Friday 18 November 2011

Projects in Thailand Part 2 – Fighting Negligence and Poverty

After a hiatus of a few countries, Thailand once again had an Ashoka presence. With about 80 Fellows elected since 1989, they had enough active ones facing ongoing challenges to keep me occupied. I was connected with a few of their Fellows who needed help moving their organisations forward. One of these was addressing medical negligence and the other two were involved with addressing poverty amongst rice farmers.

I also had the opportunity to attend a couple of farming and community conferences in the North, run a student workshop at a private university, and engage with a project rescuing and rehabilitating street Elephants.

I started in Bangkok with the Thai Medical Error Network.

Fighting Medical Negligence

The Thai Medical Error Network (TMEN) is an informal network of volunteer patients, families, doctors and lawyers across Thailand fighting for the rights of those who have been victims of medical negligence.

Thailand has a very high rate of medical negligence. Between 25,000 and 50,000 patients a year fall victim to serious negligence. Serious repercussions extend from disfigurement to mental and physical disability and death. The long-term impact isn’t just limited to the individual, but to their families too, significantly increasing the scale of people living with the consequences.

Some of the many unsolved incidences of negligence in Thailand. [Picture Courtesy TMEN]

The majority of victims fall into the low-income and low literate demographic, whose status means they cannot command the same quality of attention as the rich.

The reasons for the high incidence of negligence appear to split into four primary categories

  1. Cultural – A bias towards treating Doctors like kings, and a reluctance to challenge treatment decisions based on fear of negative repercussions and further drop in quality of care.  
  2. Personal – Lack of knowledge and awareness of rights, especially among the low income and low literate demographic. Also lack of collective voice and empowerment. 
  3. Regulatory – No legislation or policy supporting the rights of patients or their freedom of access to information about their treatment.
  4. Systemic – The Medical system protects its own, with strong unions and backup legal support for doctors. Combined with a complete lack of state support systems for patients, the result is that the individual on the receiving end has nowhere to turn.

Characteristics of Medical Negligence in Thailand- 

The overall result is a severe power imbalance in favour of Doctors, and TMEN has been working to change that. When I met them, they were already on the brink of policy change after many years of collective lobbying. The new policy would introduce the safeguarding of patient rights, and enforce medical accountability as well as a state reparation fund for the victims of negligence.

However, getting policy changed is not the same as seeing a difference on the ground. All over the world, there are laws stating rights, but no actual enforcement. This means that the job of a social entity driving change does not end at policy change. Someone has to support and drive the implementation of said change into actual practice.

From Network To Non-Profit

For TMEN to do this on any scale meant needing to raise funds to formalise services, manage the network, disseminate knowledge about rights, create a hub for collection of patient stories and so on. To qualify for funds, needed non-profit status; and to qualify for that required the creation of a formal entity.

Therefore the challenge lay in how to transition a successful non-hierarchical network of volunteers into an organisation with some paid members, without creating the usual pyramid structure or compromising the nature of the open selfless network.

So that’s where I came in. I first met with the main group who managed the network, and together we worked through the whole concept of how to address the challenge, both practically and in terms of organisational design.

They were also keen to understand how to use the web and social media to build audiences and global support, so we had a workshop to demystify and understand how to go about it. What’s super impressive is that today they have a great site up and running using blogger -

Workshop in Bangkok with the TMEN Team

Then later I worked more closely with the Founder, Preeyanan Lorsermvatta; a fabulous example of selfless drive, perseverance and never-give-up. Preeyanan has been fighting for justice for her son for 19 years. That fight continues, but along the way she has helped thousands others find not just their voice, but reparative justice.

To get to a sensible solution to the problem at hand, we aimed to go through a 5 step process, but really only got as far as step 3 because Preeyanan had other more immediate priorities with driving the impending legislative change.

  1. Review Problem Definition, Vision, Mission and Strategies
  2. Lay out a development plan
  3. Design org structure and operating principles
  4. Identify resourcing infrastructure and capital needed
  5. Define transition plan and next steps

Here’s some take-aways for those of you who are dealing with the same problem elsewhere…

Strategy and Design for Addressing Medical Negligence 

Critical Factors Driving Medical Negligence

Regardless of which country you’re in, addressing the issue of doctor negligence requires addressing the following 8 factors:

Systemic & Institutional Change

  1. Problem Recognition at a Social and Systemic Level
  2. Regulatory Policy
  3. Medical Practices
  4. Accountability
  5. Reparation

Patient Empowerment

  1. Collective Voice and Awareness of Process, Rights and Common Issues
  2. Informal Patient for Patient Support Systems
  3. Formal Support Systems (Help-lines, Legal Support, Health Insurance…)

(See the above sketch for a breakdown of how to tackle these)

Trying to create one massive organisation, with branches everywhere never really works. Bureaucracy is a killer. A much better model is a hub and spoke network (also sketched out in the graphic above).

Designing Different

Finally to the most important challenge. Organisational structure. I’ll cover this again a number of times in future posts. It is one of the biggest challenges facing social entities, because having a workable solution is only one part of the equation. Building and designing an organisation that is able to deliver it effectively is the other.

The norm is to copy the commercial pyramidal hierarchy. Here the maximum control and financial value accrues to the ones at the top, ostensibly creating an aspirational ladder of compliance and motivation. From my experience of consulting to some of the world’s biggest companies, I can assure that mostly it just creates bottle-necks and inefficiency.

There are better ways to approach it when the primary motivating driver for participants is not money.

In this case, to prevent losing the networked culture of operating, we had to avoid a structure that created one primary owner / decision maker, and stayed true to the open network culture.

The alternative was to look at a group decision making structure, based on Agile operating principles. This non-hierarchical group would be comprised of representatives from each strategic vertical. Since the majority of those involved in the network were victims of negligence, the issue of patient representation was inherently addressed.

TMEN Org Structure

The redesign was loosely based on a model of organisation design that is better suited to ensuring that those at the coalface of helping people make the decisions. The backend functions here provide support and help make things happen, rather then other way round.

Org Design Model

I’ll cover more on the underlying model behind this in later posts.

Eradicating Farmer Poverty

Rural Capital Partners is a 20 year old organisation investing in and financing community programmes in Thailand. They’d been working with Organic Rice Farming on a significant scale (6000 tons a year) and were up for an Ashoka Fellowship, so they wanted some help with preparing for their application.

I often get requests to help put proposals together, and I usually ignore the actual proposal writing itself and help the organisation work on the robustness of their solution and operation instead. Anyone can write fancy words and spin out a semantic reality. It’s more powerful when the actuality speaks for itself.

We looked at their mission, strategies and design principles, which led us to review the problem at hand, and consider whether their existing approach would solve it.

Workshop with Pansa Tajaroensuk, Managing Director, Rural Capital Partners. Farmer Poverty Problem Definition

The typical approach to helping impoverished farmers is to train them to improve their yield, while also training them on better savings practices.

  1. There are about 35 million farmers in Thailand, 40% of 15 million of which are below the poverty line. 3 million of these are rice farmers; which straight away indicates the scale of the problem facing any entity trying to eradicate poverty in this sector. 
  2. The second problem is this. The average rice farmer in poverty in Thailand earns about 25,000 baht (about $800) per year, but is typically in debt to the tune of anywhere between 100,000 and 500,000 baht. These loans are typically from loan sharks with crazy interest rates that make them virtually unresolvable for the farmer. Therefore solutions that focus on simply increasing income by a few percentage every year via improving yield, may ameliorate immediate pressures but are never going to solve the long-term poverty cycle.
  3. The third problem is that cash is not wealth, and simply increasing cash flow to an individual or family does not in any way transform them out of poverty. Wealth is defined by the ownership of assets that hold value; ideally increasing value. So in order to ensure a lasting transition out of poverty, social entities have to consider strategies that create wealth for the people and communities they work with.

Any solution aiming to eradicate farmer poverty in Thailand, would thus have to extend beyond increasing income and improving savings practices, to debt management and eventually wealth creation systems.


Dealing with Debt

One way to address this kind of debt is to buy it over for the farmer, and then reduce the interest rate down to a manageable level. Ideally just at the point needed to cover the operational costs of providing the service. Think mortgage type repayment terms, except geared towards the benefit of the farmer rather than profit.

The next step would be to formalise savings practices and an investment or banking vehicle to return value on those savings; part of which go towards debt reduction and part of which go towards assets owned by the farmer.

If looked at on a 10 to 20 year timeframe, these kinds of debt and wealth management systems could be super scalable, as proven by micro-finance. This approach could also provide an infrastructure that could be used by other farming and rural development entities; thus establishing a potential to tackle the problem on its actual scale.

Since both these projects were conducted using a translator, it’s been difficult to keep up with progress. This means I’m not sure how much of it was practically implemented in the end, but the concept remains worth considering.

Monday 14 November 2011

Projects in Thailand Part 1 – Start-ups, Investment, Electricity, Micro-Enterprise and Anti-Prostitution

The main reason for visiting Thailand, as ever, was to get beneath its tourist veneer and engage with its social and human challenges. Over the month I was there, I worked with projects involved in Medicare, Farming, Social Investment, Community Development, and randomly even Elephant Rescue.

Starting out in Bangkok at my friend Dev’s took me back to some of the work he had been involved with as part of YSEI (Youth Social Enterprise Initiative). Dev co-wrote a guide for young social entrepreneurs called Start-up and Change the World, which I thoroughly recommend reading.

Start-up and Change the World


Dev had been working with a Swiss Bank branching out into social investment, and it gave me a chance to explore the illusion that is ‘social’ investment with an insider. Sadly what I learnt did nothing to dispel my concerns around social investment, and the fact that Dev had quit out of disillusionment about sums it up.

Social Investing

Social Investment is the big hype of the moment. The apparent answer to all our scaling prayers. It is however only an option for social businesses, and not a viable funding strategy for general development work (see my Social Effect post on Financing Social Enterprises).

The investor is not looking first to fund programs that will transform lives and then generate returns, but to fund ones that first and foremost will provide the return on investment they or their clients need.

They are usually looking to fund new technologies, utilities, energy, products, enterprises and saleable services. The typical IRR is still 30% and for many investors this is just another opportunity to make money, gain competitive advantage in an increasingly socially aware market, and look good at the same time.

Aside from the few that are really trying to do something positive, I’ve already been pulled into extricating a series of social organisations from investors doing everything from under-the-radar land grabs, to fraud and brute exploitation in the sharing of profits. As a field it’s all still too new and exciting for much of the negative aspects to surface, but be sure that it will in the next few years.

Example: Rural Electricity from Rice Husks & Social Investment

Coincidentally, while in Bangkok I was asked to mediate between a ‘Social Investor’ and one of the farming non-profits I was working with. I’ll skip specifics in the name of professionalism. The investor was connected to one of their funders, and they felt that it might be beneficial all round if the relationship could be made to work. The two parties had been discussing things for about a year, but hadn’t come to any agreement.

The community organisation had been looking into small scale energy production from rice husks to ensure zero waste operation, and additional income to farmers. The investor however was interested in financing bigger 1-3megawatt size rural electricity infrastructures and the community organisation was being encouraged to sign up on the promise of exciting new financial opportunities.

Example: Husk Power System, India

The trouble is that no-one had asked the critical questions to understand the investor’s real motivation. After a little probing I realised they simply needed a local community partner entity to minimise their risks

  1. To smooth out getting all the planning, build and running permissions at a local level, which is otherwise a major risk in getting up and running.
  2. To ensure a steady and fixed price supply of rice husks for energy production. Previous experience had shown that farmers would agree on a price before start-up and then increase it once the infrastructure was up and running. These had major risk implications for profits and continued operation.

Further pushing revealed 3 major issues in the potential partnership

  1. The non-profit was not being made aware that they were essentially just required to minimise profit risk, rather than being seen as an equal partner in a human development endeavour.
  2. The investor had no actual intention of sharing any of their pro-formas or financial templates; so profits, costs and timelines were completely hidden from the non-profit.
  3. It also transpired that the investor wasn’t looking to commit to any set share of profits or co-ownership, but was only offering additional income for farmers through payment for rice husks, which might otherwise just go to waste. When pushed there was a lot of mention of potential ‘millions’ in the future, some of which might go to the community, but of course only after ‘breaking even’ in 7 or 10 years. It was all too cagey to be worth trusting.

The long and short of it was that the community organisation and its key resources would end up spending unknown hours of their time over months or years smoothing out administration and logistics and running of the plant, for the promise of an unknown, if any, financial return; while the investor stood to make huge amounts of money over a 5 to 20 year timeframe.

It was a no-brainer to advise the community entity against taking up the offer or wasting any more time on the matter.

Having gone through this process a few more times since then, when it comes to social investment, my usual advice is that if the organisation isn’t simply an alternative business, and doesn’t have legal, contractual and financial expertise equivalent to that of the investing entity, the power imbalance is too steep. However good it looks on the surface, the investor holds all the cards. Best avoid.

Microfinance and ‘Entrepreneurs’

While in Bangkok I was connected with a project called Step Ahead providing microfinance to women ‘entrepreneurs’. The CEO was out of town, so I didn’t really engage with them beyond the surface.

However it got me thinking. This concept of calling any recipient of micro-credit an entrepreneur is an interesting development in the social sector. ‘Entrepreneur’ is just a fancy word with implications beyond the reality. Street sellers are no longer just people trying to make a little money to get by as vendors or hawkers or stall owners, but are portrayed as vibrant exciting new Richard Bransons in the making.

It makes the financing entity look good, but the shame is that it obscures the human, the endeavour, and the struggle that continues regardless of the small amounts of over-priced credit being provided.

Below are some of the bright cheerful Thai women who have been taking out microfinance loans for years, but are still grinding it out. We should be able to do better for them.

Thai street vendors Thai street vendors

Thai street vendors Thai street vendors

Tackling Prostitution and The Importance of Listening

Through Step Ahead I met some American girls who were voluntarily working with male prostitutes in the city.

When looked at brutally, selling your body for sex is much the same as selling your body for any other kind of unpleasant physical labour. The key difference is the physical and mental risk to the individual, that makes it worth tackling and eradicating.

Physically the risk extends from STDs and the potential death sentence of AIDS, to extreme violence, all the way through to human trafficking and slavery. Mentally the risks lie in the social exclusion, damage to self-esteem confidence and hopefulness, and the emotional challenges that come with trauma, especially in the cases of forced prostitution.

Thai people are generally pretty tolerant of the sex industry and there aren’t the same stigmas attached to it as in the West. This extends even to male prostitution which is fairly common with the amount of sex tourism that goes on. In Thailand then, prostitution is often a choice, and on an individual level rather than consortia or agent controlled. This means that the individual does have the option to make a different choice, but financial circumstances counter the perceived personal risk.

The girls were aiming to start a non-profit providing alternative work options. In this case hospitality training (cleaning and making rooms or waitering in hotels), because they’d seen that the training was available and funders were offering money to pay for it. The trouble was they just couldn’t get buy in or take up from the men they were trying to help.

After some discussion it transpired that given a choice, all the men wanted to do was set up and run their own small street stalls, mostly as food vendors. Cleaning rooms or running after hotel clients was not their idea of an improvement.

This raises a really important point in the design of social programmes. The intervening agent often works from their own point of view, assumes they know what’s best, and doesn’t actually listen properly to the people they want to help.

The intent is pure but the approach is driven by what they can offer rather than what is requested. To create outcomes that last, social entrepreneurs must listen to and work within the motivations of the people they want to help. If they cannot provide what’s both wanted and needed, they’re unlikely to be successful with lasting transformation.


While in Thailand I also worked with a series of other projects, from Medical Negligence to Rice Farming, Multi-lingual Learning and Elephant Rescue, but I’m going to have to save those for another post!

Thursday 10 November 2011

Adventures in North-Eastern Thailand.

From September 2010

My first stop outside Bangkok and on my way up north, was a detour west for a break with Angelina in Kanchanaburi.

Kanchanaburi has a population of 50,000 and was originally established by King Rama I in the 1700s as a first line of defence against the Burmese. It is located where the Khwae Noi and Khwae Yai rivers converge into the Mae Klong.

In 1942 about 180,000 Asian labourers and 60,000 Allied POWs were forced by the Japanese to built the Burma Thailand Railway. Almost half the workforce died from the appalling conditions they were forced to work under; hence it’s other name: The Death Railway. It was made famous by the book and film The Bridge on the River Kwai. The immortalised Bridge 277 lies over the river at Kanchanaburi, and the railway tracks at this place have become a tourist memorial of the horrors of World` War II.

Half a century later, the surrounding area is tranquil and beautiful and the river is lined with plush resorts, hostels and campsites catering to the wide range and number of tourists that visit. Angelina and I decided to go pay our respects too, on our first weekend getaway from working in Bangkok.

We grabbed a slice of luxury at the brand new Dheva Mantra Resort, and cashed in on the peacefulness of being the only guests. As a hotel it got a 10 out of 10 from both of us for everything from it’s situation on the banks of the River Kwai, to the fab rooms and service. 


The bridge itself is located about 1km downstream from the hotel, so we hired ourselves a canoe and saw the bridge and railway from the water underneath; happily separated from the hordes of tourists wandering around on the tracks above. If you’re comfortable on water and have the energy, I totally recommend this as the best way to see the bridge and experience the area. You really get to soak it in, and especially upstream of the bridge you’re the only people on or around the water.

Death Railway 

Canoeing down the River Kwai Pagoda at Wat Thawonwararam just downstream from the Bridge

Angelina returned home to KL from Kanchanaburi and I carried on with the journey through Thailand, moving North with one of the rice farming projects I met up with in BKK. There had been a rice Expo in Bangkok while I was there and I was connected with Somruay Phadpol who founded and runs an integrated farming project in the Nan province. We had an illuminating conversation and he asked if I’d be willing to travel up to the Nan province to help with some of the challenges he was facing.

So off I went, 700km on a night bus to Nan. 10 hours of light and movies and music at a time when all I wanted to do was sleep. It’s always daytime on Thai buses!

My chaperone up to Nan was an Ashoka staff member, but my guide and translator was Phimonphan Sakitram, also known as Pang. Through Pang I got to experience the real life of Thailand, from really early morning starts and heavy breakfasts, to Thai coffee, bug fighting and crispy fried maggot snacks.

Pang getting me introduced to local iced coffee


The city of Nan dates back to the 14th century, when it was one of the 9 northern Thai-Lao principalities of the Lanna Kingdom a.k.a the Kingdom of a Million Rice Fields. Elements of Lanna architecture are still common in small details like on the roofs of the wooden houses and stilt constructions that dominate the rural areas.

Lanna architectural detail Wooden Stilt Construction

Towns in the Nan Province Town main street in the Nan Province

Like most of Thailand, the Nan province has great roads. Much of Thailand was rebuilt with American help and investment after the Vietnam War, and the infrastructure reflects the quality that comes with newer techniques. Nevertheless it’s strange to see poor villages with wooden houses that don't 
even have glass, scattered around fantastic first-world roads.

P1090844 P1090841

The city centre of Nan itself reminded me of Puerto Montt in Chile. A hardworking intersection of shops, with tangles of electric lines streaming across and down the main roads.

Nan City Centre Nan City Centre
The monsoon kicks in between August and October, and floods are common across Thailand. This year as I’m sure you know, they’ve been unusually bad. More than 500 people have died already in Thailand and the number keeps going up. My friends in Thailand tell me that most of the severe flooding is in central Thailand, and those in Nan have been spared the worst of it. The international community needs to step in and do their bit with support in the form of donations to flood relief programs. As mentioned in my last post, the official routes to help are listed here -

Floods in the Nan Province last year Floods in the Nan Province last year

The rainy season also brings the Nan Boat races. There are usually about 150 boats involved. Each boat is made of five pieces crafted from a single tree, and have ornate Dragon Heads and Tails. Interestingly the names all start with angel. When not engaged in races, the boats are kept at temples, and Monks manage and repair the boats, and perform a small ceremony on each before the race.

The smallest boats have a crew of 30, going up to 50 or 60 for the mid-sized boats and 80 rowers for the largest boats. Each community can race one of each. Men and women race on separate days. The races are grouped by boat size, and the Winner gets presented a trophy by Princess Siritorn. Last year they had 200 boats. Wooden paddles. Old boats used to have high curved  ends but now flat and long for speed and advantage at the finish.

Boat awaiting the festivities on the Nan River.

The Boat Race. Much excitement and festivities Crews practising

The rain is also crucial for rice production which is widespread across Thailand. Away from the flooding, September landscapes look lush and green with rice fields everywhere you turn.

Rice paddies in Northern Thailand, with an experimentation plot in the foreground Farmer spraying pesticides on rice

Nan is also well known for an unusually high number of temples. There are 20 temples in the city. One for every community. Regardless of the poverty in their areas, temples remain bright and gold and red, often with ornate plaster facades designed to look like cloth banners. They are beautifully maintained and well topped up with local donations. The good temples pour the money back into their communities, while others just soak up the money.

Out of the many, I visited one of the most famous: Wat Phumin. Outside, the steps are flanked by two huge snakes, known as Nagas. Inside are superbly preserved murals of illustrating the previous births of the Buddha as well as scenes of the local life at the time of restoration in the 1800’s.

Naga. Wat Phumin, Nan, Thailand Even the monks are Golden

P1090867 Four Buddhas in the Sukothai style. Apparently the shape of the ears and nose show a Lao influence.

Murals inside Wat Phumin Murals inside Wat Phumin

Thailand is well known for it’s food, and the North East is no exception. Being near the water means it’s all about seafood. Everything was super tasty and spicy, and served with rice. Loved it!

Taken out for dinner along the river by the Joko team after a late workshop

Spicy Tom Yum Goong Sesame fried fish

Breakfast is proper food too. Something that takes getting used to if you’re foreign. Eating noodles, fried meat or any other meal that usually qualifies as lunch or dinner is tough going at 7am if you’ve grown up eating toast and cereal! Even eggs don’t really prepare you. I have to admit I struggled, but a man’s gotta eat, and you take what’s on offer. In the end I found noodle soups to be the way forward. Rice with meat and fried vegetables was usually too much for my half-asleep body!

Local restaurant near my accommodation Breakfast. 


My travel destinations are always dictated by the projects that invite me there, and Thailand was no exception. Most of time in Nan was spent working with an organisation called Joko, focused on improving quality of life for rice farmers in the region. They were already working with about 4000 farmers and were facing a range of survival and scaling challenges. But that’s a story for a dedicated post on the various projects I was involved with in Thailand. Coming up after a final travelogue on my travels in North Western Thailand.


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