but in 1995, the latest data available, it was 31.6 for female and 31.9 for male.

The gender differentials of children under five years who are stunted (height-for-age) were investigated in the two national nutrition surveys in 1986 (92; 34-36 and 1996 (87), respectively (MOPH Nutrition Division, 1986, 1997). No significant difference was observed between female and male in the percentage of children under five years who were stunted in both national nutrition surveys. In 1986 (92; 34-36) survey, the percentage was 21.5 for female and 20.9 for male, whereas it was 14.1 for female and 17.0 for male in 1995 survey (87).

In consideration for urban-rural differentials, the percentages of girls under five years who were stunted were 10.1 for urban areas and 15.0 for rural areas (87). This gender differential of nutritional status was confirmed by the percentage of children in the same age group who are wasted (weight-for-height). The percentage of malnourished females was slightly than male in the past decade. It was 25.3 for female and 22.9 for male in 1986 and it was 10.3 for female and 9.0 for male in 1995 (87).

In 1995, the percentage of malnourished females (weight-for-age) was higher in rural (33.0 percent) than in urban areas (25.4 percent). However, in consideration of weight-for-height, the percentage of malnourished girls in the rural areas was slightly lower in urban areas (10.3 for rural and 11.0 for urban areas) in the same age group and in the same period. Therefore, rural-urban differentials in childhood nutritional problem were unclear (87).

The above shows consistent improvement in children’s nutritional status over the past decade. This changes are probably due to the nutritional policies and programs for example the nutritional surveillance project for children under five years old focusing on community participation using village health volunteers to weigh preschool children and collect data every three months under the supervision of health center personnel.

(d) Nutritional Anemia in Women

The most common nutritional deficiency among Thai people is iron deficiency anemia. Both specific data on rates of all women between 15 and 49 years and pregnant women are available, but no gender-segregated data for children is available. Among both pregnant and non-pregnant women the rate of anemia has approximately halved over the past decade (91; 56,87). This is a reflection of both generally improved nutrition rates resulting from improvement in economic conditions and better education and government programs addressing anemia.

Regionally, southern Thailand has the highest level of iron deficiency anemia (Table C.2.1), which may be due to hookworm infestation (particularly prevalent in this region) which further depletes the body’s iron supply. Other contributing factors include irregular antenatal attendance (65;15) and traditional food beliefs, which may deny pregnant women access to foods rich in iron and other important nutrients. These may even lead them to decline iron supplements when supplied (as is standard) through government health programs, due to unwarranted fears about these causing large fetuses and complicated deliveries (96h; 56).

(e) Other Micronutrient Deficiencies

(i) Iodine deficiency disorders

The rate of iodine deficiency disorder among primary school children from 1989 to 1994, as measured using thyroid goiter rate as an indicator, is shown in Table C.2.2. The area of highest prevalence is in northern Thailand, an area in which the problem is considered endemic due to low levels of the mineral in soil, water and plant products. Goiter as an indication of iodine deficiency is more common in girls than boys, although the reason for this difference is unclear.

To address the nation’s iodine deficiency disorder (IDD) problem among all age groups, under the aegis’s of the King’s Program on Iodine Deficiency, the MOPH has established laboratories and operation centers as well as launching a campaign to disseminate information on IDD prevention, especially to pregnant women. The campaign has focused on encouraging the use of iodized salt and iodine tablets and testing to assess the status of the newborn infants (96b: 11). The success of this program is shown in the significant reduction in the problem, as shown in Table C.2.2.

(ii) Vitamin A deficiency

In 1990, the MOPH Nutrition Division reported that amongst preschool children in the North and Northeast, 2 to 3 per cent suffered from night blindness, 18 per cent had conjunctival abnormalities and 6 per cent had low levels of serum retinol, all indicators of Vitamin A deficiency (67). No gender-segregated data is available from this study. But one study in the five most southern provinces, which hospital data indicated had a serious problem with Vitamin A deficiency among pre-school children, found there was no significant difference in the level of Vitamin A deficiency between boys and girls (82; 10).

These children had been fed with sweetened-condensed milk without vitamin A supplements. In an attempt to prevent these deficiencies occurring, the MOPH Division of Nutrition has launched a program of community education, distributed high-dose Vitamin A capsules to all children living in high risk areas and has regulated the addition of Vitamin A supplements to sweetened-condensed milk (65; 36). This has been successful in eliminating reported cases of xeropthalmia (nutritional blindness), but subclinical cases remain a problem (65; 37).

(f) Relations of Women’s Workload to Nutritional Status

According to the 1993 National Labor Force Survey, 60 per cent of the workforce are employed in the agricultural, fishery and construction sectors, and may be termed “hard labor workers”. As noted in Module B, approximately half of these workers are women.

For mothers, pressure to continue work, particularly hard farm work in rural areas, right up until delivery, and to resume work soon after delivery, is an important negative factor for both maternal and baby health. Combined with inadequate nutrition and rest, the effects can be serious, either in themselves, or through leaving mother or baby susceptible to other health problems (97; 7), although no detailed studies have been conducted on this issue.

A study by the MOPH Division of Nutrition to assess the nutritional status of construction workers has been reported. (105) A total of 303 laborers, 224 male, 79 female, were studied. Their average age was 30 years. The nutritional status was assessed using Body Mass Index (BMI) and the study concluded that one third of the female laborers in the study were undernourished, with an average caloric intake of around 1,700 kilocalories, compared to an RDA of 2,000 kilocalories. The study found that about 90 per cent of the subjects ate three meals a day. Half of them reported cooking their own food, while one-third indicated they cooked rice and bought a ready-made dish to eat with it, but it appears that in many cases this diet was inadequate.

Another study, of administrative workers, found they faced the potential of nutritionally-related health problems not from undernutrition, but from an excess of calories. Vichaidit (106) studied 223 administrators living in Bangkok and surrounding areas. The average ages of males and females were 40.9 and 41.9 years respectively. It was reported that 63 per cent of them had normal BMI, while 16 per cent had a BMI below the standard. However, around 20 per cent had a BMI above the standard, leaving them at risk of hyperlipidemia, hypertension, gout and gall stones. Only 19 per cent regularly exercised and 18 per cent reported no exercise. Another study of 3,494 officers of the Electricity Generating Authority found 23.3 per cent of the male and 18.8 per cent of female officers were obese (128; 28).

This study supports another by Smitasiri (129), who found that carbohydrate consumption among urban working women (many in sedentary occupations) was falling as meat and fat intake increased. She found overall mean intakes of Vitamin A, iron and phosphorous were adequate, but mean calcium intake was only 51-54 percent of the Thai RDA.

C3: Reproductive Health

(a) Maternal Mortality and Morbidity

According to Division of Health Statistics’ report, it was found that in 1973, the MMR was 170 per 100,000 live births, declining to 50 in 1984, and approximately 40 in 1987. According to the latest report, the rate was 0.2 per 1000 live birth in 1990. (227; 28). According to the eighth five-year National Health Development Plan (1997-2001), MMR was 23/100,000 live birth in 1996 (227; 3) and expect to be reduced to 20.0/100,000 in 2001 (2278; 8). The ratio of 20 deaths per 100,000 live births is generally regarded as a reasonable estimate. (See Table 3 for a range of the statistics quoted.) What is clear is that the rate of maternal deaths has been falling steadily over the past decade. This is primarily due to improved health services, combined with improving education, nutrition and living conditions of women associated with improving economic conditions.

The cause of death as classified by the International Classification of Disease for 1991 and 1996 shows most deaths are due to hemorrhage and obstructed labor. (See Table C.3.1). The overall increase in numbers recorded between 1991 and 1996 is probably a reflection of better reporting, during a period when the maternal mortality rate was believed to be generally declining. The reduction in deaths due to toxemia appears as evidence of improving health services.

In many cases the underlying cause of maternal deaths is believed to be lack of prenatal care which might otherwise identify high-risk births and ensure adequate care (101; 27). These conclusions were supported by a cross-sectional retrospective maternal mortality study in 1989-90, which found 63.5 per cent of surveyed deaths were in women who had no antenatal care. It found most of the deaths were preventable with adequate care (65; 15).

Despite continuing problems in certain areas, however, the significant decrease in deaths is indicative of the success in spreading appropriate pre-natal, birth and post-natal health services to the bulk of the Thai community. In 1996, over 92 percent of births were attended by a trained attendant, a figure that has remained generally stable throughout the decade, although representing a significant increase from the 1980s. (See Table C.7.1.)

(b) Differential fertility factors

Thailand has been experiencing in a rapid decline in fertility levels in the past two decades. The total fertility rate (TFR) was rather high at 4.9 in 1975, and decreased to 2.7 in 1980 and 2.0 in 1995-96, respectively, as shown in Table C.3.2. This fertility reduction was confirmed by the National Contraceptive Prevalence Survey (CPS96) (89; XIII) indicating a reduction of the average number of children ever born (CBS) for ever-married women aged 15-49 from 3.7 in 1978 to 2.0 in 1996 and that TFR has continued to decline through the 1990s.

For fertility differentials, the same study also indicated that TFR was 1.70 for urban area and 2.08 for rural areas. In addition, TFR for each of the five regions were: Bangkok (1.68), North (1.78), Central (1.92), South (2.09) and Northeast (2.11). Similarly, the same survey shown CEB was slightly lower in urban areas (1.9) than in rural areas (2.1) (89; XIII).

(c) Contraceptive Prevalence

The contraceptive prevalence rate (CPR) has rapidly increased from a low 14.4 per cent in 1970 to 72.2 per cent in 1996 (89; XIII), reflecting a great success of the national family planning program in improving availability and accessibility to family planning services (96b, 9) and the ready acceptance of family planning by the Thai community. The effective family planning IEC programmes promoted a favorable attitudes toward small family size preference among a general public. Consequently, married couples in reproductive age voluntarily adopted birth control to prevent unwanted pregnancies and to prolong birth intervals. A great number of couples considered having many children as an economic burden rather than an asset.

The CPS96 indicated no significant differential CPR in rural and urban areas with the CPR of 72.5 percent and 72.0 percent for rural areas. However, the regional differentials of CPR still exist. The CPR was lowest in the South (61.6 per cent), 70.6 percent for the Northeast and the rates for the other three regions all between 75 and 76 percent.

The national Family Planning Program provides seven alternative birth control methods, namely, female and male sterilization, oral contraceptives, intra-uterine devices (IUDs), injectables (Depomedroxy Progesterone Acetate DMPA), condoms and Norplant. There are differences in methods of contraception used by rural and urban women. It was indicated in the CPS96 that contraceptive pill and female sterilization were more likely to be accepted by urban women whereas injectables were more popular among rural women. Use of the pill was highest among women in Bangkok, injectable use was highest among women in the North and female sterilization use was highest in the Northeast. The use of female sterilization was lowest in the South.

For non-permanent methods, the oral pill has continued to increase in popularity (23.1 per cent of users in 1996). Since 1989 the popularity of injectable contraceptives has doubled. These techniques appear to have largely replaced IUDs, now representing the method of choice of only 3.2 per cent of contraceptive users. (See Table 3)

The low level of male sterilizations, and the relatively high level of the more expensive and difficult female sterilization, is largely a reflection of continuing traditional beliefs which suggest the operation may negatively affect virility and bodily strength. Despite attempts to encourage this practice as being positive for women’s health, there remains considerable cultural resistance and misinformation within the community about the procedure (103; 51).

The general figures do, however, hide the fact that agricultural workers and laborers throughout the country are less likely to practice family planning than women in other occupations (96b; 9). This raises questions of how accessible or acceptable methods and services offered are for these groups (96b; 9). For cultural reasons, the Muslim population of southern Thailand also has a relatively low rate of contraceptive acceptance. (96b; 8) The Seventh National Development Plan (1992-1996) sought to develop specific programs promoting contraceptives and providing appropriate services to target groups of these women, together with hill tribe women. (96h; 52) Although the level of contraceptive acceptors has continued to gradually increase, as shown in Table 3, it is unclear if this represents greater use by disadvantaged groups.

There is also concern about continuing low levels of understanding among women about the functioning of their bodies, which may be a barrier to effective contraceptive use. A national survey in 1988 showed only 13 per cent of married women aged 15 to 49 years had accurate knowledge of the time in the menstrual cycle when they were most likely to become pregnant, while a 1992 survey of oral contraceptive users shows a large number did not know what to do if they forgot a pill, or when they should start a new cycle of pills. These facts were reflected in a 1992 nationwide survey which showed one third of pregnancies were unexpected (134; 31).

Despite increasing rates of pre-marital intercourse, family planning information relatively directed towards married women than the single ones. This is supported by traditional beliefs that single women should ideally not know anything about sex intercourse or related topics (96h; 60).

(d) Induced Abortion

Abortion data in Thailand remains very limited, due to the practice’s illegality and cultural factors which make this both a very difficult area for researchers to approach. However, the extent of induced abortion problem in Thailand is believed to be increasing.

The only detailed study of health hazards of illegally induced abortion gathering data from hospitals records and reports by Koetsawang (See Table C3.6) found the total abortion in 1984 was 5,701, encompassing 3,700 illegal abortions, 1,227 spontaneous abortions, 750 therapeutic and 24 uncertain abortions. The number of all types of abortion in the North-east, the Central and the North was significantly higher than any other region (see Table C.3.6). For single women, the major reasons for seeking therapeutic abortion were socio-economic problems such as sustaining student status (45.3 percent) and unwanted premarital pregnancies (31.3 percent) (See Table C.3.7). Similarly, most of married women seeking a therapeutic abortions cited socio-economic problems (70.3 percent) and contraceptive failure (16.0 percent) as the reasons for their choice. (See Table C.3.8)

A more recent study, the 1996 Survey of Fertility in Thailand, found that 8.3 percent of ever-married women aged between 15 and 49 had undergone an abortion, Most (6.7 per cent) having only had one (94; 28). In the 15-19 age group, 7.8 percent had undergone an abortion, almost the same rate as the over 40 age groups (94; 28). More data would be needed to determine if this indicates the overall rate of abortion is increasing.

There are ongoing efforts by women’s groups to change the abortion law to allow for legal abortions in cases where there is a risk of the fetus suffering from disease or disability, particularly if it may be infected with HIV. These encounter considerable resistance from a number of groups in society on a variety of grounds, most particularly those of religion. However, in light in particular of the rate of HIV infection in Thailand, and on humanitarian grounds, medically-supervised abortions are now reported as being widely available in cases where there is evidence of, or the likelihood of fetal abnormalities or HIV infection. Women’s groups are working to develop networks to provide women with effective support, counseling and assistance in accessing these (134; 31). The Medical Council has stated its policy as being that it will consider complaints made to it, but not punish physicians if they are performing abortions for humanitarian reasons (134; 31).

The broader availability of medically-supervised abortions, combined with generally improved health services, is reflected in the fall in the number of deaths reported from abortion. Fourteen cases were reported in 1994, down from 42 cases in 1989 and 24 cases in 1993 (65; 18), although these are certainly underestimates of the total number of deaths. .

The fact that abortion, particularly in cases of HIV infection, is being widely offered (often from the best of motives), while being broadly illegal, presents some particular difficulties. Researchers have recorded cases where couples or women have been pushed to have abortions without appropriate advice or counseling. With the increasing magnitude of the HIV/AIDS problem, discussed below, this issue will present a continuing and increasing challenge to the Thai medical community (186; 118-9). It is generally agreed that a change in the law would be needed to provide the environment to allow appropriate services and support.

(e) Miscarriage and Stillbirth

No completed statistics on miscarriage are available. As mentioned earlier, from 5,701 abortion of all type occurring in hospitals in 1987, as high as 1,227 (21.5 percent) was miscarriage (Table C3.6). However, this number was under-reported due to some hospitals did not report the number of spontaneous abortion.

Stillbirth or late fetal mortality ratio per 1,000 live births are shown in Table 3. Over recent years, between 1991 and 1994, these demonstrate a steady decline from 0.8 in 1991 to 0.3 in 1994 (67), which is certainly reflective of improved maternal health care. However, no systematic investigation of the causes of these deaths has been done. The rate of stillbirths is estimated at 10 per 1,000 livebirths.(65; 18).

(f) Sexually Transmitted Diseases and HIV/AIDS

As in other countries, intensive AIDS prevention programs focusing on condom use and “safer sex” has reduced incidence rates of STD infection in Thailand in recent years. It seems that the rates of STD infection reported in 1991, with prevalence among youth aged 15-19 at 23 per cent, rising to 36 per cent in the 20-24 age group, have since been reduced. (96h, 58) However, figures from 1992 continued to show a high rate of infection among men and women aged between 15 and 24 (with the frequency of male infections 2.5 times greater than female), reflecting difficulties in reaching this group with the “safer sex” message (96h, 10).

The most recent epidemiological survey showed that of sexually transmitted diseases (excluding HIV/AIDS), gonorrhea (42.8 per cent) was the most common, followed by non-specific urethritis and syphilis; 20.1 per cent and 12.9 per cent respectively (Table C.3.9). Among women, commercial sex workers exhibited the highest rate of STDs in 1987-1989, 74.37 and 78.64 per cent respectively. Female laborers were the second largest group of patients (96b, 10).

As noted above, HIV/AIDS is a very significant health concern in Thailand. AIDS surveillance from the MOPH Division of Epidemiology concluded that from the start of the epidemic until October 31, 1997, 59,548 male and 13,227 female AIDS patients were admitted to government and private health service facilities. However, it is hypothesized that many more deaths and illnesses may have occurred without access to the health care system or may be reported as deaths due to other causes, in view of the social stigma still attached to the disease.

Researchers have identified four “waves” of HIV infection in Thailand. The first involved homosexual or bisexual men, many of whom had been in contact with foreigners, while the second was among injecting drug users. It was only in the third wave of infections, among commercial sex workers, and their partners, that women were seriously affected, with the rate of infection among sex workers reaching 27 per cent, according to one survey conducted in June 1994. The fourth wave is being identified now among the wives and girlfriends of men who have visited commercial sex workers (96h, 8-9) and their children. There is also concern about the fate of children whose parents die of AIDS, including children who are not infected with the virus but who may be left as isolated and vulnerable orphans. The growing importance and now dominance of heterosexual transmission is shown in Table C.3.10.

Overall, it is now estimated that infection levels have now reached close to 2 per cent among the population of reproductive age (188; 8). In Chiang Mai (in northern Thailand) the level of HIV infection among pregnant women had reached 7.96 per cent in December 1993. In 1989 46 per cent of pregnant women testing positive to HIV were identified as injecting drug users or commercial sex workers, but by 1992 this figure had fallen to 18 per cent, with heterosexual transmission from husband or boyfriend being reported as responsible for the remaining 82 per cent (189; 24).

Agricultural workers, laborers and other relatively poor socio-economic groups have been hardest hit HIV/AIDS infection (96b, 10). However, increasing rates of infection reported at private hospitals in Bangkok, primarily serving middle and upper class patients, suggest growing levels of infection among higher socio-economic groups (186, 108).

Thailand has been praised for its relatively speedy and effective response to the threat of the HIV/AIDS epidemic. Government programs have focused on a “100 per cent condom use” policy, with a particular use on encouraging condom usage by the clients of commercial sex workers combined with efforts to encourage community -based and home care services. This is generally acknowledged as being broadly successful, with various surveys reporting reduced percentages of Thai men visiting brothels, and reported rates of condom usage with commercial sex workers being high.

A number of problems have, however, emerged. Some commercial sex workers, particularly those working in poor conditions, young workers and those who have been forced into the industry, are often unable to enforce condom usage. Even women aware of the HIV/AIDS risk may, on days with low income, when faced with regular or clean and good looking customers, when receive extra pay from customers for not using condom., when suffering from painful intercourse associated with condoms, or when concerned about extra length of intercourse when condoms are used or acquiesce to unprotected intercourse (190; 47).

Increasing rates of non-commercial pre- or extra-marital sex also put many women at risk. An August 1997 study of nearly 5,000 sexually-experienced male students around Thailand found 72 per cent said they had premarital sex with their girlfriends. Almost half said they did not use condoms during sex with their girlfriends and another 24 per cent said they used them only sometimes. More than one in three (37 per cent) said they had engaged in intercourse with someone they met at an entertainment place. Almost half had engaged in sex with a commercial sex worker, although more than 60 per cent said it was not “okay” to go to commercial sex workers. Of the users of commercial sex services, 84.5 per cent said they used condoms, while 9.3 per cent had used them sometimes. More than one in four agreed with the statement that it was good to have your first sexual experience with a sex worker, in order to learn about sex (140; 6-7).

Due to cultural attitudes which suggest single women should be sexually innocent (as discussed above), women in such relationships are in a very poor position in suggesting or promoting the use of safer sex in the relationship (134; 31), and as the above survey suggests, there is significant danger their boyfriends would put them at risk. Cultural attitudes would make it enormously difficult for women to carry condoms or suggest their use, while one survey found that a significant number of women had never even seen a condom, let alone knew how to use one (96h 60). Similarly, for married women, it is extremely difficult for them to negotiate for condom use within their marriage due to the implied lack of trust and general difficulty in discussing sexual issues. One study of focus groups of housewives in seven provinces found, on average they had intercourse with their husbands three times per week, indicating they are at significant risk (191). Therefore, there is a need for active research on appropriate negotiating strategies married women might use without provoking violence or social risks (225).

In caring for AIDS sufferers, in view of the scale of the problem, Thailand has been seeking to strengthen mechanisms to support community-based services and home-based care.

A further HIV/AIDS issue is childhood infection. It has been estimated that by the year 2000 in Thailand over 160,000 children will have been infected with HIV, and 75,000 will have died from AIDS (192; 6). The transmission rate from HIV-positive mothers to their babies has been broadly estimated at 25 per cent, so there is also the likelihood of large numbers of orphans created by the HIV epidemic. The significant reductions achieved in child mortality in Thailand may thus be threatened by the combined effect of children dying from AIDS and orphans being at risk of poor care, nutrition, vaccinations, health care, etcetera (193; 3)

One way of tackling this problem is to provide appropriate care for HIV-infected pregnant women. This might include ensuring optimal nutrition for the mother, supplying anti-viral agents at key pregnancy-stages, preventing or treating infection with other diseases and taking steps during the birth to prevent infection (ranging from use of drugs in the birth canal to delivery by cesarean section (194; 37). Several Thai studies have shown that use of AZT or similar anti-viral agents at key pregnancy stages can significantly reduce transmission rates, to as low as 8 per cent. At present, however, such treatment has only been available to women involved in clinical trials, those who can gain the support of organizations such as the Red Cross, or who can afford to meet the substantial cost themselves.

(g) Reproductive Cancer

In 1994, the National Cancer Institute found that the most frequent malignancy affecting women was cervical and uterine cancer (33.0 per cent), followed by breast cancer (29.9) (see Table C.3.11). Considering the mortality rate due to cervical cancer and all ovarian cancers from 1970 to 1987, as shown in Table C.3.12, it was reported that the rate increased during 1980 to 1983. As little research has been conducted in the area, the possible reason for this is probably largely due to the improvement of diagnosis and the improvements in the medical record and reporting system.

After 1984, mortality rates from cervical cancer decreased due to a public awareness campaign which sought to encourage women to undergo regular examinations, which led to earlier diagnosis (97; 3). The effectiveness of curative methods also increased, but cervical cancer remains an important problem for women’s health and more education and awareness-raising is needed to encourage women to participate in regular screening.

(g) Menstruation and Menopause

There have been only limited studies about the problems associated with the onset or continuation of menstruation among Thai women.

On the average, age of menopause for Thai women is 49 (97; 6). The normal range is 44-52 years (96b; 11). Very limited existing data indicates that 50 per cent of women suffer from negative symptoms of menopause, ranging from mild to severe. Historically, these problems have not been considered or recorded, although the level of discussion has increased in the last few years (96; 10-11).

The findings (See Table C.3.13) suggested that women are likely to suffer most during the middle period of menopause, when they are having irregular menstrual periods. About three-quarters of the women in this group indicated they were suffering from a variety of symptoms, while about half of the menstruating and non-menstruating groups indicated no health problems. Most of the symptoms recorded relate to emotional or psychological state.

As for sexual desire in menopausal housewives of lower education, it was found that 59.4 percent of 1,200 post-menopausal women in Chiang Mai have lost all sexual desire after menopause period (Table C 3.15). Twenty-seven per cent reported reduced libido and 13 per cent reported no change. Only 39.2 per cent still had intercourse with their husbands (135; 28). These findings have important implications for issues of family stability, mental health and the possible transmission on HIV/AIDS.

There has been considerable discussion about hormone replacement therapy, and one survey by the Drug Study Group has shown that most women (largely middle and upper class women as the therapy is relatively expensive) have adopted it without a prescription from a doctor, despite its potential side effects and dangers (136). There has also been concern about the use without prescription of what has been described as a “herbal” medicine, “thyroid hormone” (this is a description some herbalists and doctors reject). Prolonged and inappropriate use of this drug has been linked to uterine cancer, and is also believed to increase the risk of osteoporosis. As yet there is no data available about the incidence of the later condition in Thailand, but increasing lifespans. The relatively low rate of consumption of dairy products and generally sedentary lifestyles among the female urban community suggest this is a health issue which may arise in the future (137).

(h) Infertility

Only limited data on infertility in Thailand is available. A survey of 6,315 currently-married women aged between 15 and 49 years of age, conducted in 1996, found 2.5 per cent had primary infertility and 9.9 per cent secondary infertility. There was no difference in the rates of infertility among rural and urban women, although regionally, women in the south had the highest rates of infertility, women in the north-east the lowest.(195; I)

Another study (195;1) of one clinic providing infertility services in Ubon Ratchatani Province (in the north-east) found that between 1990 to 1997,of 356 clients who are mostly farmers, 90.5 percent suffered from primary infertility. On average the women were aged 28.6 years and had been married for nearly four years, having sexual intercourse on average between two and four times per week. Only five per cent returned to the clinic more than twice. It was unclear if this was because they were successful in becoming pregnant.

Statistics of infertile couple compiled by Infertile Unit, Department of Obstetics and Gynaecology, Faculty of Medicine Ramathibodi Hospital during 1982 to 1987 found that most of female infertility were from abnormality of ovulation (44.9 percent) followed by fallopian tube problems (29.7 per cent), adhesions in the pelvic cavity (28.2 per cent) and cervix (20.3 percent) respectively (see Table C.3.15). Results from diagnoses of 1, 061 infertile couples, revealed that there were only 4.4 percent of male abnormalities, which mostly due to varicscele (1.7 percent), followed by abnormal testis (1.5 percent) (see Table C.3.16).

(i) Reproductive Technologies

For those who can afford to pay, Thailand offers virtually the full range of high-technology reproductive services available in Western nations, including in-vitro fertilization and related technologies. No statistics are available on the usage of this service, but it is likely to be low, as is general knowledge of its availability.

Concerns have also recently begun to be expressed about the application of high-technology medicine, particularly during births. It is known that rates of cesarean section at some Bangkok private hospitals have reached 50 per cent of total births, which by international standards is very high (138) and may be adversely affecting the health of both mother and baby. Those raising concerns about this statistic have tied it to broader issues about the doctor-patient relationship, which still tends to be highly paternalistic and directive.

Unfortunately, no current national or even specific hospital surveys on the overall rate of caesarians is available. A study on birthweights in Thailand (227) which collected data from birth records from the provincial hospitals, four regional MCH centers and four large Bangkok hospitals (Rajvithi, Ramathibodi, Siriraj and Chulalongkorn) from 1979 to 1983 indicated that the incidence of caesarean section of all regions in Thailand varied between 2-7 percent in 1979 and 3-7 percent in 1982, but this has certainly increased significantly.

C4: Health Issues Related to Life Styles and the Home and Work Environment

(a) The household environment:

A 1989 housing evaluation showed that about 40 per cent of housing throughout Thailand was below a basic hygienic quality standard, with more than half of these housing units located in the northeast. However, economic growth has improved this situation. In 1993, 98.6 per cent of the population had access to electricity, 84.5 per cent had sanitary toilets and 77 per cent had a continuous supply of safe drinking water (See Table 3).

Many of the health and lifestyle issues of particular importance to women have thus been addressed, but the continuing existence of substandard housing, particularly “slum” housing in city areas, is no doubt a factor in some health problems. These areas are frequently exposed to toxins and pathogens from industrial production, traffic pollution, garbage and sewage. (187; 14). This particularly affects women because of their responsibility for housework and childcare, and the consequently longer periods they are likely to spend in the household environment.

There have been no studies in Thailand on any risk associated with fuel from cooking stoves, but in view of the Thai climate, and the fact that the majority of cooking is done out-of-doors, this is not generally a significant problem. The exception is in some hill tribe groups (which live in higher, cool areas) in which respiratory illness resulting from cooking fires and poor ventilation may be a problem (65; 28). Similarly, fuel collection is not a serious problem, as a variety of sources, including gas and electricity, are generally available, except to the very poorest groups.

(b) The gender division of labor

In Thai society, factors influencing gender roles have been identified as individual, cultural, economic, and political, or through government policy. All of these factors interrelate in creating a role for women that has particular stress on household responsibilities, both in women’s responsibility to provide an appropriate physical environment through good economic management (often of meager resources) and their responsibility in maintaining and managing it. All of these factors influencing women’s role are also closely related to women’s health status.

(i) Rural and Urban Responsibilities

Thai women, in both rural and urban areas, usually having both household and outside responsibilities. On average, northeastern women spend 11-15 hours a day for household chores, not including time spent for child care, which runs concurrently with these chores (104; 4-2) Another study found that in rural areas women spent an average of 1644 hours per year working in agricultural production, compared to 2294 hours for men. But when women’s domestic burdens were seen as “light” and “boring”, as well as being solely women’s responsibility (104; 3-3).

Women in urban settings have different patterns of domestic responsibility when compared with their rural counterparts. They may face a choice between leisure, child care, housework, work in the informal sector and formal employment. Formal employment in particular is likely to lead to a reduction in the time available for domestic work, which at differing wage levels and social groups may be met by the employment of domestic labor, the use of extended family networks, or by sacrificing leisure time or adopting lower household standards.

The childcare burden, however it may be arranged, is, for both rural and urban women, a substantial barrier to other potential activities, including those related to health. It reduces their exposure to health information campaigns, nutritional information etcetera, particularly through the mass media and indirectly has an impact by preventing them developing their education and skills to obtain better, healthier work or better-paid work which would allow greater expenditure on medicine, nutritious food, accommodation, etcetera.

(ii) Child Care Responsibilities.

Particularly for urban women, usually employed outside the home, child care is often a source of considerable stress and concern. The increase in nuclear families also means that mothers may be removed from traditional sources of advice and information on family planning, and there has been increasing concern that there are no courses in parenting and related skills which might replace the traditional learning method.

(iii) Household Decision-Making

General Thai cultural expectations suggest that women should be responsible for managing household finances, and that in fact they are more responsible and capable in such matters than men. This fact is reflected in Thai law, which requires that both men and women have their spouse sign any loan agreement (103: 52). It also means that Thai women are generally able to direct household expenditure to basic needs such as nutrition and health care, if the resources exist in the household.

This means, however, that women often feel responsible, and are regarded by others as being responsible, if basic household needs cannot be met. This stress often affects a woman’s physical and psychological health status, as discussed under section C1. It also means that directing health messages to women will ensure the household manager is being provided with information she may need for her work.

(c) Occupational Health Problems

Occupational health problems can be caused by the physical environment, including factors such as temperature, light, sound, dust, chemicals, and machinery. Other factors are physical conditions of the female workers themselves, their understanding of the work, their health behavior and emotional status, and their readiness to work. It is generally agreed that many of these factors present risks to the health of female workers, although due to the sensitivity of the topic with officials and employers, the difficulty of accessing female workers and identifying work-related illnesses, it is extremely difficult to quantify the problem, or even identify the most significant problem areas.

Another problem which is very difficult to quantify is the threat to women’s health, particularly their mental health, from harassment or assault they may suffer in the working environment. Levy and Wegman (196; 482) studied women’s status in the workplace among 500 women and found that 42.88 per cent of women workers had been sexually assaulted or harassed at work which, in some cases, resulted in physical and psychological disturbances. Only very recently, in January 1998, was legislation passed prohibiting sexual harassment in the workplace.

(i) Female Agricultural Workers

Chemical use in agriculture poses a great health hazard to the user and environment. In 1985 a study on pesticide poisoning in selected areas of three SEAR (Indonesia, Sri Lanka and Thailand). This study show pesticide poisoning rates of 13.38 per cent, 11.9 per cent and 19.4 per cent respectively in agricultural workers using pesticides (198).

The Division of Epidemiology’s report shows that the morbidity of occupational pesticide poisoning in 1987 was 8.6 per 100,000 population (which is almost certainly an under-estimate. Moreover, pesticide residues such as organochlorine were detected which could have direct impact on potable water and its users (probably including many of the workers who applied it).

A 1995 study of the female labor force reported that most of the female laborers hired to spray pesticide were poor, the average age was 20-40 years old and had only elementary education. About 20 per cent of these women have been exposed to pesticides due to poor practices in self-protection. The health problems reported included headache, nausea, vomiting and skin rash. The study also found young children were exposed pesticide residues on their mother’s clothes. The women workers were usually unaware of any minor symptoms and unlikely to seek treatment or change their behavior. (199).

Pain-killing drugs are widely used among female workers in the agriculture. It has been reported that 72 per cent of agricultural workers take pain-killing drugs, while 63 per cent take them routinely; without pain killers they would feel fatigue and could not continued working. The consequences include peptic ulcers, addiction, and psychological problems (226, 143).

(ii) Industrial and Non-formal Sector Employment

Industrial workers face a variety of health threats, depending on their industry. Textile workers, more than 90 percent female, face a particular danger from inhaling fiber dust, which can lead to byssinosis. It has been reported that there has been an increasing trend of workers with byssinosis disease applying for the work compensation funds. The occupational Medicine Department reported in 1993 that there was 520 cases of byssinosis, while a study from 1990 to 1994 found that over a ten year period, 30 per cent of workers would develop the disease (96d; 19).

Women in the electronics industry are particularly at risk from exposure to lead, aluminum, trichloroethylene and many other chemicals (96d; 19). Lead is the best-studied of these, with one study finding 36 per cent of female workers of the Seagate Technology (a major manufacturer who might be expected to have better than average safety standards) had blood lead level higher than the standard.

As in agriculture, a problem which is widespread across many industries is the abuse of drugs by workers who find, or feel, that they are essential to their ability to complete the job. Analgesics and amphetamines are particular problems, with the former being used to hide the pain of existing occupationally-related health problems and diseases, and the later being used to enable workers to continue for very long hours (96d;20).

(iii) Female Health Problems in the Construction Industry

About half of the 1,913,900 construction workers in the whole country are female. Most of them are non-skilled laborers and have to work as hard as their male co-workers. After working at the construction site, these female laborers have to take care of their housework and children. A study of the health status of female construction workers in Bangkok found that 17.2 per cent were between 13 and 15 years of age, uneducated, and separated from their families. These workers laboured hard, often worked overtime and reported many emotional and physical problems. Ninety-five per cent said their need for health examinations was not currently being met.

Jirawattanakul (198) studied health problems in female construction workers in the northeast. The results show that the workers spend at least 10 hours per day at the construction site. They encounter similar emotional and physical problems to those of female construction workers in Bangkok. Furthermore, there were reports of work accidents (68 per cent) and traffic accidents (32 per cent).

C5: Women and Violence

(a) Domestic Violence

Women within Thailand are most at risk of violence within the family environment (97; 7). Domestic violence is common in Thai society. Its primary cause is seen as a male’s right over the body of his subordinate, dependent wife, which legitimizes violent action against her. Many Thai women have internalized or accepted this concept and tolerated it. Thai society, as many other societies, considers this kind of violence as a private problem of the family, rather than the concern of society.

As a result of this lack of social concern, almost no statistics on family violence have been collected. Despite the fact that many female victims of domestic violence have been admitted to hospitals’ emergency departments with serious conditions, there is no law or regulation requiring that these cases be reported to the police.

The category of domestic violence has never been recognized in Police Department statistics, although anecdotal evidence suggests thousands of cases of this form of violence have been reported directly to police stations each year. The Public Welfare Department has assisted many women who are abused by their husbands but such cases are similarly not recorded as cases of family violence. Similarly, because of the lack of any comprehensive study on family violence, the impact of this violence against women is not clear (199).

One small-scale study of 400 women attending the outpatients clinic at a central provincial hospital in January 1997 found that 68.8 percent of the women reported they had suffered mental or physical violence. Of those, about one quarter reported being subjected to physical violence, most frequently being described as being pushed or pulled. Over 40 percent reported suffering physical or mental violence from their husbands, and half reported they had been sexually assaulted by a stranger. This is only a limited survey, with limiting methodology, but it certainly illustrates the urgent need for further research and programs. (200)

An earlier study examined the causes of domestic violence. It found the major reason for wife beating and killing is jealousy, followed by economic constraints. Other factors involved are drunkenness and gambling. Some wives were killed just because they refused sexual intercourse with their husbands (201).

(b) Rape and Sexual Assault

Thailand is a country where virginity is valued very highly. Sexual assault is thus especially damaging to its victims. Victims suffer not only from the incident itself, but from the double standard that makes women feel ashamed about the fact that have been violated. Thus they tend to keep the trauma to themselves, rather telling their parents, relatives, friends or going to the courts (202). Victims may also have (well-founded) fears about how they may be treated if they report the case to police. They may fear being treated with disbelief, or subjected to further humiliations.

Ironically, it is very common to find a rape case reported each day on the front page of daily newspapers, with considerable and often lurid coverage. This practice is an important factor in public perceptions that the rate of sexual crimes, including rape, is increasing.

Criminal statistics collected by the Research and Planning Division of the Police Department (shown in Table 3.4.1) indicate the number of rape cases has been steadily increasing over the past 14 years. These figures do not include cases of rape which culminated in murder. On average, two women are raped and killed each month (202).

Out of 139 rape cases reported on the front page of five daily newspapers in 1995, 31 per cent of the victims were raped and killed. Fifty four per cent of the offenders were persons close to the victims (202). However, it has been estimated that reported cases of rape crime in Thailand, as shown in the table above, represent only 5 per cent of the total incidence (203), while the proportion reported in newspapers is smaller again, so it is not possible to draw any real conclusions from these figures, except that they grossly underestimate the scale of the problem. Similarly it is impossible to determine if the increase in the figures above represents an increase in the overall incidence of the crime, or merely a slightly increased willingness to report it. (103; 60)

Although the law allows for very heavy penalties for sexual abuse and rape, it also provides a loophole which allows the involved parties to seek agreement among themselves on the incident. In many cases this is encouraged by police, especially when the offenders have some social status. A middle rank policeman gave an explanation: “rape cases are widely regarded among policemen as easy money-making opportunities. The defendant is willing to pay, and this is why you see all sorts of tactics to discourage the victim to back off … The attorneys, too, will be co-opted into the process” (139; 29).

Moreover, if the offender is the father of the victim, the child cannot take legal action against her parents. They must depend on the “legal inspector” or attorney to take action for them. On many occasions, these officials do not want to bring a court case against the father as they believe in traditional values that parents should not be accused by their children (204; 266).

Evidence from the court cases in which the Centre for the Protection of Women’s Rights has been involved in assisting victims indicates that many rapists are well aware of the many ways in which they may evade the law. Many confessed that they waited until the situation was open for them or sometimes deliberately set up circumstances in which they can both provide for committing the crime and hope to avoid punishment (205).

(c) Sexual and Physical Abuse of Girls

Sexual violence against girls in Thailand can be broadly divided into two forms: incest or rape, and child prostitution. Statistics collected by the Children’s Rights Protection Center from newspapers indicate that at least one or two girls under 16 years old is raped, or raped and murdered, or raped and beaten, or assaulted every week. The youngest girl in this study was only one year old.

As with rapes and sexual assaults on adult victims, it is highly likely that these statistics represent only a small percentage of total offenses committed. It is extremely difficult to estimate the number of cases of sexually abused girls not only because the crime is often committed by children’s relatives (such as father, brother, grandfather, uncle), or by persons to whom the children are entrusted (such as teacher, male neighbor, and priest), but also because the sexual abuse of girls is usually committed in secret when the sexual offenders are alone with the children. It is, therefore, difficult to find witnesses (199).

One study (199) concluded that the level of child sexual abuse in Thai society is increasing. For example, para-social workers working in four provinces reported that child sexual abuse is one of the most common forms of violence against female Thais at a village level. Children encountering this sort of violence were most likely to combat or cope with the problem alone (206).

In the 139 rape cases reported in newspapers in 1995, (in the study already noted above), 40 percent or 72 victims were girls aged under 15 years, and six of them were aged 0-3 years old. The youngest victim was only eight months old (199). However, despite the incidence of in-family sexual assault, probably the greatest number of girls who are victims of sexual assault in Thailand are individuals who have been trafficked, forced or coerced into prostitution. This issue is discussed in some detail in Section C6.

With regard to battery and other physical abuse of girls, no data is available and no studies have been done within Thailand, although data from throughout the world, suggesting the widespread nature of this problem, indicates that it almost certainly occurs. Due to traditional values about parents rights over their children, this issue has not yet been significantly considered in Thailand.

(d) Health Consequences of Violence against Women

(i) Domestic Violence: Cases of domestic violence which have been published on the front pages of newspapers usually involve severe physical assaults and murders of women. This is primarily because a large number of husbands who beat their wives have used sticks, knives, guns or other weapons, and victims of such attacks are obviously likely to suffer severe health effects. No data is available on the effects of lower levels of violence, but it is obvious that it must affect its victims’ health, not only in terms of injuries received, but of the health effects of fear, stress and other emotional trauma.

Another important impact of family violence is that it causes significant damage to even members of the family, including children, who may not be directly injured. Statistics collected by an NGO working with homeless children indicated that almost all children who left their families and were living on streets were from families where mother and children were often beaten by their father (203). In addition, domestic violence in Thai society is likely to happen to women during pregnancy, and may result in pregnancy loss, pre-term birth, low birth-weight, fetal injury and fetal deaths.

4.2 Rape and Sexual Assault: Sexual violence against women causes mental anguish, fear, and other psychological effects, in addition to the physical injury. In addition it is also a form of terrorism against all women. Its threat makes many women refrain from actively participating in social, economic and political activities. Additionally, fear of sexual violence has become a rationale for excluding women from certain public offices and from certain kinds of jobs in the private sector (207).

4.3 Child Prostitution: Young girls and women who are lured or forced into prostitution encounter the torture and exploitation. They are forced to work hard and long hours with little sleep and for very low payment. Brothel owners use violence to control the children, frequently beating them if they refuse to work, sometimes so hard that some children have become handicapped or have been killed. On many occasions, they are drugged with either stimulants or addictive drugs (204).

(e) Policies and Measures taken by the Government and NGOs

(i) Domestic Violence: Since the 1980s, many NGOs have established programs providing assistance to women and children who are victims of the domestic violence. Among these are the Children Rights Protection Centre run by the Foundation for Children, the Emergency Home for Women and Children, run by the Association for Promoting Women’s Status, and the Centre for Protection of Women’s Rights’ and ‘Women’s Club run by Friend of Women Foundation. However, the Emergency Home for Women and Children is the only refuge specifically aiming to assist battered women and sexually-abused women in Bangkok, and there is none in the rest of the country (199). However, there are two refuges in the North, Baan Taufhun in Chiang Rai and Baan Mareena in Chiang Mai, which provide shelter for women who face with any form of violence or danger, including AIDS, trafficking and domestic violence. Campaigns against domestic violence have been carried out by NGOs, and as noted above, the NCWA recently inaugurated a sub-committee to work on campaigns and new official approaches to the problem.

(ii) Rape and Sexual Assault: The specific problems which rape victims face before, during and after the trials have rarely received attention from the government departments due to the lack of consideration and understanding of the rape crimes. In the last two years, there has, however, been some limited government action. The Police Department, in conjunction with the NCWA, has set up a pilot program, appointing female police officers as investigators at three Bangkok police stations (a position not previously occupied by women), with the expectation that they will be more able to sensitively and effectively deal with the victims of sexual crimes. The program is as yet only small-scale and experimental, but it does represent an acknowledgment of the need for improvements in this area. The NCWA also arranged training for these officers, together with about 60 of their male colleagues, in the investigation of sexual crimes. (103; 60)

In addition, the Office of the Attorney General in association with the NCWA has drafted two proposed new laws which would be of considerable assistance to victims of sexual crimes and investigators seeking to locate and prosecute the offenders. The first is a proposed amendment to the penal code, which would replace current legal definitions of rape (which relate only to penis-vagina contact) and indecent assaults, with a broadly-defined law of sexual assault. This law would focus on the degree of harm to the victim, rather than the nature of the sexual act involved in the offense. (It is broadly in line with the nature of laws already enacted against sexual assault in many Western countries) (104; 23-5).

The Office of the Attorney General has also drafted an amendment to the Criminal Procedure Act which would allow child witnesses and victims to, immediately after being located by police, to make statements and be questioned in a video-taped interview, with a psychologist or social worker present. This would then be presented to the court as their evidence-in-chief. Any questioning during a court case might then be carried out by video-link. For child victims of sexual assault, this would be particularly valuable, as it would remove the need for them to face their attacker in court, or to repeat their story many times. (104; 30-32.)

NGOs have been active in attempting to create increased awareness of the incidence of sexual violence against women and improvements in the treatment of victims. Entrenched social attitudes have made this a difficult task.

Module C: Women’s Health (Part 2)

C6: Women In Special Circumstances

(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.

C.7 Access to Health Care

(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.

C8: Women as Health Care Providers

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).

C9 Policies and Programs on Women’s Health

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.

3.10: Recommendations Arising From This Report

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.

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Authors

Principal Investigator:

Asst. Prof. Dr. Chaninat Varothai

B.A. (Journalism), M.A. (Educational Administration), Ph.D. (Community Health Development)

Department of Health Education and Behavioral Sciences, Faculty of Public Health, Mahidol University.

Editor:

Ms Natalie Bennett,

B.A. Hons (Asian Studies), B.Ag.Sc. Hons

Freelance consultant and editor, Bangkok.

MODULE A: COUNTRY SITUATION

Dr. Paitoon Kraipornsak

B.A.(Econ), LL.B., M.A. (Econ), Ph.D. (Econ)

Centre of Health Economics, Faculty of Economics, Chulalongkorn University.

Asst.Prof. Dr. Naowarut Charoenca

B.Sc., M.S. (Public Health), Ph.D. (Env.Health),

Department of Sanitary Engineering, Faculty of Public Health, Mahidol University.

Assoc. Prof. Dr. Orathai Ruayajin

B.A., M.A. (Sociology-Demography), M.P.H. (Family Health), PhD (Behavioral Science and Social Epidemiology)

Department of Social Science, Faculty of Social Science and Humanities, Mahidol University.

MODULE B: STATUS OF WOMEN

B1 National Policies for the Advancement of Women

Asst.Prof. Dr. Chaninat Varothai

Asst. Prof. Pattana Mulphruk,

B.Sc.,M.Eng.

B2 National Machinery for the Advancement of Women

Asst. Prof. Dr.Chaninat Varothai.

Assoc. Prof. Dr. Orathai Ruayajin

B3 Women’s Movement in the Country

Miss Waraporn Chamsanit Journalist

B4 Women and Work

Mrs. Sulee Tongvichean

B. Sc.(P.H.N.), M.Ed. (Nursing Service Administration), PhD Candidate

Department of Public Health Nursing, Faculty of Public Health

Mrs. Wacharee Katesopit

B.A., M.S.P.H. (Health Education)

Division of Health Education, Ministry of Public Health

B5 Women’s Status in the Family and Society

Assoc. Prof. Wilai Kusolvisitkul

B.A. First Class Honours (Statistics), M.Sc. (Biostatistics)

Departmant of Biostatistics, Faculty of Public Health

B6 Women’s Educational Status

Mrs. Wanaladda Tongbai

B.Sc., M.S.P.H. Candidate

Asst.Prof. Dr. Chaninat Varothai

B7 Women’s Political Participation

Ms Sheila Thomson

B.A., M.A.,

Gender and Development Research Institute

B8 Women and Religion

Asst. Prof. Dr. Chaninat Varothai

Mrs. Jureerat Pettong

B.Sc., M.S.P.H. candidate

B9 Women and Sport

Mrs. Sompit Sukwitura

B.A., M.A., Department of Physical Education, Ministry of Education

MODULE C: WOMEN’S HEALTH STATUS

C1 Nutritional Status

Asst. Prof. Dr. Chutima Sirikulchayanont

M.D., Dip. Thai Board Of Pediatrics

Department of Nutrition, Faculty of Public Health C2 Leading Causes of Morbidity and Mortality

Asst.Usa Lek-Thai

B.Sc., M.S.P.H., Ph.D. Candidate.

Department of Parasitology, Faculty of Public Health, Mahidol University. C3 Reproductive Health

Asst. Prof. Dr. Chaninat Varothai

Asst. Dr. Jarueyporn Suparp

B.Sc., M.D., M.P.H. (Urban Health) Department of Maternal and Child Health, Faculty of Public Health, Mahidol University.

C4 Women and Violence

Asst. Prof. Dr. Krittya Achavanikul

B.Sc. (Education), B.A. , M.A., Ph.D. (Demography) Institute for Population and Social Research

C5 Women in Special Circumstances

Ms Natalie Bennett

C6 Health Issues Related to Lifestyles and to Home and Work Environment

Miss Somboon Kuasakul

B.Sc., M.S.P.H. (Health Education),

Division of Health Education, Ministry of Public Health

C7 Women’s Access to Health Services

Assoc. Prof. Dr. Orathai Ruayajin

C8 Women as Health Care Providers

Miss Poranee Surin

B.Sc., M.S.P.H. (Health Education)

Department of Health Education and Behavioral Sciences

Mrs. Sulee Tongvichean

B. Sc.(P.H.N.), M.Ed. (Nursing Service Administration), PhD Candidate Department of Public Health Nursing, Faculty of Public Health

C9 Policies and Programs for the Enhancement of Women of Women’s Health Status

Asst. Prof Dr. Chaninat Varothai

Miss Lakana Temsirakulchai

B.Sc., M.S.P.H. (Health Education)

Department of Health Education and Behavioral Sciences FOCAL POINT MEMBERS

Dr. Saisuree Chutikul, Advisor to the Office of the National Commission on Women’s Affairs

Prof. Dr Pensri Phijaisanit, Acting Chairperson, National Committee on Women’s Health and Environment

Assoc. Prof. Dr. Amara Pongsapich, Chairperson National Committee on the Development of Women’s Information Systems

Dr. Suteera Thomson, Administrative Committee of Gender and Development research Institute

Assoc. Prof. Dr. Apichart Chamratrithirong, Former Director, Institute for Population and Social Research, Mahidol University.

Stage 2

Following a Working Group Meeting in Myanmar to consider experiences of Thailand and Myanmar in piloting the Women’s Health and Development Profile, the framework was adapted and additional work suggested.

Further information collection and analysis was then completed by:

MODULE A

Dr. Paitoon Kraipornsak, B.A.(Econ), LL.B., M.A. (Econ), Ph.D. (Econ)

Centre of Health Economics, Faculty of Economics, Chulalongkorn University.

MODULE B

Ms. Sheila Thomson, B.A., M.A.,Gender and Development Research Institute

MODULE C

Assoc. Prof. Orathai Ruayajin, B.A., M.A. (Sociology- Demography), M.P.H. (Family Health), PhD (Behavioral Science and Social Epidemiology) Department of Social Science, Faculty of Social Science and Humanities, Mahidol University.

Dr. Suwanna Worakamin, M.D., Board of Gynaecology, Director of Family Planning and Population, Department of Health, Ministry of Public Health

Table C: Assoc. Prof. Wilai Kusolvisitkul, B.A. First Class Honours (Statistics), M.Sc.(Biostatistics), Departmant of Biostatistics, Faculty of Public Health

Acronyms

EPI Extended Program of Immunization

GDRI Gender Development Research Institute

MCH/FP Mother and Child Health/Family Planning

MOPH Ministry of Public Health

NESDB National Economic and Social Development Board

NCWA National Commission on Women’s Affairs

NGO Non-government organization

NIB National Identity Board

NSO National Statistical Office

ONCWA Office of the National Commission on Women’s Affairs

RDA Recommended Dietary Allowance

TBA Traditional Birth Attendant

TDRI Thai Development and Research Institute

UNDP United Nations Development Program

WHO World Health Organization

Financial values in this report are given in US dollars or Thai baht. For most of the period of this report, $1US was approximately worth 25 baht. This has recently risen to about 50 baht.

References in this report are in an amended Harvard form, with the initial number referring to the number allocated to each source in the Bibliography and the second (where relevant) referring to the page(s) from which the material was drawn in that source.

2 Comments

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