An assessment of the positive partnership project in Thailand: key considerations for scaling-up microcredit loans for HIV-positive and negative pairs in other settings.

Stigmatization and discrimination against people living with HIV/AIDS (PLHA), and their families, remains a barrier to participation in prevention and care programmes. This barrier takes on added significance as Thailand expands provision of free antiretroviral therapy (ART). This paper documents an innovative approach to improve quality of life for PLHA, while reducing levels of stigma and discrimination. The Population and Community Development Association (PDA) began implementing the Positive Partnership Project (PPP) in 2002. In this project, an HIV-negative person must team up with an HIV-positive person to become eligible for a loan for income-generating activities. The use of microcredit to explicitly reduce stigma and discrimination is a unique feature of the PPP. While the microcredit component of the project is an important dimension for improving the status of participating PLHA, the impacts of the project extend far beyond the PLHA who receive loans. Both directly and indirectly, it has contributed to improved quality of life and economic conditions for PLHA, while raising their visibility and acceptance in hundreds of communities throughout urban and rural Thailand. This paper identifies key features of the project and considerations for adapting its use in other settings.

Health and rural-to-urban migration in Thailand. The Population and Community Development Association's experience in rural development.

The Population and Community Development Association (PDA), a non-governmental organisation, has designed and implemented a new model of rural economic development in which health is considered to be the cornerstone of all development strategies. By attacking migration as the root cause of current threats to the population's health, PDA's Thai Business Initiative in Rural Development program provides economic opportunities to villagers in the poorest areas of the country. This structural approach to health enhancement includes specific components to address primary health care, family planning, and HIV/AIDS prevention, education and care.

PIP: Since its establishment in 1974 as a nongovernmental organization with funding from a number of agencies, including the US Agency for International Development, the Population and Community Development Association (PDA) has implemented a practical, community-based program to address the changing needs of the rural Thai population. Over the past decade, rural-to-urban migration in Thailand has emerged as the single greatest threat to the health status of the population. The PDA has designed and implemented a new model of rural economic development in which health is considered to be the cornerstone of all development strategies. PDA's Thai Business Initiative in Rural Development Program is working to provide economic opportunities to villagers in the poorest areas of the country. This structural approach to health enhancement includes specific components to address primary health care, family planning, and HIV/AIDS prevention, education and care.

The Thai Business Initiative in Rural Development (TBIRD): a new dimension in rural development.

PIP: The Population and Community Development Association (PDA) promotes family planning (FP) throughout Thailand through a community-based approach. The Thai government actively supports rural development. In 1986, 80% of Thailand's people who lived below the poverty line were in rural areas. The poverty line in rural areas is an annual per capita income of 3823 baht, or US $153; in urban areas, it is more. Since 1984, Thailand's gross domestic product (GDP) has increased by more than 50%. Per capita GDP has risen dramatically, also, with the success of FP efforts. This economic achievement, however, has not been shared by most of the Thai population. Incomes in the agriculture sector are far below those in the nonagricultural sector. The government and the nonprofit organizations, however, do not have skills. The corporate sector does have these skills. The Thailand Business Initiative in Rural Development (TBIRD) helps companies sponsor villages and aids them in developing business skills, whereupon income levels and local living standards are improved. Companies thus help in the employment transfer from agriculture to nonagriculture. There is a "one-company-one- village" formula. Company employees have the skills needed in the villages. They are directly involved. Since 1988, PDA has been working with companies in Thailand to help villages develop business skills. In Saraburi province, PDA and Volvo Swedish Motors have been aiding villagers to grow saplings and sell them to golf course and housing developers. In Ayutthaya Province, PDA and the same company are helping the residents with needlepoint and embroidery to supply a wedding dress manufacturing operation. These programs have succeeded. PDA wants to expand the program by September 1990, to include 50 companies. It is hoped that once the companies are comfortable with their relationship to the village, they will start associations with additional villages. PDA has established the "Ten Steps to Adopt a Village."^ieng

Marketing contraceptives in rural Thailand.

PIP: It can be difficult to administer and motivate field workers in family planning programs. In the case of social marketing, the last distributors in the chain are small shopkeepers who keep part of the final sale price. Thus contraceptives become part and parcel of their routine business, and the margin becomes both their remuneration and their motivation. In Thailand and most other countries with social marketing programs, part of the selling price also returns to the program, providing some degree of cost recovery. As family planning succeeds and per capita incomes rise, individuals will be able to pay an increasing part of the total cost of family planning. In the interim, international agencies and governments will continue to provide subsidies. In rural countries like Thailand, social marketing programs can be initiated and expanded relatively rapidly because they build on an existing infrastructure; they can also reach the most distant parts of the country. Skills of local advertising agencies are available in practically all Third World countries. Sales are a reliable record of progress and can be used to suggest innovations or practical solutions to problems. Small shopkeepers often feel more comfortable vending contraceptives than many experts would expect and as members of the community, intuitively know what the community's standards are. Individuals handling oral contraceptives often require some training and supervision by full-time staff who can answer questions that arise; local physicians may also be notified of the program for referral of problem cases. If there is a problem with social marketing programs, it is that they are sometimes too successful--leading to large bills for contraceptive commodities. However, if evaluated in terms of cost-effectiveness, they are less expensive than their alternatives. Along with access to voluntary sterilization and community-based distribution programs, social marketing is a keystone in the arch of family planning in the 1990s. Experience in Thailand shows family planning is wanted and relatively rapid changes in fertility and family size can be achieved. Social marketing is a common sense, cost-effective, democratic way of meeting a universal need in a culturally appropriate way.^ieng

Motivating communities through economic incentives.

PIP: Thailand's pilot Community-based Incentives Program in the northeast illustrates the high level of contraceptive prevalence that can be achieved when entire communities profit from economic incentives. This particular community incentives program began in 1983 with funding from the Special Projects Fund of the Population Crisis Committee under the auspices of Thailand's largest nongovernmental organization, the Population and Community Development Association (PDA). PDA, with its long and impressive record as a grassroots family planning service network, had almost a decade of experience in creating demand for family planning by offering income generating incentives to individuals. Through the community incentives program, PDA used the grant from abroad to establish loan funds of about $2000 in each of 6 villages. The loan funds grew in size as the overall contraceptive prevalence rate in the villages increased. Loans between $80 and $200 were made available to villagers for income-generating activities, mostly to buy fertilizer, rent tractors, or hire workers for planting and harvesting the local crops. Elected villagers administered the funds and reviewed loan applications with assistance from PDA. By the end of 2 years, loans totaling $72,000 had been granted in the 6 villages, and 75% of all village households had received at least 1 loan. Repayment was nearly 100% on schedule with no defaults. The 6 loan funds are still operating in 1986 but without outside assistance. Contraceptive practice increased from 46% to 75% of all married women aged 15-44 in the 6 villages between 1983-85. In a comparative study of 3 villages in which no loan fund operated, contraceptive prevalence increased from 51% to only 57%. In the Thai experience, the private PDA appears to have several advantages over the central government in implementing a community incentives approach: because PDA works closely with community members, it is able to determine community needs, involve the community in decisionmaking, and create the foundation for community self-management; it is able to provide close supervision to assure that performance is rewarded; and it may be perceived as a more credible source of rewards than a government that is removed from the people. Community incentives programs work because family planning and economic development reinforce each other to increase per capita income.^ieng

Community-based incentives: increasing contraceptive prevalence and economic opportunity.

PIP: This article describes the implementation of a project in rural Thailand that used loan incentives for promoting small-scale income-generating activities and contraception practice. The project was initiated by the non-governmental Population and Community Development Association. Quarterly bonuses to a village fund are tied to the village's contraceptive prevalence rate, loan applications to individuals are prioritized according to applicant family planning (FP) practice, and members receive fund shares according to FP method used, e.g. 80 shares for a vasectom, 20 for an IUD. FP practice was monitored and the loan fund administered by trained loan fund officers from the community. The proiject was evaluated using 6 project villages and 3 controls with no loan fund. 3 of the experimental villages's loan funds were managed by female committees and benefits were available to all women regardless of marital status. The other funds were male/female managed and available only to married reproductive age couples. The proportion of women practising FP increased form 46% to 75% in 2 years, as opposed to from 51% to 57% in the contrrol villages. Pregnancy rates declined sharply. The strongest mechanism forFP use seems to have been the village-level incentive. Loan officers were able to motivate villagers to use FP. Women's status appears to have improved in the villages with female-administered funds. By encoraging capital investment, the fund appears to have gbreatly improved farm profits, and the loan repayment rate was almost 100%. The program attempted to avoid coersion, and did not compete with other loan programs. It appears helpful to emphasize training officers. Futre programs can tie incentives to pregnancy rates to deemphasize modern contraception. Services being promoted must be accessible and socially acceptable.^ieng

Maintaining family planning acceptance levels through development incentives in Northeastern Thailand.

The results of a two-year longitudinal study of the effect that development program incentives have upon family planning in Northeastern Thailand are presented. These incentives, implemented by the Population and Community Development Association, Thailand, included animal raising and agricultural, home industry, and environmental activities. An experimental design including baseline and follow-up surveys supplemented by a continuous monitoring system was utilized to test hypotheses on the family planning impacts of the incentives. Findings indicate that the incentives contributed significantly to the maintenance of high levels of family planning practice through the program period 1982-1984.

PIP: The results of a 2-year longitudinal study of the effect that development program incentives have upon family planning in Northeastern Thailand are presented. These incentives, implemented by the Population and Community Development Association, Thailand, included animal raising and agricultural, home industry, and environmental activities. An experimental design including baseline and follow-up surveys supplemented by a continuous monitoring system was utilized to test hypotheses on the family planning impacts of the incentives. It was hypothesized that: 1) couples in experimental areas with a greater number and availability of development incentives will have a greater increase in contraceptive practice than couples in experimental areas with a lower number and availability of incentives; 2) in the experimental areas, couples who accept development incentives will have a greater increase in contraceptive practice than other couples; and 3) continuation of family planning practice in the experimental areas will be more prevalent among users who accept a development incentive than among others. Data collection focused on currently married couples in which the females were aged 15-44 years. In the baseline survey, data was collected on social, economic, and demographic factors and family planning. Over 1000 households were interviewed for each experimental model. The 1st hypothesis was not supported by the findings. The 2nd was supported by results from 1 model. The 3rd was supported by the data. Findings indicate that the incentives contributed significantly to the maintenance of high levels of family planning practice through the program period 1982-1984. The findings from this study suggest several avenues for further research and evaluation. Additional data need to be collected from the control area to assess the extent and impact of development incentives introduced by the government. Additionally, the process of program implementation in the experimental areas needs to be given greater attention. As the program continues, its impact on income, employment, migration, and fertility and mortality need to be measured carefully.

Prevalence of schistosomiasis and other parasitic diseases among Cambodian refugees residing in Bang-Kaeng holding center, Prachinburi Province, Thailand.

Isolated cases of schistosomiasis were discovered on stool examination among Cambodian refugees residing in Thailand. Further epidemiologic investigations were conducted on a sample of 5,085 Cambodian refugees in the Ban-Kaeng holding center, using the intradermal skin test as a screening device to determine the prevalence of this disease. A positive diagnosis of Schistosoma mekongi was confirmed in 17 of those examined by recovery of eggs in the stool. The prevalence of schistomiasis in the Bang-Kaeng camp was 3.3 cases/1,000 population. All positive cases came from geographic areas in cambodia where schistosomiasis has not been previously reported, indicating that schistosomiasis in Cambodia is currently more widespread than generally believed.

Self reliance and local support of CBD projects: the Thai experience.

PIP: The Community Based Family Planning Services of Thailand launched its community based distribution program in 1974, with a goal of attaining self reliance and local support. The program was designed in 2 phases. In the 1st phase, a supply of contraceptives was donated together with financial resources to cover establishment of a distribution program and most of the operating costs. The principle was that, since supplies were not provided free, some income would have to be generated in the local communities to pay for them. By the end of this phase, the proportion of local income should have increased so that all expenditures for the program could be met by sale of the contraceptives (except the cost of the contraceptives themselves, which would continue to be supplied by the donor agency -- International Planned Parenthood Federation). In the 2nd phase, additional local income would be generated, so that ultimately all aspects of the program, including purchase of contraceptives, could be paid for by the local community. As of January 1979 the program had successfully reached the end of the 1st phase. In 1974 IPPF funds represented 88% of total income, declining to 72% in 1976, 22% in 1978. Local income represented 100% of expenditure by 1979. For the 2nd phase, the program relies on the use of a village distributor and on realistic pricing of the contraceptives offered. With the realization that foreign assistance in family planning cannot last forever, the Thai program aims at demonstrating that family planning services can pay for themselves.^ieng