The health profile at present reflects Thailand's epidemiological transition, where morbidity and mortality from infectious diseases and peri-natal disability have declined while behaviour-based morbidity and mortality, such as traffic accident, AIDS, cardio vascular diseases from smoking have been increasing. The family planning (FP) activities and services have been integrated in maternal and child health care from the start of the programme in 1970 and have currently been able to provide a nation-wide coverage of service delivery for the general population.  Thus the total fertility rate (TFR) was brought down  to 1.9 in 1996, with a population growth rate of 1.2percent and contraceptive prevalence rate (CPR) at 75.1 percent.  Good accessibility to maternal health care is reflected in health indicators that show 94.5 percent of births were attended by trained health personnel in 1995.  In 1996, the maternal death ratio was 43.9 per 100,000 live-births and infant mortality rate was 26.0 per 1,000 live births.  These important health indicators can demonstrate the extent and quality of maternal and child health care in Thailand.

Sexually transmitted diseases (STDs) had an increasing trend prior to the era of the HIV/AIDS epidemic. After a serious social concern of AIDS in the late 1980s, strong campaigns for AIDS control and prevention resulted in a gradual sexual behavioural change.  Subsequently, a levelling off of HIV infection rate in the general population and also a lower STD prevalence rate were noted.   Male STD cases were outnumbered by those of their female counterparts while the commercial sex workers (CSWs) formed the largest group of STD cases.  Sex education and AIDS education have been integrated into family life and education for primary school students since 1990.  At the same time, a sex education curriculum was also developed for secondary schools. However, an effective sex education course in schools has yet to be in place for every school. The extent of adolescent reproductive health (RH) problems can be seen in a more prominent STD infection which includes an HIV infection rate of more than 40 percent of all reported cases in this population group.  Teenage pregnancy currently accounts for 14.7 percent of all pregnancies.  In a 1997 national health examination survey, all types of abortion rate in one year among female aged 20 - 34 years was found to be 13.6 percent.  Furthermore, the fact that induced abortion in Thailand is illegal makes it difficult to accurately obtain information in this area.

Responses to the HIV/AIDS Problem

It was only over the last few decades that HIV/AIDS emerged and spread in Thailand.  However, substantial progress in the fight against HIV/AIDS has been made which sees the risky sexual behaviours changing significantly, with an increasing condom use and declining visits to commercial sex workers (CSWs).  The spread of HIV infection has slowed dramatically, but not before close to a million people being infected with the deadly virus.

The predominant means of HIV transmission has changed over time.  In 1984, the first case of AIDS was recorded as a homosexually transmitted infection. Three years later, the importance of male-to-male sex as a risk factor was quickly overshadowed by the rapid increase in infection among injecting drug users, followed by a parallel increase in sero-prevalence among female CSWs.  Subsequently, the third wave of infection appeared in clients of CSWs, reflected in an increase of sero-prevalence among men seeking services at the government STD clinics.  The fourth wave indicates a spread of the virus to the wives and girlfriends of men who visit CSWs, reflected through the increasing sero-positive rates among women attending ante-natal clinics.  As a result, the incidence of reported paediatric HIV/AIDS cases also increased and can be observed as evidence of the fifth wave of the epidemic.

Thailand's response to the epidemic is influenced, to a great extent, by the availability of information.  Modifications of health and social services to cope with the evolving epidemiological trends of the disease are vital to the success of HIV prevention.  Findings from the first round of HIV sentinel sero-surveillance in 1989 had alerted the  health and other related authorities, as well as the public, and HIV/AIDS control became instituted as the national policy by 1990.  In the same year, the first national behavioural study, the Survey of Partner Relations and Risk of HIV Infection, was conducted and demonstrated the pervasive extent of risk behaviours throughout Thai society. The results were so profound that the policy-makers decided to allow HIV/AIDS warning messages to be publicised through the print as well as broadcast media.  In 1991, the convincing messages were aired regularly and repeatedly on television as part of the national strategy to minimise transmission of HIV.

The HIV/AIDS health promotion has also evolved through a number of stages since the onset of the epidemic. The initial stage was characterised by programmes focussed on individual risks and responsibility through provision of information, awareness-raising, campaigns and sometimes, fear-induced messages. As the epidemic progressed, it was clear that the efforts to maintain the behavioural change were paramount, and health promotion messages needed to focus on sustaining safe behaviours. Greater understanding of the cultural and social dimensions of behaviour were crucial to developing more sophisticated responses aimed at facilitating community support for changed behaviours.  Four key models have been developed and used in HIV/AIDS health promotion programmes. They are: 1) the Information Giving Model; 2) the Self-Empowerment Model; and 3) the Community-Oriented/Social Transformation Model.

Prevention measures can work on a national scale with strong and sustained political and financial commitment from the government in a sustained manner. Effective responses require joint action of all sectors of society to provide multiple simultaneous intervention approaches to ensure effective HIV prevention and care. The subsequent active recruitment of the various sectors to participate in the national response allowed the country to move more quickly to a broad-based holistic response emphasising joint actions of multiple sectors to create enabling environments for risk reduction, socially vulnerable mitigation, as well as care and support. Some HIV/AIDS interventions in Thailand have demonstrated the country's sincerity and high level of understanding of an evolving strategy to control the HIV/AIDS epidemic.

100 Percent Condom Prevention Programme

Since the major spread of HIV in the beginning of the 1990s was through commercial sex, efforts were made to reduce risk from this setting through active promotion of condom use among CSWs and their clients.  The "100 Percent Condom Programme" which enlisted the cooperation of sex establishment owners and CSWs to make it difficult for a client to obtain sex without using condom, was made a national policy in 1991.  The information for the mass media on the HIV/AIDS situation in the country and instruction on condom use, then, were allowed to be widely disseminated to the public.

All 75 provinces of the country have adopted the policy of 100 Percent Condom Programme since 1992. The policy covered the support and distribution of condoms, encouragement of condom use among CSWs and their clients, provision of knowledge of STDs, AIDS and condom use, and related health services for CSWs. The programme has been implemented through the existing health service infrastructure nation-wide, which include well established STD clinics in all provinces for more than 30 years.  Since its adoption as the national policy, the 100 Percent Condom Programme has also enlisted collaboration from various parties concerned, i.e., provincial governors, police, and owners of sex establishment. Periodical dialogues among these parties have been mediated by the health officers to create positive perception and attitudes towards condom use.  This intervention has culminated in a good partnership in social support of condom use in commercial sex.

STD clinics have played a major role in providing examination, STD treatment, health education as well as condom distribution free of charge to CSWs.  Health workers have also extended their outreach services to the commercial sex setting in order to encourage both the CSWs and sex establishment owners to comply with the programme.  Lesson learnt from these activities have provided a valuable and firm foundation for empowerment of the CSWs, which would help reduce their vulnerability and contribute towards ameliorating their disadvantaged circumstances.

An evaluative study of the 100 Percent Condom Programme  conducted in 1997 has demonstrated the successful results.  General knowledge of HIV/AIDS was found to be fairly good among CSWs and also among the general Thai population, as a result of continuous dissemination of appropriate information/messages through the mass media and health officials. Not only was the knowledge of condom use high among the CSWs, but the level of their condom use was also high in their sexual encounters.  More than 90 percent of these women reported regular use of condom with customers.  The sources of condoms for the indirect CSWs were drug stores and health centres while the governmental STD clinics were the main source for those working in the brothels.  A trend of STD and HIV infection among CSWs has, at the time the study was conducted, levelled off.  The study also reflected a more supportive social environment as a result of the HIV/AIDS programme.  It found that a common practice of frequenting CSWs among Thai men in the present day is declining. Knowledge of condom use was almost universal for men and the experience of condom use with CSWs for men was also very high. However, the rate of condom use was getting lower as the relationship between sexual partners became closer.  The finding about the majority of men buying condoms from either drug store or grocery store shows an easy availability of condoms in the community.

It is crucial for the public and policy-makers to realise that the overall reductions in incidence of HIV infection does not mean that the epidemic is over.  The reduction in the infection through commercial sex transmission has created a more complex scenario, with

Multiple important modes of transmission via indirect commercial sex, injecting drug use, casual sex, and men having sex with
men.  A failure to sustain the reduction trend in the commercial sex sector or a failure to properly address these other modes of transmission could result in a resurgence of the epidemic.  The authorities must not be too complacent or ignore the fact that over ² percent of the Thai adult population is either infected with HIV or suffering from AIDS.  With such high prevalence, HIV/AIDS will rapidly resurface and spread via new avenues.

Integrating Activities into the FP/MCH Programme

It is fully recognised that the spread of HIV/AIDS in the adult population through the predominant mode of transmission of heterosexuality will have a strong implication on children.³  The extent to which the children will be affected by the AIDS epidemic will likely be determined by the spread of the disease among the adult population.  The Royal Thai Government has imposed the strong policy and programme measures to mitigate HIV vertical transmission and the AIDS impact to children.  According to this policy, three main strategies have been implemented through multiple sectors' participation.

Firstly, life skill modification among adolescents, both in and out of schools, has been strengthened and earnestly implemented by the committed policy-makers and related personnel in Ministry of Education and Ministry of Labour and Social Welfare.  Such services as pre-marital counselling and screening test for the  HIV virus have been provided through the Ministry of Public Health's (MOPH) service outlets throughout the country.  This strategy aims at preventing  HIV infection in adolescents, an effort which is considered to be highly cost-effective.

Secondly, FP clinics and ante-natal care clinics have been modified so that they can provide counselling and HIV testing services to all the pregnant women who are willing to be tested. The ante-natal care, counselling service and child birth/delivery for pregnant women with HIV have been gradually developed through a process of research and development for appropriate and standard care all over the country.  Anti-retroviral medication to prevent vertical/peri-natal transmission has recently been given much attention and eventual financial support from the government can be expected.

Lastly, the economic and social pressures can be expected to have an impact on AIDS orphans, particularly in an environment where there is a lack of community acceptance of individuals and families affected by AIDS.  While a governmental endeavour to develop the existing social welfare infrastructure to cope with these AIDS affected children has been underway, these welfare schemes cannot fully support and alleviate all of the monumental burden.  Consequently, the idea of civil society as a potential and most powerful structure to undertake social welfare support for this target group of children under difficult circumstances should not be discounted. The joint programmes between governmental organisations (GOs) and NGOs as well as groups of people with HIV and AIDS have become a strong instrument in supporting and cooperating with the community to alleviate the consequences from the AIDS impact.  Family planning and maternal and child health (MCH) care must take a leading role as the major entry point for continual HIV/AIDS care and support.  Women and their spouses/partners should be assisted to recognise and assess their status and risks from HIV/AIDS by deriving the benefit from these available services.  Further psychological and social support should also be planned and made readily available.  The affected people may be medically or socially referred to higher authorised specialists for more complicated care and support, as well as horizontally referred to community and family support so that they can continue to live a normal life.

Other Strategies

The basic implementation strategies to control the HIV/AIDS pandemic in Thailand are as follows:

Impact to Date and Future Plans

Even though, the country's HIV infection rate reflects a declining trend after a peak of 3.6 percent in male youth in 1993 and 2.4 percent in pregnant women in 1995, approximately 15,000 pregnant women are estimated to become infected with HIV each year.  From this estimate, about one-fifth of the infants born from these infected mothers would certainly become infected as a result of vertical transmission.  This means that although a large number of children will be spared from the HIV infection they will still be indirectly affected by AIDS through the death or disability of their parent(s) anyway.  A substantial number of children can be expected to be living in families in which one or both of their parents are affected by the HIV virus and an increasing number will have one or both of their parents die before they are capable of independent living.  After the year 2000, it is estimated that each year there would be an increase of more than 20,000 AIDS orphans under ten years old. Even if we can reduce the number of HIV infected infants in the next few years, the AIDS impact will continue to relentlessly affect a large number of children. The social and economic consequences of the impact of AIDS on children are wide ranging, both for the families of the affected children and for the communities. The future plan to cope with this situation, therefore, aims at strengthening the Thai community and the social infrastructure so that their resources and cultural cohesiveness can be fully tapped to alleviate the debilitating effect of AIDS.

Lessons Learnt on HIV/AIDS Prevention and Control

Over the years, the government as well as the NGOs have had their share of success and setbacks.  Some of the lessons learnt are as follows:

Reproductive Health Policy: Post-ICPD

Thailand's FP achievement was attained within a short span of about 25 years, during which time the country's FP programme put great emphasis on fulfilling the quantity targets.  However, in the current Eighth National Economic and Social Development Plan (1997 - 2001), the overall FP objectives have shifted to the quality oriented ones.  While, for the first time, no target of population growth rate was set, there was a specific goal mentioned of people as a centre of development for better quality of life and sustainability. These are in accordance with the ICPD's vision that RH be used as a tool for human development from womb to tomb.

What Is the Policy?

Thailand announced its RH policy on World Population Day, 11 July 1997, three years after the Cairo conference. The policy statement clearly assures that  "all Thai, both men and women, of all ages must have a good reproductive life".

How Was It Formulated?

Formulation of the RH policy is based on the scope of RH which deals with human life from before birth until death under the principle of equity and equality of male and female in all aspects. Besides this, its focus should mainly be on quality of services extended through all the components of RH and cover all groups of people without discrimination.  Before finalisation of the policy statement, RH had been under  review to ensure its compatibility with the Thai culture.  Furthermore, its scope and components were also established as guidelines to facilitate the management and implementation of the RH activities by the health administrators and personnel at the national and provincial levels.

Institutional Arrangement to Implement the Policy

After the 1994 ICPD, MOPH became the main agency charged with planning and implementation of the Cairo Plan of Action (POA).  The Department of Health (DOH), as responsible agency implementing the National Family Planning Programme was assigned to be the RH programme coordinator (see Chart 1 for DOH organisational structure).  Before the Cairo conference, the DOH took initiative to reorganise its health promotion infrastructure to shift its area-oriented approach to the holistic life cycle approach.  The overall health promotion services including RH are planned for all age groups of the target population.

Currently, all the RH components are the responsibility of several departments which include all existing services through all levels of the health care delivery system of the country on the primary health care (PHC) basis.  These departments separately make their own plans, budget, and targets.  However, for Thailand to achieve the goal of good reproductive life for all as stated in the national policy, the concept of RH per se, and related health care delivery system need to be further carefully reviewed so that all agencies involved in the RH activities/services will work towards achieving similar goals.  Perhaps the country's health delivery system will need to be reformed, as the next step to achieve the goal.

Experience to Date

Some of the RH components have yet to become the public health problems and some are not under the high priority list. For many RH components which have not received much attention earlier, programme development and research studies are being carried out for basic information or additional data.  Such components under the programme development stage include reproductive tract malignancy and adolescent health, post-reproductive age, infertility, abortion and sex education. Some other RH components which are now well established but still require attention to maintain their level of success are FP, Maternal and Child Health (MCH) and AIDS programmes.  These programmes are currently in their optimum situation, much better than in many neighbouring countries, geared to serve the needs of the people and are suitable for use and application in many situations or areas.

Family Planning

In the current national development plan, family planning (FP) projects the information, education and communication (IEC) concept of a happy family norm.  Each family is to decide on their own the number of children they are able raise with quality.  The FP activities will be strengthened where high fertility areas are prevalent.  Male participation will also be encouraged along with quality of care in FP, especially counselling for an informed choice to maintain or prolong continuation and enhance the quality and use of contraceptive method.  Standard care for pre-marital couples is also available to encourage couples to seek the service. This activity should be of relevance at this time of the AIDS pandemic. This pre-marital service is becoming more popular among young people, not only among the highly educated ones from the urban areas but also among the less educated couples in the rural communities.

Maternal and Child Health

There has been an attempt to come up with more accurate measurement of maternal mortality ratio for Thailand between 1995-1996 .  A study was done by using the RAMOS approach which found that the maternal mortality ratio (MMR) was 2.6 times higher than that estimated from the Safe Motherhood Project.  This study resulted in the revising of the maternal death certificate and registration.

AIDS in relation to maternal and child health (MCH) in Thailand has received much attention lately.  One of the major issues being investigated is the prevention of vertical transmission of HIV from mothers to newborn babies. In 1997,  the HIV infection rate in pregnant women screened voluntarily at ante-natal clinics throughout the kingdom was 1.6 percent or about 16,000 pregnant women. This pilot study showed clear benefit of AZT administered to pregnant women, a 50 percent reduction in transmission rate. The study has now been expanded for feasibility testing in other areas.

Reproductive Tract Infection

Owing to the impact of an intensive programme to prevent and control HIV/AIDS, prevalence rate of other STDs has been found to decrease markedly, more than 10 times, both in the government and private sectors.  But the highest incidence of STD infection can still be found in the age group 15 -24 years or adolescence.  Other reproductive tract infections (RTIs), besides STDs, seem to be a minor issue in Thailand where further studies to get more information are needed.

Post-reproductive Age

The programme activities to serve the needs of this group of people of both men and women started since 1995.  Menopausal clinics are established in the service unit at the secondary and tertiary care levels. Counseling for sexual problems and sex therapy are being developed intensively in some medical research institutes which pay considerable attention to this area.  Attempts are underway to physicians realise its importance.

Infertility

While the FP practices are very popular among most of the married couples, infertility should not be a neglected issue. Some attention should be paid to this issue even though the results from a recent study showed that the incidence of infertility in Thailand is comparable to the global figure.  Nowadays, infertility management in Thailand is far more advanced but it mainly serves only a limited group of well-to-do people at a tertiary care level or at private clinics due to its high costs and complicated procedure.  The DOH is now trying to expand the service down to the PHC level for wider and equal access to the service for all groups of people.  Moreover, an uncomplicated screening service for the infertile couples should be made available at the front line service outlets.

Abortion and Its Complications

Induced abortion in Thailand is illegal except under a few circumstances, i.e., in case of risk to mother's health, rape or incest.  The actual number of induced abortion performed is unknown but predicted to be on the rise, especially in big cities.  The adolescent group still constitutes the majority of cases.  Obtaining such data is challenging but they are needed for medical as well as legal purposes.

Sex Education

Unlike other developing countries where sex education is still considered a taboo subject, Thailand's cultural restrictions are somewhat of a lesser degree.  However, slow progress is being made in terms of education programmes. As a result of the MOPH pilot study on adolescent reproductive health counselling programme in the formal and non-formal education settings, it was realised that parents, teachers and other age related groups of people also need to learn about sex and sexuality along with young people.  Consequently, the DOH is now using a variety of approaches as well as media to serve the needs of each sub-group of the target population. The services provided are telephone hotlines, counselling networks and pre-marital counselling.  Sex education training packages for both teachers and parents are now being developed.  They are expected to be one of the key tools in solving many of the RH problems, that is, if they are to be implemented from the family up to the school levels.

Malignancy of Reproductive Tract

The most common causes of women's death from genital cancer are malignancy of the cervix, ovaries and breast cancer, respectively.  Even though the cancer control policy which includes primary, secondary and tertiary measures are not well established, an early cancer detection programme in MCH/FP services has been implemented as part of the quality of service programme since the National Family Planning Programme started.  There is much to be done to achieve success in this RH component which deserves a recognition of high priority among other chronic illnesses especially at a time when cancer causing substances abound.

Adolescent Reproductive Health

In 1985, Thailand started a pilot implementation programme to meet adolescent RH needs.  The programme was planned for implementation in phases from the beginning up until the present time. There have been various obstacles in the implementation of the programme nation-wide inspite of the availability of cumulative information on RH for all the adolescent groups of single and married status through the government health service delivery outlets, NGOs and secondary schools which participate in the family life education programme. At the present time, the concept and some activities of the programme have either been changed or adapted to suit the current situation.  In addition, the programme has recruited all other related sectors to participate in order to enable the sustenance of the programme and expand its coverage of all the emerging issues involved (see next section for further details).

Integrating Other RH Services in Primary Health Care

Health Service Delivery System

As earlier mentioned, all of the RH activities and services have either been long established or recently revived and given more attention (see Table 1).  However, they are being carried out separately under different jurisdiction and agencies.  There has never been any one place which offers a complete array of the RH services under the same roof, not to mention similar service hours.  Therefore, a model or models of integrated RH services should be designed and tested for further implementation as the new approach to RH services under the principle of PHC.

Pilot Projects

The following projects are the pilot models initiated by the MOPH and have been tested or are being tested around the country.

A Model of Integrated RH Care Package

Based on the concept of RH that aims to serve the needs of women on the basis of equality and equity, holistic approach and one stop service, the project entitled "A Model Programme for Integrated RH Services" was accordingly designed.  The project has been conducted in the Health Promotion Centres (HPC).  The goal of the project is to establish a model health facility that is "client-centred" and "women friendly", providing a primary reproductive care programme.  Specific services to be provided by the respective units will include FP counselling, contraceptive provision, RTI/STDs, cancer screening, infertility and menopause.  The project is still on-going.  It has been found that it is very hard to change the existing RH service system which provides separate services in different units and dates. Therefore, the project activities have to be adapted to suit different target areas of the country.

Table 1 RH Activities and Services

Models of Adolescent RH Programmes

Thailand's adolescent RH projects were designed in support of the recommendations of the ICPD which urged each country to promote and provide complete services of RH system which address appropriate adolescents' needs.  The MOPH has implemented two pilot projects Ñ the Health Development and Education for Muslim Adolescents Project and the Development Model to Improve the RH Services for Thai Adolescents Project.

The project for Muslim adolescents was created under the purview of Family Planning and Population Division (FPPD) in collaboration with an international NGO called Programme Appropriate Technology on Health (PATH). The objectives of the project are as follows: 1) To increase knowledge and awareness level regarding health risk of Muslim adolescents; 2) To strengthen capabilities of HPC12 and NGO for the clinic-based services, hotline telephone counselling and information dissemination; and 3) To generate support and  participation of families, schools and community leaders. The primary target groups are four Muslim religious schools in Yala and Pattani provinces.  Secondary targets groups are parents ,community leaders, GOs and NGOs in the areas. Strategies used in the projects are education, service delivery and advocacy. Education activities include training of peer educators, teacher workshop, IEC material production and youth health camp.  Service delivery activities consist of technical skill training and counselling for GOs and NGOs. Advocacy activities consist of parents workshop and consultative process with Muslim communities.

At the end of the project in December 1997, adolescents were found to have a statistically significant increased awareness level on health risk.  RH is a new concept for many teachers and NGO staff. There is a misunderstanding that RH involves only sexual health. It is important that school administrators, NGO staff and trainers should be well informed and prepared for their expanded role.  The Teen-line telephone service is more popular among adolescents than counselling clinics at the provincial hospital and at HPC.

The problem of drug addiction is a critical problem for Muslim communities in the South, and it has a direct effect on AIDS infection.  Thus the training programme concerning adolescent RH should be integrated so that the problem of drug addiction will be included.  Since RH, including FP and sexual health, is not an easy issue to introduce among this target group and their communities, the emphasis on drug abuse, quality of life improvement and MCH should be used as the points of entry.  Any IEC materials and training curriculum for Muslim adolescents should be carefully developed paying due respect to the religious context of Islam and their culture.  Religious leaders, including the Provincial Islamic Committee, play an important role in ensuring that the project activities will be implemented smoothly with little resistance.  Support from school administrators will determine the degree of success of the school-based activities and adolescent training.

The issue of male/female segregation does exist within the Muslim communities and schools.  This is a big challenge for  the NGO participating in the implementation of the project activities and service delivery.  Empowering girl students would be a difficult task to handle by NGOs alone.

The Development Model to Improve the RH Services for Thai Adolescents Project is conducted by the Family Planning and Population Division with financial support of WHO/SEARO and the government of Thailand. The project aims to provide counselling services for adolescents, to establish linkages among GOs and NGOs, and to provide life skill education to adolescents and teachers. Two districts in Nakorn-Sritamarat have been selected as study area. Two secondary schools and two private vocational schools in these two districts are participating. The project mainly involves adolescents, peers, teachers, parent and health staff in the study area. Now four counselling clinics called "Youth Friendly Clinic" set up at the Provincial Public Health Office (PPHO), Provincial Hospital (PH), District Hospital (DH), and Buddhist Association (local NGO). The clinics are set up based on the needs of adolescents. The clinics are providing face-to-face counselling and telephone counselling. Regarding life skill education, all teachers in these four schools were trained to integrate life skills into their existing lesson plans. Peers are trained to be aware of RH problems, to guide their friends, to refer adolescents at risk to counselling clinics, and to conduct RH activities in the schools. This project is expected to finish by October 2000.

Lessons Learnt in Institutionalising RH Programmes

To effectively implement the RH programme, certain guiding principles are required: accurate knowledge, broad understanding and realisation of the RH problems and concept.  Such accrual of information can then be conveyed to the administrative level of both the GOs and NGOs as well as the private sector.  This practice creates the partnership and commitment for launching the programme with success.

The RH programme should be planned by all the stakeholders and parties concerned, together with the current social contact, especially at the PHC level to serve the real needs of the target population groups.  Adolescent health and sex education seem to be the prominent issues critical in helping to solve or ease other RH problems.  IEC methods and materials as well as service channels, particularly for adolescents, should be evaluated for better accessibility and quality.  A well planned data collection should be organised in order to gain more accurate and meaningful information concerning RH.  Furthermore, periodical monitoring and evaluation programme must be undertaken to solve problems and improve the services offered under the programme.

For some other countries, comprehensive RH care may not need a full range of integrated services at the outset.  The magnitude of some of the RH issues is not too intense for an integration approach.  The existing problems may be solved or reduced in their degree of seriousness before progressing to the next step of programme implementation.  Resource mobilisation is one of the obstacles faced in implementing the programme.  Even though the integration may save time and money, the present economic hardship will overshadow the health problems, particularly those under the RH.  It takes a while before the full impact from this problem will be felt.

Chamratrithirong, A., Thongthai, V., Boon Chalaksi, W., Guest, P., Kanchanachitra, C., Varangrat, A. (1998).  "The Success of the 100 percent Condom Promotion Programme in Thailand. "  Nakornpathom: Institute for Population and Social Research, Mahidol University.

Department of Health, Ministry of Public Health (1997). Mother and Child Health  Report, 1997.

Department of Secondary School (1996).  Report of AIDS Prevention and Alleviation in School.

Fretichs, R., Ungchusak, K., Htoon, M., Detels, R. (1995).  "HIV Sentinel Surveillance in Thailand An Example for Developing Countries."  Asia - Pacific Journal of Public Health 1995, 8 (1):20-26.

Koetsawang, S., Ford, N. (1993).  "An Investigation into the Psycho -Social Factors Influencing Condom Use Among Female Sex Workers in Thailand", Report to EEC.  Project ATF 002/90.

Lyttleton, C. (1996).  "Messages of Distinction: the HIV/AIDS Media Campaign in Thailand."  Medical Anthropology. 1996, 16 : 363-389.

Malcolm, A., Dowsett, G. (1998).  "Prevention in Practice: Summation of Guiding Principles." Partners in Prevention: International Case Studies of Effective Health Promotion Practice in HIV/AIDS.  Joint United Nations Programme on HIV/AIDS (UNAIDS), 1998: 58-66.

National AIDS Committee (1997).  National Plan for the Alleviation of HIV/AIDS 1997-2001.  Bangkok: National AIDS Committee, 1997.

National Board of AIDS Prevention and Alleviation (1998).  Preventive Programme to Protect Thai Children from HIV/AIDS.

National Economic and Social Development Board (1994).  Projections for HIV/AIDS in  Thailand: 1987-2020.  Bangkok: NESDB, 1994.

Nelson, K., Celentano, D., Elumtrakol, S. et al. (1996).  "Changes in Sexual Behaviour and a Decline in HIV Infection Among Young Men in Thailand."  NEJM 1996, 335:297-303.

Over, M. (1998).  "The Effects of Societal Variable on Urban Rates of HIV Infection in Developing Countries: An Exploratory Analysis, Confronting AIDS: Evidence From Developing World", edited by Martha Ainsworth, Lieve Fransen amd Mead Over. Published by the European Commission and the World Bank,1998:39-51

Phoolcharoen, W. (1998).  "Experience from Thailand."  Partners in Prevention: International Case Studies of Effective Health Promotion Practice in HIV/AIDS, UNAIDS Best Practice Collection.  Joint United Nations Programme on HIV/AIDS (UNAIDS), 1998:36-48.

Phoolcharoen, W., Ungchusak, K., Sittitrai, W.,Brown, T. (1998).  "Thailand:Lessons from a Strong National Response to HIV/AIDS."  AIDS 1998,12 (Suppl B) : pp.S123-S135.

Porapakkham, Y., Pramarnpol, S., Athibhoddhi, S. (1992).  "The Evolution of HIV/AIDS Policy in Thailand: 1984-1994." AIDSCAP Policy Working Paper Series WP 5.  Bangkok:FHI Asia Regional Office,1996.

Sittitrai W., Phanuphak P., Barry J., Brown T. Thai (1992).  "Sexual Behaviour: A Report on the 1990 Survey of Partner Relations and Risk of HIV Infection in Thailand."  Thai Red Cross Society Programme on AIDS,Research Report, Nov.1992.

Thailand Health Research Institute (THRT), National Health Foundation (NHF) (1996).  Review of the Health Situation in Thailand: Priority Ranking of  Diseases.  Bangkok, 1996.

Thailand Health Research Institute (THRI) (1998).  Report of Health Exam Survey of Thailand in 1997.  Bangkok, 1998.

UNAIDS (1998).  "Relationships of HIV and STD declines in Thailand to Behavioural Change: A Synthesis of Existing Studies."  UNAIDS Best Practice Collection.  Jointed United Programme on HIV/AIDS, 1998.

Warakamin, S. (1998).  "Reproductive Health in Thailand: An Overview."  Nonthaburi: Family Planning and Population Division, Department of Health, 1998.

Warakamin, S., Permpaengpun, S. (1998).  Final Report: The Health Development and Education for Muslim Adolescents, Project THA/97/Poz.  Nonthaburi: Family Planning and Population Division, Department of  Health, 1998.

Warakamin, S., Poonkhum, Y. (1999)  Project On Development Model to Improve Reproductive Health Services for Thai Adolescents.  Nonthaburi:  Family  Planning and  Population Division,  Department of Health, 1999.  (Mimeographed