The Constitution of the Kingdom of Thailand B.E.2560, Chapter 5, Duties of the State, Section 55 stipulates that the State must ensure that the people receive efficient public health services universally, ensure that the public has the basic knowledge in relation to health promotion and disease prevention, and shall promote and support the advancement of wisdom on Thai traditional medicine to maximize its benefits. The public health services under paragraph one shall cover health promotion, control and prevention of diseases, medical treatment, and rehabilitation. The State shall continuously improve the standard and quality of public health services.

The Ombudsman is aware of civil rights in public health and whether state agencies are able to efficiently provide public health services under their duties and mandates to citizens. In the meantime, there have been complaints filed with the Ombudsman concerning the need for pregnant women to take folic acid (vitamin B9) supplements to prevent birth defects in newborns in a daily dose of 0.4 milligrams before pregnancy, especially during the three months before getting pregnant and the first three months of pregnancy.

According to the World Health Organization (WHO), there are guidelines to reduce birth defects in all countries worldwide. Women of reproductive age or those preparing for pregnancy should take folic acid supplements of 400 micrograms daily before getting pregnant. However, the fact that Thailand had not yet produced folic acid tablets (vitamin B9) with a specific dosage in milligrams causes ineffective prevention of birth defects in newborns. The cost of folic acid tablets (vitamin B9) was also expensive, making the vitamin unaffordable for people with insufficient income. Therefore, the Government Pharmaceutical Organization (GPO) was requested to produce 0.4 milligram folic acid tablets for distribution to the public to prevent birth defects in newborns because the currently available folic acid (vitamin B9) supplements were 5 milligrams, which exceeds the body’s daily requirement.

The Ombudsman conducted a fact-finding and held meetings with related agencies. The facts obtained from the investigations show that if women of reproductive age take a daily folic acid tablet (vitamin B9) of 0.4 milligrams, it can prevent 50 percent of birth defects in newborns, including the prevalence of neural tube defects, congenital heart disease, limb deformities, urinary tract dysfunction, an rectal malformation, cleft lip and cleft palate, as well as Down syndrome.

Hence, the Ombudsman recommended that the Government Pharmaceutical Organization (GPO) produce 0.4 milligrams of folic acid (vitamin B9) supplements for people to conveniently acquire in general within May 2020. The Ombudsman also suggested that the Ministry of Public Health, Ministry of Education, Ministry of Interior, Ministry of Social Development and Human Security, Ministry of Labour, National Health Security Office, Thai Health Promotion Foundation, and Bangkok Metropolitan Administration promote and raise awareness among citizens, youths, students, university students, and the working-age population, especially women of reproductive age, about the benefits of folic acid (vitamin B9) supplements. This is to ensure that they understand the importance of taking folic acid (vitamin B 9) supplements to prevent birth defects in newborns and have access to these supplements.

Referring to the Ombudsman’s decision stated above and Section 48, paragraph one of the Constitution of the Kingdom of Thailand B.E.2560, which stipulates that the rights of mothers during the period prior to and after giving birth shall be protected and assisted, and the designated government agencies must provide people with public health services per Section 55 as mentioned previously; the Ombudsman decides to formulate a campaign to remove causes of problems, prevent birth defects, and reduce the number of handicapped people. This campaign will focus on mothers’ rights to take folic acid supplements during the period prior to and after giving birth, offering reproductive age women an opportunity to obtain enough folic acid supplements free of charge.

Later, the Ombudsman convened a meeting to discuss matters with related agencies, including the Provincial Public Health Offices, Provincial-level Agencies, and the Sub district Health Promoting Hospitals. The Ombudsman made site visits to the four regions, encompassing a total of eight provinces, namely Pathum Thani, Chiang Rai, Kamphaeng Phet, Phitsanulok, Sukhothai, Maha Sarakham, Songkhla, and Satun. The purpose of these visits was to gain insights into the challenges and obstacles faced by the agencies involved in providing public health services to women of reproductive age or mothers during the period prior to and after giving birth, particularly in relation to access to folic acid (vitamin B9) services.

The fact-finding showed that public health service agencies in most areas have been implementing the project “Vitamin Supplements for Healthy Thai Women”, which is the policy of the Department of Health under the Ministry of Public Health aimed at encouraging women between the ages of 20 and 34, who are planning to have children, to maintain good nutrition by taking iron and folic acid supplements once a week, in addition to receiving a balanced diet from all five food groups. This comprehensive approach not only helps in reducing the prevalence of anemia but also mitigates the risk of birth defects in newborns, thereby contributing to safe deliveries and the birth of healthy newborns.

However, the challenges and obstacles found included problems in the operation processes of related agencies, including the Ministry of Public Health, Ministry of Education, Ministry of Labour, Ministry of Social Development and Human Security, and Ministry of Interior. Although there was promotion of the rights to access folic acid among women of reproductive age at a certain level, the problems included irregular and incomplete operations affecting the access of folic acid supplements for the target group (women of reproductive age), a problem of data collection at some provincial public health offices that didn’t fully input the health data to the Health Data Center (HDC), a problem about policy enforcement, a budgetary problem that led to irregular and incomplete project operation, a legal problem about protecting mothers during the period prior to and after giving birth, a problem about insufficient population of staff in designated areas causing additional workload, a deficiency of staff counseling skills about pregnancy preparation and the importance and benefits of folic acid (vitamin B9), as well as a problem with communication and networking.

At the present time, social media are part of daily life, but there are still not various techniques to proactively access and educate the target group of reproductive age women in both formal and non-formal education segments as well as in the community. This prevents the group of reproductive age women from getting the folic acid (vitamin B 9) supplements. Additionally, the operation of the mother and child working group is a cohesive collaboration among agencies, which still needs the responsible activities coordinator.

According to the aforementioned problems, it is the duty of State agencies to provide effective public health services to the public, as well as to educate citizens about basic knowledge on health promotion and disease prevention programs, especially the target groups – women of reproductive age and mothers during the period prior to and after giving birth. They should be informed about the benefits of folic acid (vitamin B9) supplements, which can reduce the risk of birth defects in newborns, and be aware of the importance of healthcare, contributing to a good quality of life. Moreover, State agencies should provide women of reproductive age with access to folic acid (vitamin B9) supplements free of charge as part of the welfare state. Therefore, in accordance with the Constitution of the Kingdom of Thailand B. E. 2560, Chapter 5, Duties of the State – the Ombudsman, by virtue of the Constitution of the Kingdom of Thailand B.E.2560, Section 230(3), presented the fact-finding report that the practice of government agencies is not fully compliant with Chapter 5, Duties of the State and provides recommendations for the Council of Ministers’ consideration about mothers’ rights to take folic acid (vitamin B9) supplements during the period prior to and after giving birth as follows:

1. Recommend the government to advance the protection of birth defects into the national agenda – to carry forward the policy on unceasing actions of related agencies and to further improve the population’s quality of life – because the newborn statistics reveal that among 700,000 newborns annually in Thailand, there is an amount of over 20,000 birth defects, and the amount of this group is increasing every year.
2. Recommend the government to formulate the propulsion committee for a cohesive collaboration of agencies actions in accordance with the national agenda concerning the protection of birth defects at the national and provincial levels, which is the substantial mechanism in proficiently managing all schemes.
3. Recommend the government to formulate the law of the rights of mothers during the period prior to and after giving birth to protect mothers and pregnant women in accordance with the Constitution of the Kingdom of Thailand B.E.2560; and to assign related agencies to develop a guideline of mother and child rights that outlines all about privileges, which are in range of the agencies’ responsibility, for mothers during the period prior to and after giving birth to ensure convenience, swiftness, and easiness of action in accessing the welfare state and protection as well as assistance from the government.
4. Recommend the government to allot more funding for the Ministry of Public Health in providing health promotion and disease prevention programs in order to reduce long-term medical expenses and to constantly and proficiently establish vital policies about an improvement of population quality of life.
5. Recommend the State agencies, namely Ministry of Health, Ministry of Education, Ministry of Interior, Ministry of Social Development and Human Security, Ministry of Labour, National Health Security Office, Thai Health Promotion Foundation, the Government Pharmaceutical Organization (GPO), and Bangkok Metropolitan Administration to collaborate in campaigning and promoting through various channels of communication to the groups of reproductive age women, mothers during the period prior to and after giving birth – about the benefits of taking folic acid (vitamin B9) supplements to reduce newborns’ birth defects. According to the duty on campaign promotion involving with many agencies, Department of Health, Ministry of Public Health is then nominated as the core agency to work with related agencies in developing the master plan for promotion of birth defects protection and to formulate the promotion committee or subcommittee at the central and provincial levels to appropriately and proficiently access the target groups in each area.
6. Recommend the Ministry of Health and related agencies to urgently input the health data to the Health Data Center (HDC) for the purposes of quality, accuracy, completion, reliability, and timeliness which can be used to proficiently formulate the policies and strategies about health and health promotion to protect diseases at the particular area and national levels.
7. Recommend to educate the Village Health Volunteer (VHT) who work under the supervision of the Department of Health Service Support, Ministry of Public Health in the delivery of knowledge about birth defects protection to reproductive age women because VHTs are currently considered the critical part in providing community health services, particularly for gaining the trust from the group of reproductive age women.
8. Recommend all provinces to emphasize the importance of birth defects protection by establishing the propulsion committee to push forward agencies’ collaboration at the provincial level and to formulate the provincial agendas about policy deployment. The committee has the responsibility and authority concerning matters of birth defects protection to enhance the provincial agencies’ collaboration. Additionally, the committee responsible for campaigning and the committee in charge of monitoring and evaluating the project shall be established to ensure that the target group of reproductive age women is educated and able to access the folic acid supplements which can result in a reduction of birth defects.
9. Recommend that the Ministry of Public Health, as the core agency, collaborates with related agencies to select a pilot province as a prototype for implementing actions and activities to protect against birth defects, in accordance with the operational plan of the Ministry of Public Health’s 2nd national reproductive health development policy and strategy (2017 – 2026) for the promotion of quality birth and growth. Additionally, recommend the development of a handout as an operational model for public health staff and health professionals in every province.

Proceedings according to the Ombudsman’s decision:

1. The Prime Minister has instructed the Ministry of Public Health to consider and act upon the Ombudsman’s opinions and recommendations, and to prepare an issue for consideration and propose it to the Cabinet for further orders.
2. After the Government Pharmaceutical Organization produced 0.4 mg of folic acid (Folic F GPO) as recommended by the Ombudsman, public hospitals and the Thai Red Cross have contracted to purchase 0.4 mg of folic acid for public service, free of charge, and have made it available to the general public at all GPO pharmacies.
3. The Department of Health has organized a workshop on the development of prenatal preparation services by encouraging women of reproductive age to take iron and folic acid supplements, which can help reduce anemia and the risk of birth defects in newborns.