Collegian (2009) 16, 49 53 available at www.sciencedirect.com Leveraging the role of public health nursing in managing HIV/AIDS in Thailand: A journey of international collaboration Kathleen Potempa, DNSc, RN, FAAN a,, Kobkul Phancharoenworakul, PhD, RN b, Nancy Glass, PhD, RN c, Sanchai Chasombat, MD d, Billy J. Cody, PhD, MA e a School of Nursing, University of Michigan, 400 North Ingalls, Suite 1320, Ann Arbor, MI 48109-5482, USA b Faculty of Nursing, Mahidol University, Bangkok, Thailand c School of Nursing, Johns Hopkins University, Baltimore, MD, USA d Bureau of HIV, TB, STIs, Ministry of Public Health, Bangkok, Thailand e Portland, OR, USA Received 18 November 2008; accepted 9 February 2009 KEYWORDS HIV/AIDS; Public health nursing Summary Thailand is one of the first countries to have achieved significant advances in control over the HIV/AIDS epidemic occurring within its borders. Despite this impressive accomplishment, the disease continues to be a leading cause of death in Thailand and is migrating into Thai populations heretofore relatively free of it, such as married women. In 2003, a unique Thai, American, academic, and government collaboration formed to address the on-going challenges of HIV/AIDS in Thailand and its emerging characteristics. The objective of this collaboration was to increase the capacity of Thailand s public health infrastructure to address the challenges of HIV/AIDS by utilizing a larger and more empowered role for nurses within the country s existing health care system. This collaboration consisted of the Deans Consortium of Nursing Educational Institutions, the Thai Ministry of Public Health, the Faculty of Nursing at Mahidol University, and United States university nursing educators. This paper describes the process that brought this collaboration into being. It also describes the outcomes achieved by this collaboration; a collaboration that realized a national strategy to leverage and expand the role of public health nurses and the initiation of a nurse practitioners role in the prevention and treatment of HIV/AIDS. This collaboration and strategy increased the capacity of the health care system in Thailand to more effectively meet the challenges posed by all infectious diseases in Thailand and, in particular, HIV/AIDS. 2009 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved. Corresponding author. Tel.: +1 734 764 7185; fax: +1 734 764 7186. E-mail address: potempa@umich.edu (K. Potempa). 1322-7696/$ see front matter 2009 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved. doi:10.1016/j.colegn.2009.02.002
50 K. Potempa et al. Among the major causes of loss of life in Thailand, HIV/AIDS is either the number one or number two cause of death in both men and women between the ages of 15 and 44 years (ranking depends on the sex and age group that is being considered) and the second leading cause in men between the ages of 44 and 59 as well (Thailand Public Health Profile: 2005 2007, 2008). As such, Thai health care authorities remain deeply concerned about the on-going character of the disease in Thailand, as well as the dramatic increases of infection rates among populations that were not at high risk before (AIDS in Asia and the Pacific: Overview of the Epidemic in Asia, 2008). Women outside the commercial sex industry (especially wives and lovers), and injection drug users are the most prominent representatives of the populations into which HIV/AIDS is rapidly migrating, and manifest the new challenges of fighting HIV/AIDS in Thailand (AIDS in Asia and the Pacific: Overview of the Epidemic in Asia, 2008). In 2003, recognizing that an effective approach to this problem needed to be broad-based, the Thai Ministry of Public Health (MOPH) joined with other key stakeholders to form a collaboration with the objective to specifically address both the on-going and new challenges of HIV/AIDS in Thailand. This paper describes the development and outcomes of this collaboration of stakeholders and partners, later called the ALLIANCE. The formation of the ALLIANCE After an extensive analysis of the state of the HIV/AIDS epidemic in Thailand, and after having surveyed Thailand s public health workforce assets, the MOPH determined in 2003 that working with the nursing community, if sufficiently conceived and executed, could significantly support and enhance existing infrastructure designed to address HIV/AIDS comprehensively in Thailand. Capitalizing on existing conversations with Thai and U.S. faculty concerning how academic nursing might partner to help control the epidemic, the MOPH convened an informal summit to discuss how nursing could be more extensively and effectively utilized to address HIV/AIDS prevention, care and treatment. Invited to this summit were members of the Deans Consortium of Nursing Educational Institutions (CONSORTIUM), the nursing faculty of Mahidol University, and individual faculty from the United States (U.S. PART- NERS). The members of this informal summit concluded that a nurse-led, community-based primary prevention program linked with secondary prevention and treatment would produce the most effective, broad-based and immediate support for present and future strategies of the MOPH in its efforts to control and treat HIV/AIDS. The member organizations contributing to this summit formed a relationship that came to be known as the ALLIANCE. Its purpose was to execute these nurse-led strategies. Fig. 1 describes the ALLIANCE partners and the role each partner played in the collaboration. In the Thai public health system, nurses function at virtually all points of care and reach underserved urban and rural populations on a daily basis. It was the intent of the ALLIANCE to enhance and expand the role of Thai nurses at every point of contact in the public health system and thereby leverage an existing resource to have far greater impact on the epidemic. It was this capacity of nursing, both in numbers and in quality of preparation, that enabled this multidisciplinary ALLIANCE to leverage the enormous (and under-utilized) resource of nursing to achieve a major national strategy to control HIV/AIDS. The process that brought about this new care model also came to represent an example of achieving multidisciplinary success on a national level and within an international context. The collaboration The next step in the evolution of the ALLIANCE was to further develop the conceptual framework for the model of care that was broadly outlined at the initial summit. A major aspect that characterized this collaboration was the ability of the partners to fully bring the relative strengths of their respective group to the project. In addition to granting the imprimatur of the government, the MOPH provided the administrative and logistical resources needed for the parties to meet and much of the data upon which its analysis was based. The CONSORTIUM members provided a disproportionately large part of the required intellectual capital and physical effort, most of which was directed at identifying the detailed elements of the strategy. As in the utilization of community partnership models among which is that of nurse practitioners applying such an approach to urban and Hispanic settings (Courtney, Ballard, Fauver, Gariota, & Holland, 1966), the U.S. PARTNERS participated in the group s meetings at every important stage, though their role was relatively passive by intent. Early on, the U.S. PARTNERS understood that their role was to support the Thai side in whatever it determined should be the focus of the project. This was based on the philosophy of self-determination and was an important element of the collaboration. Once the Thai side decided how the group should proceed, the US PARTNERS supported these efforts in whatever manner appropriate in accordance with their expertise and experience. Furthermore, the U.S. PARTNERS stood ready to partner with ALLIANCE members to seek funding outside of Thailand. In the relatively short time of 6 weeks, in the absence of the US PARTNERS, the Thais brought their many disparate parties together and drafted a finished concept paper. 1 In a matter of a few weeks thereafter, the U.S. PARTNERS suggested an approach to implement the concepts entailed in the draft paper, and this came to be finalized by the ALLIANCE as a finished document to submit for funding. 2 1 Dr. Praneed Songwathana of Prince of Songla University, in collaboration with her Thai colleagues, wrote the Thai draft. Dr. Supinda Ruangjiratain of Mahidol University carried out the all important organizational functions in collaboration with Dr. Cheewanan Lertpiriyasuwat of the MOPH. 2 Dr. Nancy Glass, while a faculty member at Oregon Health and Science University, determined that utilization of RARE methodology would most effectively meet the aspirations of the Thai side as expressed in its draft concept paper, and with Dr. Potempa, spearheaded the team that wrote the final concept paper.
Leveraging the role of public health nursing in managing HIV/AIDS in Thailand: A journey of international collaboration 51 Figure 1 The contributions of each ALLIANCE partner to the collaboration. The new model of care Fig. 2 describes the elements of this new model of care. The focus of the model is to provide a systematic methodology for nurses to lead health care and community-based teams in a countrywide application of the model. The strategy under- Figure 2 Public Health Nursing Levels in Thailand (This is a representation of the levels of the public health system in Thailand and is not intended as an exact schematic (for a current schematic, see Ministry of Public Health Thailand Health Profile: 2005 2007, 2008, p. 366). The public health system is governed by both the Ministry of Public Health and the Ministry of the Interior. Primary health nurses function at all levels. Nurse practitioners are introduced at MOPH hospitals and districts, sub-districts and Tambon-level community clinics.) lying this model is known as Rapid Assessment Response and Evaluation (RARE) (Manderson & Aaby, 1992; Trotter, Needle, Goosby, Bates, & Singer, 2001). It utilizes multiple informants to rapidly assess and address changing public health needs in a culturally relevant context (Manderson & Aaby, 1992; Trotter et al., 2001). RARE programs have been widely used in public health to provide timely and accurate data for addressing health problems and can reveal the evolving dynamics at the local level in epidemics such as HIV (Manderson & Aaby, 1992; Trotter et al., 2001). Additionally, the model includes local outreach that utilizes Thailand s existing community-based public health system. Within this system, the model employs public health nurses to actualize RARE methodology to provide for continuous assessment of the HIV/AIDS epidemic at the village level, and to oversee community-based interventions there. At the time the ALLIANCE model was being developed, the MOPH was also introducing the use of nurse practitioners at local and regional levels of the public health system. It had already concluded that nurse practitioners would provide communities with the ability to make individual health assessments, provide for medical treatment monitoring, and emphasize long-term treatment and follow up. Linking the findings from RARE to the care provided by nurse practitioners was envisioned as a way to improve health outcomes of communities, especially as they related to HIV prevention, care and treatment. The group also believed the nurse-led RARE methodology would increase the capacity of the MOPH to better manage other health crises as well, and it resolved that it would make RARE a part of the national nursing curriculum and made provisions explicitly for this. Public health nurses The ALLIANCE came to the community-based, nurse-led strategy because nurses play a critical role in the Thai health care system. Professional nurses (34.7%) and technical nurses (13.7%) constitute the largest group of public healthcare personnel in Thailand and together make up
52 K. Potempa et al. 57.8% of all the people working in the field (2001 2004 Thailand Public Health Profile, 2005). In 2003, the MOPH employed 59,983 professional nurses as well as 23,755 technical nurses (2001 2004 Thailand Public Health Profile, 2005). With the addition of the nurses working in the private sector, the ratio of nurses to the population was 1:800 (Srisuphan et al., 1998). Besides the sheer number of nurses available in Thailand, the level of professional nurses is impressive and provided another level of resources to the ALLIANCE. The number of professional nurses relative to technical nurses as a percentage of practicing nurses is expanding and improving (Thailand Public Health Profile: 2005 2007, 2008). This may be due to the fact that Thailand was one of the first countries in the world to require a 4-year baccalaureate education for nurse licensing. Nurse practitioners What is more, at this time the MOPH was just beginning to implement its new policy of deploying nurse practitioners to its lowest administrative units (the sub-district termed the Tambon a village of 10,000 people). It envisioned that advanced practice nurses with enhanced education, assessment, and clinical skills would partner with public health nurses to augment primary treatment and care at that level. This includes the treatment of HIV/AIDS cases within the context of managing chronic care needs in general. As such, before the adoption of the role envisioned by the Alliance for nurse practitioners in Thailand, an invaluable role for them was already being explored and an educational model developed for this through the auspices of the Thai Nursing Council. The work of the ALLIANCE provided another community-based focused application for nurse practitioner interventions. The implementation Building intent Employing an enhanced role for nurse practitioners and incorporating RARE-type curriculum into nursing education as envisioned required substantial change in the Thai education and public health care systems. The government estimated that 10,000 nurse practitioners were needed to support its vision of a far more comprehensive general health care system. Thus, it was imperative that these two goals of infrastructure implementation and nursing education development proceed simultaneously. And, because nurse practitioner was a new role for nurses in the Thai public health system, the assistance of the U.S. PARTNERS with their greater experience and knowledge of this kind of nursing education played an important and necessary consultative role for the ALLIANCE. This was especially true in the development of both the curriculum and the advanced practice roles. The U.S. PARTNERS brought specific expertise in RARE methodology as well. Fig. 2 describes the role that each group played in the implementation of various steps needed to achieve these goals that the Alliance established. Initial funding and long-term sustainability The ALLIANCE, having overcome its institutional and cultural challenges and articulated its desired goals and objectives, now faced the critical issue of financing because the work it envisioned could no longer be sustained by the kind of individual institutional support that had brought it to this point. The U.S. PARTNERS from this stage forward led the efforts of the ALLIANCE to secure the financial resources necessary to implement the project. Crisis and opportunity While approaching funding sources likely to have an interest in supporting the initiative described in the ALLIANCE s final concept paper, the terrible tidal wave of December 2004 struck South East Asia and the Indian Subcontinent. Learning that a private individual was committed to financially helping Thailand cope with this disaster, the U.S. PARTNERS approached him with the idea that he could best help Thailand by funding the project of the ALLIANCE. By doing so, he could provide Thailand s nurses with tools that would not only care for victims of the tidal wave but would also contribute to providing enhanced health care to Thais on a long-term sustainable basis. Both this immediate need and long-term objective could be addressed by the ALLIANCE s project of strengthening the capacity of the public health system to address the daunting medical crisis of the existing natural disaster, while also addressing the long-term needs of the ongoing health tragedy of HIV/AIDS. Aligning of visions To help the potential donor understand how the project aligned with his humanitarian objectives, its costeffectiveness and sustainability, and in order that he could meet first-hand those who would put his resources to work, the U.S. PARTNERS arranged for his family and him to accompany the U.S. team to Thailand to witness the devastating effects of the tsunami and then to an international conference in Vietnam where the ALLIANCE presented its project. During this time, the MOPH played a critical role in pressing the case for the project when it provided a team and transportation for this family and guided them to visit the disaster affected areas of Southern Thailand. Leadership at Mahidol University and the ALLIANCE joined the U.S. PARTNERS and the family when they went to Vietnam. Having this leadership present enabled the prospective donor and his family to understand the ALLIANCE s commitment (and the commitment of university nursing in Thailand in its totality) to the project. After 2 weeks of traveling together, sharing the hopes and aspirations of those making up the ALLIANCE (witnessing the individual, institutional, and financial investments already made by its members), and visiting the places where they worked, this family funded the project and made it a reality. That they did so required vision on the part of the all parties to the ALLIANCE. Each partner in the effort took professional risk and expended precious financial resources when it agreed to participate in the effort to enable the
Leveraging the role of public health nursing in managing HIV/AIDS in Thailand: A journey of international collaboration 53 donor and his family to envision how they could manifest a reality that was worthy of their generosity. Conclusions Five years later, the HIV/AIDS project discussed here has completed its mission. The important steps in manifesting its objectives have been implemented. RARE methodology has been embedded in the national nursing curriculum of Thailand and train the trainer workshop-educated teams have taken it to all regions of the country. This in turn has led many individuals involved in the project to undertake new science and research projects that they never contemplated when the project launched. The education of nurse practitioners is expanding through newly developed education programs at the universities, and the Thai Nursing Council has set standards for the education and practice of nurse practitioners as well. This successful outcome demonstrates that both individual and group actions can advance public health objectives of a nation. Essential components of this initiative were the commitment of individual leaders and group members to the project s goals, their willingness to think creatively, and the ability of key players to build positive inter-group relationships around the work at hand. Perhaps the most important core attribute manifested by the members of the Alliance was their ability to trust the motives, knowledge, and skill of colleagues with quite different perspectives and experience. They had to be open to how different cultural perspectives, as well as different institutional norms and processes, can be optimized for positive results rather than to have these constitute barriers to progress. The HIV/AIDS project that the ALLIANCE of the Deans Consortium of Thailand, the Ministry of Public Health in Thailand, and the U.S. PARTNERS, abetted by the generosity of a single individual, has brought lasting benefit to Thailand. It has inspired the members of the ALLIANCE to think of new applications for its work through bonds that now transcend inter-professional, university, ministry, national and international boundaries. References 2001 2004 Thailand Public Health Profile. (2005). Bangkok: Ministry of Public Health. pp. 355 380. AIDS in Asia and the Pacific: Overview of the Epidemic in Asia. (2008). http://www.amfar.org/cgi-bin/iowa/programs/ globali/record.html?record=23 Accessed 15.10.08. Courtney, R., Ballard, E., Fauver, S., Gariota, M., & Holland, L. (1966). The Partnership model: Working with individuals, families, and communities toward a new vision of health. Public Health Nursing, 13(3), 177 186. Manderson, L., & Aaby, P. (1992). An epidemic in the field? Rapid assessment procedures and health research. Social Science and Medicine, 35, 839 850. Srisuphan, W., Senaratana, W., Kunaviktikul, W., Tonmukayakul, O., Charoenyuth, C., & Sirkianokwilai, N. (1998). Supply and requirement projection of professional nurses in Thailand over the next two decades: 1995 2015. Human Resources for Health Development Journal, 2. Available from http://www.moph.go.th/ops/hrdj/. Thailand Public Health Profile: 2005 2007. (2008). Ministry of Public Health. p. 168. Trotter, R. T., II, Needle, R. H., Goosby, E., Bates, C., & Singer, M. (2001). A methodological model for rapid assessment, response and evaluation: The RARE program in public health. Field Methods, 13(2), 137 159.