Survey shows inequalities in women, children’s health by socioeconomic status, location, ethnicity

The Fifth Wave of the Unicef Multiple Indicator Cluster Survey (MICS) on women and children’s health was administered by the Thai National Statistical Office (NSO) in 2015-2016, with the main report being published earlier this year. The survey illustrates how children and young people living in remote and rural areas, children from poor households, and children whose parents have low levels of education are falling behind in health, education, and overall development. The findings of the report therefore support retaining the universal health coverage embodied in the National Health Security Act and further developing of the Thai health service in a clearly structured, programmatic way.

MICS 5 collected data on health, together with the development and protection of children and women, in over 28,000 households across Thailand from November 2015 to March 2016, with cohorts from each of the four regions of Thailand as well as Bangkok, thus allowing for regional comparisons.

Officially, according to the Human Development Index, Thailand has a high level of human development, being ranked 87th in the world and a distant fourth in ASEAN, after Singapore (5th), Brunei (30th), and Malaysia (59th). As such, the survey highlights the country’s progress for children and women, especially in birth registration (99%), access to clean drinking water and sanitation (98%) and primary school attendance (95%).  

Yet, major disparities remain. In particular, 6.7% of Thai children under five years old are moderately or severely underweight. The survey found 10.5% of children younger than five years of age are moderately or severely stunted, meaning too short for their age. The rate is significantly higher among children whose mothers have had no education, at 16.6%. Male children, children living in the South, and children in the poorest homes are more likely to be malnourished.

Violence against children is a key issue. In the month before the survey, 75.2% of children aged 1–14 years experienced at least one form of psychological or physical punishment by a member of their household. 61.5% experienced psychological aggression, such as shouting, yelling or screaming at them and/or were called an offensive name. 55.9% experienced some type of physical punishment. Children in the North (80.8%) and Northeast (78.9%) are more likely to receive violent discipline, with violent parents more likely in poorer and poorly educated households. Unfortunately, research shows that even mild forms of physical discipline are harmful to children, causing low self-esteem, emotional distress and depression.

Another very serious issue is salt iodization, the lack of which is a major contributor to low IQ levels, with low salt iodization impacting IQ by up to 15 points. IQ can vary between ethnic communities in Thailand by as much as 10 IQ points. In Thailand, the lowest salt iodization is in the Northeast, where the Thai Lao ethnic community suffers from the second lowest IQ of the major Thai ethnic communities, after the Thai Malay, where low salt iodization, the language barrier, and the lack of integration may be affecting IQ test scores. This indicates a dire need for more effective salt iodization campaigns. This is essential as low salt iodization has become a political issue, with supporters of the former Prime Minister being stereotyped as having low IQs and needing iodine supplements.

Cartoon from Manager, September 21, 2012. Khanit na Nakorn, chairman of the Truth for Reconciliation Commission of Thailand: Have some grass with iodine, then I’ll show you something. [meaning the Red Shirt buffaloes need iodine to reduce Iodine Deficiency Disorder and increase their IQs in order to understand the report]

As regards literacy, the official level of Thai literacy is 94%, based on primary-level literacy, i.e., being able to read and write a short, simple statement about their everyday life. Access to books is crucial for child stimulation and development. However, only 41% of children under five years old live in households with at least three children’s books in the home. The rate drops to only 23% in the poorest households, compared with 73% in the richest households. The lowest number of books found in the home is in the Northeast, then in the North, reflecting very low scores for education in the Northeast in the Thai Lao and especially the Northern Khmer populations.

Also, crucially, the survey confirmed other research noting Thai fathers play almost no role in their children’s upraising, leaving the task almost exclusively to mothers. Only one in three fathers in Thailand had engaged in four or more activities that promoted learning and school readiness over the previous four days. The rate is even lower among fathers from poorest household (one in four) compared with the richest households (52%).

Unfortunately, Thailand’s failure to educate many mothers, especially those in the poorer ethnic communities such as the Tibeto-Burman and Hmong-Mien uplands minorities and the Thai Malay and Thai Lao, results in negative outcomes for children in terms of development, education, and health. For example, 24% of children whose mothers have no education are out of school, compared with just 0.4% of children whose mothers have higher education. The rate is actually highest among non-Thai children (34%).

Thailand still experiences very young women giving birth. Nationally, the birth rate for women aged 15-19 years is 51 births per 1,000 women. The North records the highest rate of 72 births per 1,000 women. The adolescent birth rate is much higher among girls from poor households, standing at 82 births per 1,000 women, and among girls with only primary education being 104 births per 1,000 women. The rate for girls from the richest households is only 12 births per 1,000 women, and for those from households with parents having higher education the rate is only three births per 1,000 women.

Urban migration for work, together with divorce, mean about one in five children up to 17 years of age, or approximately three million children, are living with neither parent although both are still alive. Instead, they may be living with grandparents, placing considerable strain on the grandparents, who may be less physically healthy and less literate than parents. The proportion is highest in the Northeast, meaning the Thai Lao and Northern Khmer, and among children from the poorest households, where one in three children are not living with parents.

“Children in rural areas and in poor families are facing the toughest journey growing up. It should not be this way. Every child deserves a fair chance in life. UNICEF is committed to working with partners to strengthen social services and social protection system that promotes equal opportunity for every child in Thailand.” Thomas Davin added.

The MICS report recommends the RTG invest in integrated early childhood development (ECD) services, together with civil society and the private sector, targeted at improving the first 1,000 days of each child’s life, focusing on nutrition, mental and physical stimulation, early learning, and protection from violence. Salt iodization appears to be a key issue, as does reducing violence against children. This means reviewing Section 1597 of the Civil and Commercial Code, which states a person with parental power has the right “to punish the child in a reasonable manner for disciplinary purposes”, and the use of corporal punishment must be prohibited by law in all settings, including child institutions and schools.

The RTG is seeking to apply technology to improve health at the village level: “We are also working with Ministry of Public Health on the e-health village project which will connect citizens with health service providers. This will help ensure that all citizens including children and women have equal opportunity to access quality healthcare,” stated Dr. Pichet Durongkaveroj, Minister of Digital Economy and Society.

The major disparities in health show that nutritional development is lowest in the South, which is surprising given the South’s historical support for the establishment party, the Democrats, with the Tai Rak Thai 30-baht health scheme clearly benefiting them most in this regard. In addition, the net intake rate in primary school is lowest in the South. Factors influencing child development, namely fathers’ support for learning, availability of learning materials and adequate care, together with lack of iodized salt, are all most serious in the Northeast. This suggests a relative failure as regards fostering child development in the region bordering on the criminally negligent, possibly due to the bureaucracy being dominated by Central Thais. However, the literacy rate for young women is actually lowest in the Central Region, then Bangkok, both traditionally Democrat strongholds.

It is clear that the general picture reveals much to do in alleviating regional and ethnic inequality. Thomas Davin, UNICEF Representative for Thailand, noted, “Thailand’s progress for children in recent decades has been truly impressive. At the same time, this survey confirms a significant difference in the well-being of children depending on where they live, their ethnicity, their household income and their mother’s education level. Inequality must be seriously addressed now. And we believe that Thailand can do this.” Unfortunately, under the current military authoritarian regime, which intimidates health rights campaigners, there is little transparency, no real policy imperative, and no accountability to ensure inequality is addressed and progress is made in women and children’s health.