Recent studies on catastrophic health expenditures often use arbitrary and universally cut-off shares
(e.g., 10 percent) of health expenditures on household income (or on total household expenditure) as the
main indicator of catastrophic health expenditure. However, some empirical studies in Thailand which
employed such indicators ended up with counter-intuitive findings, e.g., a substantial percentage of households
in the richest quintile were found to be prone to catastrophic health expenditures, and more often
than not, at higher rates than those with lower income.
This paper uses the same set of data to demonstrate that the counterintuitive results resulted from
such faulty indicators. Using sophisticated household-specific poverty lines as a measure of household catastrophic expenditure, the study finds that, unlike households in the two lowest quintiles, it is extremely
rare for those with higher-than-median income to have their post-health-expenditure income fall
below the poverty line, a result which is completely opposite to those derived from the former indicator.
However, since the head count of health-related impoverished households is not sentitive for those
households that are already below the poverty line, the study proposes a supplemental indicator, that is,
changes in the normalized poverty gap due to health expenditure, as an indicator that measures the healthexpenditure
impact on poverty.


Capacity-building for health policy and systems research (HPSR) is a vital component in supporting
health system capacity in order to achieve certain health goals. Currently, a number of obstacles prohibit
the use of HPSR in real policy decision-making. These include selective use of evidence to support previously
set policy agenda, inadequate funding and support for HPSR, inadequate human resources and
poor research capacity, resulting in low-quality research. It is belived that capacity-building for HPSR
would help break the above-mentioned vicious cycle.
This paper is aimed at informing all stakeholders about the potential approaches to build up HPSR
capacity. It was conducted by (a) reviewing the literature, (b) using a questionnaire survey of existing
research capacity within the Health Systems Research Institute (HSRI) network aimed at identifying capacity
gaps and the current practices in building up research capacity, and (c) in-depth interviews with
key persons of leading research institutes, namely, the International Health Policy Program (IHPP), Epidemiology
Unit of the Prince of Songkhla University, and the Thai Research Fund, to learn from their
experiences in capacity-building.
Definitions of capacity-building and HPSR, and the potential approaches for building research capacity
were given. Results from the survey indicated that there is an urgent need to build up research
capacity at both the individual and research institute levels through formal and informal education, networking,
involvement of policy actors and the public in setting up research agendas, conducting research
and disseminating the research results. Lessons learned from the leading research institutes revealed
several key successes, including leadership, long-term and flexible research grants, critical mass,
multidisciplinary teams, and relevant policy research. At the end of the paper, the information gathered
was used to construct recommendations for HPSR capacity-building in health research institutes.


The importance of primary care has increased since the recent health-care reform but no systematic
evaluation has been done. This study was aimed at assessing primary care in Thailand. The primary-care
system questionnaire originally developed by Barbara Starfield was used to assess nine primary-care
domains, namely, resource allocation, adequacy of facilities, first contact and co-payment requirement, longitudinality, comprehensiveness, coordination, family-centeredness, community orientation, and professional
personnel. Respondents were 77 primary care practitioners from 13 different provincial hospitals.
The findings showed a response rate of 53.25 percent. Providers stated that (1) the resource allocation
was not appropriately based on intimate needs, although there were some special provisions for
underserved segments of the population, (2) basic equipment and supplies were not adequate in some
regions, (3) consultation with a provider at the primary-care level was required before assessing to seek
other care, whereas the co-payment requirement was low, (4) most patients were seen by the same provider
team on every visit, (5) primary-care services are comprehensive although regional variations were
evident, (6) coordination, family-centeredness, and community orientation were satisfactory, and (7) nurses
were key providers at primary-care facilities.


Regular and proper exercise behavior was part of a method to control blood sugar levels in type-2 diabetic patients. This research was aimed at studying the exercise behavior of type-2 diabetic patients residing in urban communities as well as studying the effect of exercise on their health condition and diabetic complications. Volunteers in this project included type-2 diabetic patients who had received medical treatment from BMA Health Service Center 12 from February to June 2006. All the volunteers first completed the personal questionnaire form and exercise behavior questionnaire form, and underwent blood testing, anthropometric measurements, and diabetic complications check-up. The study found that 75 of 203 volunteers (or 36.9%) had regular exercise behavior; while 128 of 203 volunteers (or 63.1%) refrained from performing regular exercise; however, only 42 of the 75 volunteers in the regular-exercise group were within the standard criteria for regular exercisers. The regular exercise group had lower fasting blood sugar and triglyceride levels than those of the non-exercise group, with the statistical significance being (p < 0.05), and tended to have a lower proportion of occurrences of diabetic complications than those in the non-exercise group. The result of this study indicates that diabetes patients residing in urban communities had a lower level of regular and proper exercise behavior. To solve this problem, the body of knowledge on proper exercise and patterns of exercise behavior modification must be taken into consideration.


The objectives of this study encompassed three elements to study: (1) the financial resources of the
Health Systems Research Institute (HSRI); (2) the budgetary allocation of HSRI; and (3) the relationship
between budget allocation and outcomes of HSRI. Data were collected from existing documents and studies on health research in Thailand and from financial data and activity reports of HSRI. The results showed
that (1) in the period 2002 and 2007, HSRI received 1,445 million Baht for health systems research, and
budgets from other sources dominated the government budget;  (2) the major research themes involved
data systems and knowledge generation;  and (3) the outcomes of HSRI activities, in terms of social movement and policy linkage, were related to the themes of research that received funds. The author recommends the following: (1) the private sector should play a greater role in supporting the national health
research system;  (2) the efficiency of a research funding agency should be measured by the proportion of
administrative costs to the total expenditures, and the real practices of staff of that agency compared with
the agency’s existing protocol on funding and terminating a project;  and (3) the effectiveness of a research
funding agency should be measured through total outcomes of that agency compared with the targets
mentioned in strategies rather than the figure of unit costs per program/project.


During the past two decades health research has contributed substantially to health system development in Thailand. Health system has been increased its system complexity and thus increases demand for
health research for further development. This paper is aimed to explore the current health research system
in Thailand and its capacity to cope with the increasing demand. Literature review and in-depth interview of key informants were used for data collection. In addition, a series of brain-storming meetings and
a synthesis workshop were organized to help analysis and to draw recommendations for future development.
It was found that the national health research system was facing many problems including lack of
leadership, limited health research resources both research budget and health researchers with inefficient
use. Strengths of the system which could be a foundation for future development included an establishment of autonomous research funding agencies which created a productive working environment for
health researchers to work effectively and a new working model called “triangle that moves the mountain” which involved stakeholders and civic groups in the research management process which could
promote research utilization and health system change based on knowledge. In addition, capacity building has been shifted from a conventional formal training model to on the job training under mentorship of
senior health researchers.
It is recommended that capacity building of health researchers is urgently needed and this has to be
done on the job-training basis. Mobilization of additional research budget is needed not only for supporting more research studies required for on-going health system reforms but also for capacity building. A
possible solution for mobilizing addition research budget is through making research more responsive to
demand of other public organizations. Using earmarked budget, 1 percent of total health budget, by enactment of the National Health Research Bill could be a long term solution and needs a strong political
support. Research management system needs to be strengthened through competent research managers.
Increasing management capacity of these research managers needs a special training programme and
research management tools. Finally, strengthening leadership of national health research system needs a
structural reform. However, a temporary solution is to use an existing health research funding agency to
perform this leading function with an acceptance of other health research funding agencies


This research was aimed at investigating the reasons for and the motivation of medical graduates of
Khon Kaen University choosing to work in community hospitals in northeastern Thailand after completing
their compulsory three-year bonded period of work. The population comprised 557 physicians who
had graduated during the years 1979-2003. A total of 233 samples were selected by stratified random
sampling and the data were collected by questionnaire. The research findings were as follows:
1. The factors that were significant in the retention of medical graduates who were working in
community hospitals in northeastern Thailand were the usefulness of knowledge of the community, the
preference for rural life and the requirement to work in/near their place of birth, respectively. To compare
the retention factors, the subjects were classified by sex, type of entrance, age range, grade and work
place. It was found that (1) male medical graduates prefer to work in administrative jobs compared with
female medical graduates, and (2) medical graduates who were working in community hospitals prefer to
work in administrative jobs rather than medical graduates working in a regional hospital.
2. The significant factors to support medical graduates who worked in community hospitals were
the extra money, improvement in hospital facilities and physical social welfare improvement, respectively.
3. The order of magnitude of the factors for choosing or changing the location of work was related
to postgraduate education, children’s education and individual factors, such as distance from home, quality
of life, etc. In making a comparison of the factors, the graduates could be classified by sex, type of
entrance, age range, grade and workplace as follows : (1) male medical graduates gave a greater priority
to their children’s education than their female peers; (2) medical graduates who had gained entrance by
quota gave greater priority to postgraduate education more than the other group; (3) medical graduates
who ranged in age from 44 to 53 gave greater priority to the management system than those in other age
groups and medical graduates who ranged in age between 34 and 43 years gave greater priority to postgraduate
education and their children’s education than any other age group; and (4) medical graduates
who were working in community hospitals gave greater priority to their task than the other group.


The objectives of the research were to study the health risks and risk-related behaviors of 24,717
people aged 15 years or older who resided in Tan Sum district, Ubonratchathani Province. Information
related to illnesses was collected by asking about their health history, behaviors that made them prone to
health risks, and laboratory check-ups. The work was conducted in the period from October 2006 to September 2007, and the data were analyzed using the Health Check program. The results showed the following: that from the body mass index in 11 percent of the sample were overweight, and 2.29 percent were
obese; waist circumference was above normal in 18.87 percent, and was more prevalent in women than
men; blood pressure in 7.5 percent was in the risky category, among which 4.94 percent suffered high blood pressure, and 0.14 percent suffered severe high blood pressure; blood cholesterol levels in persons
aged 40 years and over showed high levels in 0.10 percent among the risk group (3.99 percent); blood
sugar levels were 16.24 percent in the pre-diabetic stage, and 4.15 percent had diabetes, which was most
prevalent in women; the hematocrit was 51.47 percent in the anemia stage; 6.29 percent of stool samples
contained worms, the majority of which were liver flukes; 21.85 percent had calcium deposits on their
teeth, 2.27 percent had caries and 5.49 had both conditions; 0.74 percent had cataracts; among 38.26 percent of women aged 35-60 who came for cervical cancer checks, 0.37 percent had positive results, and 0.02
percent were positive for breast cancer.
With regard to behavior assessment for health risks, it was found that 0.06 percent consumed alcoholic beverages daily, 3.59 percent smoked cigarettes habitually; 3.50 percent had previous accidents; 0.11
percent had extra-marital sex without using condoms; 0.65 percent of both men and women drank energy-boosting beverages; 34.75 percent exercised 3-5 days a week while 3.94 percent exercised more than
5 days per week; with respect to riding motorcycles and driving cars, 1.89 percent of motorcycle riders did
not wear helmets, and 2.41 percent of car drivers did not wear safety belts; women took steroid-mixed
drugs more than men, and women suffered stress more than men; 0.97 percent consumed raw meat frequently.


The goal of Thai health system development is to achieve a balanced and sustainable society in which
all Thai citizens have the security needed to live a happy life in a healthy and better condition. The objective
of this study was to perform a literature review to form a foundation and knowledge base on good governance
in the Thai health system, analyze and plan for research mapping.
In this study, good governance in the health system was divided into 10 sectors: rule of law, ethics,
transparency, participation, accountability, value for money, human resources development, knowledge organization,
management and information technology. These were simultaneously analyzed in macro- and
micro-analysis systems that were influenced by economic, social and political conditions as well as the agency’
s role.
The literature review revealed that there were problems in every aspect of health governance. If these
problems were solved more effectively, that would generate better and improved services in the health-care
system. Consequently, it would create a sustainable society in which all Thai citizens would live a happy life
in a healthy condition.
The study found that governance is a function of the health system, that each governance principle
should be developed and adapted, and that governance issues should be identified at all levels. The problems
encountered in studying health governance were that the issue needs more research, especially that
undertaken with a qualitative approach and comparison of the international governance functions.


This research encompassed two objectives: (1) to assess the competencies of the personnel of the
Chiang Mai Provincial Health Office and compare these acquired competencies with expected competencies of the organization; and (2) to compare results of competency assessment by self-assessment with the
results of assessment by peers, by heads of sections and by the Competency Assessment Committee. The
target group comprised personnel of the Chiang Mai Provincial Health Office. Respondents were recruited
by the accidental sampling method during the days that the Committee collected data (between October
1, 2006 and March 31, 2007). The research tool was the competency assessment form adapted from the
competency assessment guideline of the Public Sector Development Commission, which comprised eight
dimensions. Data were collected from 147 respondents (94.2 % of the total staff).  Results showed that:
(1) in the deputy director group, the underdeveloped dimension was mentoring for personnel development; (2) in the assistant director group, heads of clusters and heads of sections/technical experts, the
underdeveloped dimensions were ethical issues, holistic thinking and proactive management; (3) in the
technical operator group, the underdeveloped dimension was proactive management; and (4) from the
overall competency scores, the self-assessment produced similar scores to those assess by the Committee.
These findings will be useful for formulating individual development plans.


This survey was conducted in four districts in Chiang Mai Province as part of a multidisplinary
research study by academic staff of three universities, namely Chiang Mai, Songkhla and Khon Kaen
university, in collaboration with researchers from the Thailand Institute of Nuclear Technology and the
Royal Institute, with the aim of verifying the association between residential radon exposure and lung
cancer risk. The study was carried out by measuring radon gas levels in the homes of proven cancer
patients and in other homes as controls for the purpose of comparison. As the findings in both categories
of residences showed that the radon levels did not exceed the safety threshold (148 Bq/m3), it was concluded
that radon gas exposure in such a situation of low levels would likely not be a significant cause of
lung cancer, but rather attributed to the heavy smoking habit of the northern citizens.


Accumulating evidence from randomized controlled trials have shown that diabetes mellitus can be
prevented or delayed in high-risk individuals by an intensive lifestyle modification program. However, to
be meaningful for clinical practice in the real world, the results need to be both widely generalizable and
the methods practical and affordable enough to implement in a wide variety of health-care settings. This
review described some aspects of the intensive lifestyle modification program in groups at high risk for
diabetes. Topics included epidemiologic evidence about the relationship between lifestyle factors and
diabetes risk, clinical outcomes and cost-effectiveness of the intensive lifestyle modification program, and
predicting factors for its success. Some details of the three example programs, including the Chinese Da
Qing IGT and Diabetes Study, the Finnish Diabetes Prevention Study (DPS), the US Diabetes Prevention
Program (DPP) and Look AHEAD Study, were described. The information provided could be utilized in
the development of practical lifestyle interventions for diabetes prevention in Thailand.


A case-control study was carried out in Panomsarakham Hospital, Chachoengsao Province
 from October 1, 2001 to September 30, 2006 to determine the risk factors associated with birth
 asphyxia. The study group comprised 107 women who delivered asphyxiated neonates (1-minute
 Apgar score ≤ 7); the control groups comprised 107 mothers who delivered non-asphyxiated neo-
 nates (1-minute Apgar score >7). The control group was selected by systematic sampling. The data
 were analyzed by univariate and multiple logistic regression analyses, which revealed the following
 significant risk factors prevalent for asphyxiated newborns: thick meconium-stained amniotic fluid
 (OR 8.82; 95% CI: 1.35-57.45), drug-induced labor (OR 8.63; 95% CI: 2.80-26.63), vacuum
 extraction (OR 4.66; 95% CI: 1.28-16.90), and dystocia (OR 4.43; 95% CI: 1.33-14.78). In
 recognizing that the most common risk factors in birth asphyxia are antepartum and intrapartum
 incidents, early recognition of these factors followed by prompt and appropriate management would
 reduce the incidence of birth asphyxia.
Key words: risk factors, birth asphyxi


The purpose of this quasi-experimental research was to evaluate the health status and risk
 behavior of Tayang Hospital personnel who had earlier joined the Good Health by Yourself
 Program. The selected sample population of 88 had a body mass index (BMI) ≥ 25 kg/m
2
 and
 /or blood cholesterol ≥ 200 mg/dl. One pre and post test was carried out on a group in the period
 from August 2006 to September 2007. The study group was kept for a three-day two-night session during which the staff members joined empowerment activities in the implementation of health
 education and self-adapting behavior. Six months later, data were collected again and analyzed by
 computer program to determine the percentage, means, standard deviation and paired t-test results.
  The study revealed that, following implementation of the Good Health by Yourself Program,
 related risks, namely systolic and diastolic blood pressure, blood cholesterol and triglyceride levels,
 were significantly lower than at pretest (p< 0.05). However, waist circumference, BMI and fasting
 blood sugar (FBS) were not different both pre- and post-Program implementation. This proved that
 the Good Health by Yourself Program activities could help in lowering blood pressure, cholesterol
 and related risks, and as a consequence, help to improve health. Therefore, the Good Health by
 Yourself Program should be implemented in order to develop a caring process for populations at
 risk as well as for other patients.


This descriptive research study was carried out with the aim of assessing the accuracy
  of the World Health Organizationûs dengue hemorrhagic fever diagnostic criteria, as used in
  Nongbuadeang Hospital in 2005 and 2007. The verification was conducted by investigating
  52 blood samples in 2005 and 15 samples in 2007 based on virology (RNA-PCR) and
  serology (ELISA).
   It was found that the diagnoses of dengue fever (DF) and dengue shock syndrome
  (DSS) by using the WHO diagnostic criteria were 100 percent confirmed throughout, while
  the diagnosis of dengue hemorrhagic fever (DHF) was 94.74 percent in 2005 and 95 percent
  in 2007, as confirmed by virological investigation with RNA-PCR and ELISA in 47 cases
  (90.38%) in 2005 and 13 cases (87.67%) in 2007.
   Thus, this study indicated that the WHO diagnostic criteria for DHF yield highly
  accurate results and make unnecessary any other means of confirming dengue viral infection.


This descriptive research aimed at studying factors related to blood pressure
  controls in patients with hypertension attending Thabsakae Hospital, Prachuap Kiri Khan
  Province. The subjects comprised 340 patients with hypertension who continuously attended
  the outpatient department of Thabsakae Hospital in the period October 1 to December 30,
  2007. Simple random sampling was conducted by using an interview questionnaire. The  method for analyzing the data were frequency, percentage, mean and standard deviation.
  A chi-square test was employed to determine the factors associated with blood pressure
  controls.
       The factors were identified as age, sex, marital status, education, occupation,
  income, knowledge about hypertension, self-care behavior, body mass index, period of
  illness and presence of other co-morbidities, by compliant hypertensive patient care control
  groups, that is, those with a blood pressure of less than 140/90 mm Hg (at least 3 SD),
  and accepting those with a diastolic blood pressure of more than 140/90 mm Hg (only 1
  SD); however, those with a diastolic blood pressure equal to or more than 92 mm
  Hg were those considered as having high blood pressure that could not be controlled
  (at least 5 SD), The research results show that occupation, self-care behavior and body
  mass index were statistically significant with blood pressure controls in patients with
  hypertension (p<0.05). This finding can be applied to plan and develop an appropriate
  method for controlling blood pressure in patients with hypertension.


The objectives of this study were to compare the results of the care services
   provided at two primary care settings, a one-stop service clinic of Nongwuasaw
   Hospital and the Nonwai Medical Care Center, both located in Udon Thani Province.
   A simple random sampling method was used according to the specified criteria in order
   to recruit the subjects for study in the period from March to May 2008. As a result,
   271 patients from each of the medical centers were obtained. The variables to be
   compared were fasting blood sugar levels, other clinical variables, knowledge, practice
   and satisfaction of the patients. The questionnaires approved by five experts were used
   for collecting study data. The descriptive statistics, number, percentage, mean, standard
   deviation, median, minimum and maximum values were used to analyze the data
   obtained. The student t-test was used to show the differences in the knowledge,
   practice, patientsû satisfaction and the results in controlling the level of the fasting
   blood sugar in the blood as well as other parameters; the results were presented along
   with the degree of freedom, df, and p-value at the statistically significant level of 0.05.
   Most of the subjects (70.1%) were females; the subjects were aged 20-86 years, with
   the median age being 58 years and 31.4 percent were 51-60 years old; 74.2 percent
   were married and 71.2 percent had completed primary school; the economic status of
   almost all of the subjects (97 percent) was at the average level; and they were diabetic
   for 3.5 ± 2.2 years. These general characteristics of the subjects of the two centers
   were compared, and showed no statistically significant differences. The results of the
   clinical parameters, however, showed that the levels of fasting blood sugar and urine
   albumin of the DM patients who had received services from the Nonwai Medical
   Center were statistically lower than that of the DM patients who had attended the One-
   stop Service Clinic of Nongwuasaw Hospital (p-values = 0.003 and 0.05, respectively).
   The levels of HbA1c, cholesterol and triglyceride in the blood and the body mass
   index of both groups were not statistically different. With regard to DM knowledge,
   the patients who had received services at the One-stop Service Clinic of Nongwuasaw
   Hospital had lower knowledge scores than those who had received services at the
   Nonwai Medical Care Center (p-value < 0.001). However, there was no statistical
   difference in terms of practice scores. Patients who had received services at the One-
   stop Service Clinic of Nongwuasaw Hospital had significantly lower satisfaction scores
    than those who had received services at the Nonwai Medical Care Center (p-value = 0.05).
    The study concluded that diabetic care at the Nonwai Medical Care Center is
   more efficient than that of the One-stop Service Clinic of Nongwuasaw Hospital.
   However, the study had a limitation in that it was not a randomized controlled trial;
   therefore, such study is needed in the future to make conclusions.


This research was aimed at the preparation of a health education handbook on contraception
 for teenagers according to the standard criteria of a 90 percent effective index and a study of the
 sampleûs opinions. The study population consisted of 40 students from Piboonrakpitaya School in the
 second semester of the 2007 academic year. The experiment took two days to conduct. The
 instruments used in this research were a handbook in the health education subject çcontraception for
 teenagersé, a learning achievement test and questionnaires. The collected data were analyzed by
 simple statistics, percentage, mean, and standard deviation.
  The findings indicated that the health education handbook on contraception for teenagers was
 at a good level (92 percent effectiveness, with an effectiveness index of 0.68). In the opinion of the
 student subjects the effectiveness of the handbook was at a high level. Therefore, the handbook
 would be appropriate for use in the health education program.


The objectives of this empirical research were to survey the attitudes of
healthcare teams and health service recipients in Thailand with regard to home healthcare services and community health promotion as services in a sufficiency
economy. There were two groups of samples: health personnel who provided home
health care and the people who received home health care in four regions of
Thailand, i.e., the Northern, Northeastern, Central and Southern regions. Sixty health
personnel were purposively selected from one province in each region, making 240
subjects for the personnel team; 120 people were purposively selected from one
province in each region, making 480 subjects for the healthcare recipient group.
The results showed that 83.2 percent of the persons in the personnel team and
79.4 percent of the healthcare recipients thought that home health care was a
sufficiency economic service. While 55.8 percent of the health personnel were very
satisfied with home healthcare services in providing sufficiency economic services,
42.9 percent were moderately satisfied, and 1.3 percent were not satisfied; 71.5
percent of the people in the subject group had experienced highly satisfactory
services and 28.5 percent considered such services as moderately satisfactory.
In conclusion, both health personnel and health service recipients accepted that
home health care and community health promotion represented sufficiency economic
health services.


OPD reports from hospitals and health centers in Khamsakaesang District in 2007
  showed that 52.78 percent of the outpatients were in the age group 60 years and older; of that
  proportion of elderly patients, the cause of their seeking medical care in 62.53 percent of the
  cases was improper self-care behavior. The objective of the present quasi-experimental research
  study was to assess the effectiveness of the self-care health promotion program for the elderly.
  The study samples were selected from the total database population numbering 5,252 persons.
  Using multi-stage random sampling, 60 cases were identified for this study.  The descriptive
  data were analyzed by the STATA program, version 10, to obtain percentages, means and  standard deviations; paired sample and independent sample t-tests, with statistical significance at
  the 0.05 level, were used for the data analysis. The qualitative data were analyzed according to
  the content of the questionnaire interviews on self-care behaviors for health promotion, together
  with observations and personal discussions. The results showed increased statistically significant
  behavior in the control groupûs test, i.e.,  the patientsû paired sample t-tests showed mean
  differentials of 0.49 ± 0.05,  t = 48.00.  A comparison between the groups showed that the
  control group acted more properly than the comparison group (t=40.32, p value 0.001).
  Qualitative data showed that family lifestyles, and economic and traditional beliefs influenced
  their behavioral change. The results of this study could be used to integrate and adapt care for
  the elderly and other patient groups in primary care or clinic promotions. At least they could be
  used to increase efficiency in protecting the elderly against untimely illness and from
  developing complications from improper self-care behaviors.


Diabetes mellitus is a chronic disease and a major health problem in Thailand. The objective
 of this study was to develop a problem-solving model for diabetes mellitus in a community, in the
 hope that it could reduce hemoglobinA1C and increase the quality of life of diabetes mellitus
 patients. The diabetes mellitus problem-solving activity was operated in six villages of Ubonratana
 District in Khoan Kaen Province. Fifty-two diabetes mellitus patients participated for six months in
 the problem-solving activity, which was operated by health volunteers; it involved promoting exercise,
 controlling diet and optimizing drug compliance. The problem-solving patterns were monthly
 meetings, home visits and health education. The average hemoglobinA1C of the diabetes mellitus
 patients was 9.9 percent, but after their participation it dropped to 8.7 percent. The quality-of-life
 score (WHO QOL short form 26) was 88.7; it increased to 101.1 after the activity. The changes in
 the average HbA1C and quality-of-life scores are statistically significant. The conclusion of this study
 was that a diabetes mellitus problem-solving activity in a community may be able to reduce HbA1C
 and increase the quality-of-life score.


The purpose of this study was to determine the effectiveness of healthcare services of
doctors and nurses in the Primary Care Network of Na Klang Hospital, Nongbua Lamphu Province,
under the Universal Health Care Program (UC). The study was conducted as a quasi-experimental
research in the period August›December 2004. The experimental group consisted of 48 networked doctors and nurses working at the Na Klang Primary Care Unit (Na Klang PCU) and the control group consisted of 47 networked doctors and nurses working at the Sri Boon Reung Primary Care
Unit (Sri Boon Reung PCU). Subjects in the experimental group received training using a problem based approach in order to improve their service effectiveness; there was no intervention for the control group. A questionnaire was used to gather general information, information on the health
promotion service, medical treatments, disease prevention, and rehabilitation. Data were gathered twice: pre and post experimental period and were analyzed using percentage, arithmetic mean,
standard deviation, and paired sample t-test. The results showed that, after the experimental period,
the Primary Care Unit networked doctors and nurses in the experimental group had higher
effectiveness in providing healthcare services, which was higher than that of the control group at a
statistically significant level. It was concluded that the advantage of this study includes the
application of the research results as a guideline in improving healthcare services, health promotion
service, medical treatments, disease prevention, and rehabilitation of the Na Klang Hospital
Network in order to make the services more effective.


Community hospital care providers have the pivotal role in the care of people with dengue
 hemorrhagic fever, and it is imperative that such care be improved. This short review describes the
 following issues concerning dengue hemorrhagic fever management in a community hospital : the
 goals and provision of care for dengue hemorrhagic fever, organization of care, and the education,
 training and skill of the health-care team. It also describes the current situation of dengue
 hemorrhagic fever management in community hospitals, both in Thailand and other countries, the
 predictors of high-quality care, and the barriers to control of dengue hemorrhagic fever, while
 suggesting indicators for auditing the quality of dengue hemorrhagic fever care and the strategies to
 be utilized for improving dengue hemorrhagic fever management in a community hospital.


This research aimed to comprehend the concepts, practices and judgment on mechanisms of health system reform movement and impacts of the past and present health system reform mechanisms by studying perception and expectation of people concerning the reform process, the outcomes, participation and role of people.  The study also intended to determine the development trend and formation of various groups and agencies involving in health system reform process.  The qualitative research method was employed.  Study population included people attending health assembly forums and people who lived in Phayao, Nan and Chiang Mai provinces in the North of Thailand during October 2003 – March 2004.	The main findings of this study are as follows:	1. Most people still held on the biomedical model of health that emphasized on physical health mainly illnesses and diseases.  Few people gave other health concepts that linked to other dimensions such as occupation and socio-economic aspects.  Even among health personnel, they seemed to have no clear concepts and judgment on health in the new paradigm of “holistic health”.  The so-called holistic health was just a discourse commonly used among people without obvious explanation.	2. People’s concepts and judgment of health still affixed to physical and mental health and absence of disease.  This reflected the practices on health promotion and medical care that also concerned mainly physical health.  People continued to perceive that health promotion was an approach to prevent themselves from getting diseases and was responsible solely by doctor or health personnel.  It was evident that health care and health promotion activities depended on activities of health personnel.	3. The symbol of health was still the “hospital or doctor”.  Health care was a matter of explanation in relation to the conventional structure of health service system such as hospitals and health centers.  People or even health personnel still could not elucidate how school, temple or other organizations in a community could help build the health and how people can promote their health.	4. There was a disparity of perception among samples with different education levels.  Most of subjects who took part in health assembly forums could explain the reform process better than other groups.  Subjects who did not directly participate in the forum mostly did not know or were not aware of the reform process.  Although some subjects mentioned that they had heard about the process, but they could not describe its definition or meaning.  Most people noticed the ongoing changes through the development of health care facilities in the community in forms of building extension, sophisticated equipment, and presence of specialized doctors.	5. Activities and formation of groups, besides actions taken by health personnel, for example, livelihood, income and well-beings, were perceived as matters not related to health.  Health personnel mostly initiated health campaigns during health system reform movement.  These included groups or clubs connected to health centers like an exercise group, an herb group, and an elderly group whom people could not interpret as health or holistic health issues and as results of health system reform.	6. Health system reform process or movement in community level did not sufficiently stress on learning process.  Exercise groups, which were set up almost everywhere, were promoted as activities without the promotion of learning process.  This did not stimulate people to modify their thoughts on health care satisfactorily.  The promotion of various job clusters was not linked to learning process in health as well.	7. People partially involved in health system process particularly in cooperation, policy acknowledgement and implementation.  The involvements in lesser extent were participation in thinking, initiating, and making decision by people themselves.  Concepts and beliefs of most people still stuck to conventional thoughts that those who were skillful of health care were exclusively health personnel whom people placed their trust on and ready to follow suit.  It was perceived that the major role of health movement propulsion belonged to health personnel and health volunteers.  Community leaders or tambon administration organization committees also regarded health as a separated issue from other modes of development.	In performing the health system reform policy implementation, the learning process must be integrated to the developmental activities.  The lessons learned will thus be the analytic thinking exercise.  Health promotion needs the new paradigm of health that connects all dimensions of health particularly the spiritual aspect.  Shifting of health paradigm among health personnel is needed in the development of understanding in health system reform process among villagers, groups, local agencies including health personnel itself.  The research should also focus on the learning process of civic sector.


Pattern of hospital delivery in Thailand 1990-1996There is no comprehensive information of the pattern of hospital delivery in Thailand. The Ministry of Public Health (MOPH) statistics only report normal and abnormal deliveries. Non-MOPH and other private hospital information is totally lacking. The objective of this study is to demonstrate the  pattern of hospital delivery in Thailand during the period of  1990-96. Questionnaire survey to all public and private  hospital was done with a result of 62 percent response rate.  Important parameters include total hospital deliveries, mode of delivery (vaginal, cesarean, vacuum, forceps and others),  primary or secondary cesarean, and number of full and part time obstetricians in each hospital during the period of 1990-96. The following results are very interesting. 1.MOPH distric and  provincial hospitals got a lion share, 67 percent of total national hospital deliveries. Private hospital delivery is less  common, only 9 percent of totals. 2.In 1996, cesarean rate in distric hospitals was percent 7.2, provincial hospitals percent 22.9, other public hospitals percent 21.2 and private hospitals  51.5 percent. The national cesarean rate was 22.4 percent. 3.In 1996, vaginal birth rate was 67 percent, other type of delivery 11 percent. During 7 years (1990-96), vaginal birth rate  gradually decreased, cesarean rate gradually increase and forceps and vacuum extraction stays constant at 10-11 percent  of total hospital deliveries.    4.Cesarean rate steadily increased from 15.2 percent in 1990 to 22.4 percent in 1996 and showed a further increasing trend. 5.In 1996, of the total cesarean cases, 64.1 percent was primary and 35.9 percent was secondary cesarean  (indicating previous cesarean). 6.In district hospitals, cesarean rate in 1996 was 7.2 percent , of which 5.5 percent  was primary and 1.7 percent was secondary sections. Primary  rate increased at a higher rate than secondary in the past seven years. 7. In provincial hospitals, cesarean rate in 1996 was 23 percent, of which 14.4 percent was primary and 8.5 percent was secondary sections. Secondary rate significantly increased at a higher rate than secondary in the past seven years. 8.In other public hospitals, cesarean rate in 1996 was 21 percent, of which 14.1 percent was primary and 7.1 percent  was secondary sections. Primary and secondary rate has similar  rate of increase in the past seven years. 9.In private  hospitals, cesarean rate in 1996 was 51.4 percent, of which 32  percent was primary and 19.4 percent was secondary sections. Primary rate increased at a higher rate than secondary in the past seven years. 10.The national average, cesarean section  rate increased from 15.2 percent to 22.4 percent during the seven years. Primary and secondary rate has similar pace of  increase. 11.The number of obstetricians in sample hospitals increased from 648 in 1990 to 882 in 1996, a 36 percent increase. At the same time, number of cesarean childbirths increased from 58,183 cases in 1990 to 109,867 cases in 1996, a 89 percent increase in the same perid. 12.Casarean surgery  workload per obstetrician increased from 88 cases per year in 1990 to 121 cases in 1996.


This study is an assessment of the operation of Governmental Homes for the Aged through three case studies . The study employs both quantitative and and qualitative methods within the adapted CIPP framework utilizing gender dimensions  for data analysis.	Assessment of the environmental context  of the Homes for the Aged revealed that the space and surroundings of the Home affected the interaction and behavior of the aging residents. Meanwhile, the community adjacent to the Homes and the public were found to have no participation in and investigation of such Homes.	As far as the assessment of the aging residents in the Home is concerned, the sample population comprised the women in the lower socioeconomic strata as the majority. Most of the aging sample were admitted to the Homes due to no carer at home. The study found that the high proportion of the aging residents did not participate in any activity arranged by the Homes due to their health problems. However, the majority of the residents were of the opinion that their current lives were better off. The study also found the increasing trend of the Homes to admit the residents with better socio –economic conditions and to confront the residents’ voicing of their rights and benefits. 	The gender analysis yielded the results that the men residents had better previous socio-economic conditions and more current income than their women fellows. They also had better physical conditions, more kinship network, and participated more in the activities of the Home. The study also found that such men residents had better mental health, more psychological and spiritual needs compared with women. Regarding the potentiality, although the women residents who possessed certain skills were proportionately higher than men, men were more willing to contribute for the social goods than women . Besides, the women residents expressed the will to further live in the Homes more than men.	Assessment of the administrative resources of the Homes disclosed that the unit cost  per resident was as high as Baht 34,500 annually. In terms of policy, the policy formulated by each Home was found to be lacked of unity due to adherence to various policy orientation. Added to this, the programs and projects were extremely flexible while no mechanism was devised to monitor and evaluate them. Administratively, it was found that the Home locating in the provinces operated as independently as “the Kingdom” and was connected with the central administration than the provinces they attached. As far as the budget allocation was concerned, each Home was found to be highly dependent upon public donation. For personnel administration, the study found that the personnel  distribution in each Home  was imbalanced with those earmarked.	With reference to  the services provision, the study found that  the aging residents who were not in dire need were admitted. The fact that the main strength of the Home was its capacity to respond to the physical needs of the residents while the main weakness of the Home was its unresponsiveness to psychological and spiritual needs of the residents were also found. For personnel performance, the major problem of the Home was the low quality of the personnel at the services level were also found to be incapable of solving the problems of the residents of the Homes effectively.	As regards the operation of the Home, the study found that the services and activities provided were adequate and  that the residents were indiscriminatory treated. However, the inequality existed was that the better off residents enjoyed similar benefits of the Home with the poor and needy residents and that the declining residents were somewhat inaccessible to the services provision. Furthermore, since the residents were mere beneficiaries, the sustainability of the services and activities of the Home was far from reality. Lastly, the study found the direct impact of the Home to be the benefits the needy obtained  from the Home while the main indirect impact was the inception of the Elderly Social Service Centers in the various communities.


The objective of the research is to study evidences of Dental Health Service in private hospitals regarding the Universal Coverage of Health Care Policy, in the selected province in Thailand. The research has been started at June 2001. Research findings are as follow:	Preparing to participate in the Universal Coverage of Health Care, the managers of health service providers in private hospitals considerably study the policy in detail. Therefore, they can clarify their management goals, policies and strategies conforming to the policy of Universal Coverage. Generally, all health workers are trained and prepared for the new policy. Dental health practitioners, however, did not have as much information as other health practitioners. Some private hospitals even had never employed a full-time dentist according to the governmental criteria of basic essential health care service. New systems of data collection are designed conforming to the characteristics of works in private hospitals, which are different from the system that the Provincial Public Health Office need. Interestingly, since April 2001, it was the first time that a private hospital network has been established. Nevertheless, such network does not influence any decision making of each hospital to be the participant in the policy of the Universal Coverage of Health Care. In general, the reason that each private hospital becoming a part of such policy are the appreciation of the concepts and principles that based on the benefits of citizens, increasing health care accessibility with less expense, in other words, improve health at least cost. The budget managing system of the Universal Coverage provides a higher access for population than previous systems. It encourages consumers for a transparent accountability role, and provides more chance and authority for consumers to participate in deciding local health policy. In addition, the system provides a higher possibility to share resource utilization, which would decrease the nation cost of medical technology. It might be said that it is a rather disadvantage for health institutions that do not participate in the Universal Coverage policy since the beginning, for it could affected to the amount of consumers. Or, considering in a long term, there is a high tendency that finally the Universal Coverage of Health Care in the future will cover all private hospitals. Therefore, it would be wise to learn from problems of the procedure since the beginning. The faster the problems are learned the faster they could be solved and developed. Furthermore, the participation of private hospitals could influence other governmental hospitals to develop or reform their health service, which finally it is the advantage of consumers. Before the private hospitals participating in the Universal Coverage Project, the dental health management depended on the hospital managers, while dentist do not have any authority. There are various payment systems for dentist, i.e., a fixed-rate salary, a minimum rate guarantee, or the 50:50 sharing income. For some hospitals the dental health service should be developed regarding to the core package. One important point found in almost every hospital, except only one hospital, is that the health promotion and prevention in the community are ignored. After attending the Universal Coverage Policy, every hospital have re-arranged and developed their service and management. They have tried to contact and coordinate with government institutions, and find many problems in practical level about the communication and co-operating systems. Finally, many private hospitals decide to solve the problems by themselves. Therefore, the management systems tend to be centralized to the managers, in order to clarify the strategies and determine the method and approach for problems solving. Later, the authority has been distributed more to the head of each section. Each hospital considerably analyse and manage their income and expense. However, the information of financial system cannot be revealed. The dental health care service is relatively developed after entering the Universal Coverage of Health Care. For instance, hospitals pay considerably attention to dental health service to cover the core package. The working time planning for dental health service is extended further to overtime. Nevertheless, in some hospitals dental health service are controlled by the hospital managers. For example, the dental prosthetic service is limited for its high expense; each patient is limited to have only one dental health service each time; and the limitation of service time for health insurance consumers. In case of dental health care in communities, they merely assign nurses to screen oral health status in the school-children and finally refer to the hospital for further treatment. There are three types of health service networks among private hospitals: (1) the hospital that have their own primary care unit (PCU), in case of hospital that have small amount of catchment area without the primary health care institution, (2) the hospital that have PCU of their own together with another PCU in a primary health care institution, in case of private hospital that have a primary health care institution in the catchment area, (3) the hospitals that the catchment area cover a primary health care institution but they merely use it as a subcontractor rather than a PCU, and open their own PCU outside the hospital. At present there is a low possibility to extend health service network to private clinics, for there is not much catchment areas for each clinic. If a private clinic would like to be a subcontractor for a private hospital, it should received a reasonable payment. For example it should be more than 200 baht per head for at least 10,000 patients. However, the highest possibility would be that only severe cases are referred to private clinics. According to the interviewing of dental consumers from private hospitals, large amounts of the consumers appreciate with the core package and service from the health practitioners. Some of them, however, complaint that the core package is not enough and the queue for the next service is too long. The consumers’ need of health promotion and prevention are relatively ordinary; dental health education, oral health examination, mobile service, which is conforming to the planning of private hospitals. The research findings provide an important and interesting evidence of dental health and general health service in private hospitals. There are some further suggestions for the Universal Coverage of Health Care policy and practice in the future as follows: The understanding of participants are needed to be adapted conforming to the philosophy of the Universal Coverage of Health Care, in particular, the Health Insurance has a deeply meaning than a donated project for the poor. The understanding of public health practitioners regarding the difference between the concepts of health promotion and disease prevention need to be improved. In particular, the activities of dental health promotion should be more clarify. Whereas the efficiency of health promotion is the population capability of self-care, at present the primary care unit pays less attention to health promotion and prevention and work as the extended OPD instead. Therefore, in the future the roles of primary care unit should have been seriously considered. The development of community capacity should be developed. Moreover, there should be an encouragement for a consumer social network in order to examine the efficiency of hospitals. Regarding the Universal Coverage of Health Care, the health care budget will deliver directly to the hospital, thus, it is possible for consumers to estimate cost and assess local health service. In order to offer alternating to the consumers, the hospital should have an efficiency primary care unit, not merely work as an extended OPD. Particularly, the tertiary care hospital should clarify between the managing of primary and tertiary health care, otherwise the health care referral system would totally be demolished. Previous health care systems wrongly influence consumers to seek for the specialist health practitioners only thus health-seeking behaviour of the consumers should be improved. The separation of dental core package from general health core package has to be considerably concerned together with the studying of dental health cost-effective and types of dental treatment. Although it would help clarifying dental health planning, the most important point we should keep in mind is that, by separating dental core package it would possibly affect the concept of holistic approach. Thus, the question of a possibility to exclude dental health promotion and prevention from other works need to be seriously concerned. The health assessment institution should not merely finding faults and assessing, but suggesting and encouraging health institutions as well. Health expense must be carefully regulated, especially among the health providers. According to the research findings, the competition among health institutions could effect many in-appropriate health services. For instance the over expense of medical technologies and specialist employment. Consequently, the budget from the Universal Coverage of Health Care would be insufficient. At present none of private hospitals have data base of oral health status of their catchment area and lack of information about the important factors related to local oral health status. This would effect the health promotion and prevention assessment. Therefore, the data collection systems have to be re-arranged, and developed to achieve the efficiency of health care in the future.


The social and health related problems of construction workers in the northern regionThis study was a part of the research collaboration project of the same study conducted throughout the country, using the same research framework, format, and methodology.  Its aim was to acquire social and health-related information of construction workers.  It consisted of both quantitative and qualitative study.  This paper is a report of the quantitative study, using a cross-sectional survey to collect information on the social, environmental, and health-related problems of construction areas and the workers in the northern region.  The survey was conducted in Muang Chiangmai and Muang Pitsanulok Municipalities.  It included 40 small and large construction areas that employed more than 20 workers and were in the early stage of construction.  The contractors and the workers were interviewed.  The study showed that the mortality rate was about 1.17 per 1000 and injury rate was 8.9/1000/month.  Safety, sanitation, environment and living condition of the workers were poor.  Most of the workers were male, aged between 20 – 49, completed primary level of education, and were from agricultural background.  90% of them were from the northern region, and more than 50% resided in the same province as their workplace.  80% of the workers were married, 20% living separately from their children, and 10% had children with no opportunity for education.  The study also reported that 90% of the workers earned less than 5,000 Baht/month and most of them were satisfied with their job although their living condition was poor, including the employment status, the right and benefits, and the safety issues.  It was rare to see the workers gathering for the protection of their right and benefits.  There was also little support and supervision from government.No less than 25% had such serious illness that they had to stop working during the past year.  The major cause of illness was fever of unknown origin and influenza.  While on sick leave, only one-third of them received wages and support from employer.  Female workers were in worse condition than male, with lower wages, less career opportunity, and more family responsibilities.Recommendation for further studiesSet up guidelines for the protection and reduction of mortality and injury rateConduct a long term study of the family of the workersStudy an organization structure of workers that is suitable for employment status and working conditionStudy problems associated with alien workers and its effect to Thai workers


The study aims to a review of measures and policies on gender and AIDS in Thailand The author would like to propose that from the beginning, the management of the spread of HIV/AIDS and interest around AIDS issues has been characterized by social bias towards marginalized groups, such as gays, prisoners, drafted soldiers, drug users, women in prostitution, laborers who are considered by society as lower class, and women, who, in patriarchal society, are considered the inferior sex.  The role of middle class men, especially white men, as husbands and partners in the spread of HIV/AIDS is typically overlooked (whether intentionally or through the prejudice inherent in the structure of patriarchy).  A great number of men engage in promiscuous sexual behavior and fail to protect themselves, and may in fact be considered a large group with high-risk behavior. Although twenty years have passed, the state still hasn’t made a serious effort to address issues involving this group.  This is despite the fact that data shows that more than half of the people infected with HIV/AIDS are women who have had a sexual relationship with only one man their entire lives, which should be a good indicator of where the problem lies.  	Education around and/or responses to the HIV/AIDS pandemic must include consideration of the importance of sexuality and related issues. because the biological conditions of women make them more susceptible to infection.  It’s because the socially constructed context of gender disempowers women socially, culturally, economically, and politically and makes infection from men easy and with severe impacts.  Social constructs of gender have led hundreds of thousands of women to become infected and hundreds of thousands more to take on the burden of caring for both male and female family members who are infected.The unequal power relations between developed and developing nations places science and technology under the control of Western scientists who adhere to mainstream patriarchal ideology.  Smaller states tend to reproduce these patriarchal structures and accept the world economic order in the era of globalization.  This makes trans-national corporations able to control access to the medicine and vaccines necessary to prevent and treat AIDS. Under developed or developing countries are not able to handle the problem alone due to its magnitude and the economic power and capacity required to access knowledge and information.  The lack of clarity around the origins of AIDS leads to further problems.  Scientists outside the mainstream both in and outside the West come up against barriers in transmitting information and research findings in wider circles.  There is little or no space for natural or alternative methods of treatment and prevention within the larger global media. Knowledge and information concerning women, AIDS, and gender on individual, family, and community levels, as well as among NGOs, groups of people living with AIDS, government, and inter-government agencies, is still quite lacking.  It is necessary to work together at every level to conduct wider research and create discourse on the body of knowledge to be used as a conceptual basis to advocate for the equal rights, creativity, and sustainable development necessary to ensure the human security of both men and women.


Health Promotion in the Support Services Department’s Personnel and their Families	The pilot project of health promotion for the military personnel in the Support Services Department and their families is aimed for altering health behavior, physical environment and social environment. The expectations are hoping them to have better health, delightful office work, warm families and peaceful community without temptation by letting the personnel and member of their families to take part in the activities as much as possible. There were 997 personnel and 1,227 member of their families took part in this program.	The research was assessed by comparing the variation in 3 target groups which are administrators, military personnel and medical staffs, whose in charge of looking after their health, by hold on interview and answer questionnaires collaborating with the activities for brain storming in searching problems and answers, including physical environment survey around their office and their living area.	After collecting data for 1 year, the project was succeeded according to the 18 steps plan. 3 target groups were identified as follows: the military personnel has better knowledge how to keep healthy e.g., smoking was reduced from 26.90% to 24.82%; health problem survey is improving e.g., excess BMI was reduced from 18.21% to 9.43%, high blood lipid was down  from 11.27% to 10.36%; the administrators decided to improve their welfare, accident prevention and alter policy, rules and orders  facilitating healthiness. The promising result from this research can be used as a guideline promoting health to a military personnel at any other Thai Armed Forces’ units.


Health Impact EvaluationFast development of socio-economic environment was regarded as a promoting factor to environmental changes particularly air, water, soil pollution. This change had impact on life quality of Thais and huge expenditures for health care. For example, in 1998, economic value of life loss and injuries caused by road accidents was estimated at 100,000 million Baht. Overall, expenditure for health care represented about 6% of GDP.To reduce that loss, preventative measures and initial correction must be emphasised by all parties in our society. Health impact assessment (HIA) was a new measure to determine level of consequent impact on health. Development of the HIA system was considered important and should be stated in National Health Act.  Issues which should be available in the Act were health impact assessment or environment health impact assessment covering both acute and chronic diseases, injuries, crimes and society violence. The implementation of HIA should not be taken by sole party. Instead, working in alliance form or networking must be promoted with accountability and transparency. HIA was composed of two parts which were HIA under analysis of environment and risk management. Organisations responsible for HIA can be grouped into 3 types. The first group was the organisation responsible for determining policy, measures, standards, regulations and mechanisms for HIA. The second group was the organisations which were evaluated, involved in using information for making decision, the evaluators, trainers, responsible for accreditation, registration and monitoring standards. The third group was the organisations providing community information and performing research and development.Main issues for research and development in short term were as following:preparation for system development, education and human resource development should be firstly done,manual of risk management and health risk management should be developed,HIA under analysis of environmental impact should be strengthened.


Effectiveness and appropriateness of the LEPTO-SCORE for decreasing severity of suspected leptospirosis cases referred to Khon Kaen Hospital: A randomized-controlled field trial in a northeastern province of Thailand	The objective was to evaluate the effectiveness and appropriateness of LEPTO-SCORE for decreasing severity of suspected leptospirosis cases referred to treat at Khon Kaen Hospital. A stratified randomized-controlled field trial was conducted at 4 district hospitals in Khon Kaen province. The suspected leptospirosis patients admitted from July 2000 to February 2001 were included for study. The patients in intervention group who had LEPTO-SCORE of at least 8 on admission or of at least 10 at 12 hour apart was assigned to refer to Khon Kaen Hospital. The severity of referred patients were assessed by using Modified APACHE II score at Khon Kaen Hospital (score of < 10 was accounted to be an appropriate refer). In all, six hundred and eight patients were recruited, 241(39.6%) in intervention group and 367 (60.4%) in control group. Most patients were male (67.9%) with the mean age of 38 years and 86.7 percent were farmers. Twenty-nine patients were referred. The Modified APACHE II score of patients in intervention group (7.5 ( 3.6) was lower than that of control group (10 ( 5.3) without statistical difference (difference = 2.5, 95%CI: -1.9 to 6.4, p = 0.28). There was no significant difference of rate of appropriated refer between both groups (57% in intervention group, 50% in control group, p = 0.73). We concluded that the LEPTO-SCORE trended to be useful for decreasing severity of suspected leptospirosis cases referred to treat in tertiary care center and for development of proper referral system.


Development of Model on Community Based Rehabilitationand Quality of Life Improvement for Persons Affected with Leprosy	The objective of this study is to develop appropriate model for community based rehabilitation (CBR) and to improve the quality of life of persons affected with leprosy (PALs) through the study of their life experiences, problem solving and social processes as well as mechanism that affects their lives. The research was divided into 2 phases which took altogether two years to complete.   The first phase focused on qualitative research using Anthropological tools to collect related information in two villages in Tambol Taladsai, Chumpuang District of Nakornratchasima Province.  The researchers were assigned to live in two villages for three months to learn life experiences of target population and their communities.	Overall findings of the first phase of the study revealed somewhat mild problems of PALs. In comparision with other disables, PALs at different levels of disability appearance, economic and social status, community cultures, including level of emotional and psychological development encountered varying levels of problems and solutions.  Social prejudice varied according to their relationships with relatives and friends as well as social and economic status.  Deformities of leprosy were factors that affected and changed their life style.  Their common wishes were to seek better understanding from their communities that they were completely cured and that they should have been accepted and treated like other disables.  Early findings also found that within the communities there were other disables that should have been helped and socially rehabilitated. 	The second phase focused on the development of the CBR model.  In the beginning the researchers arranged several focus group discussions for people who were interested in and wanted to help solve these problems. The researchers provided appropriate knowledge on leprosy for interested parties as well as arranged appropriate learning process for the communities.  Within a period of six months, key resource persons who had faced and understood these problems planned to find joint solutions under the support of related organizations.  Finally, each village formed a development group for  disables by conducting activities such as surveying disables, bringing them to hospital for rehabilitation, registering disables, raising funds, and organizing stores that disables worked as shop-keepers.  Both villages created disability development centers which still remain function.  	In conclusion, model of community based rehabilitation for PALs started to be concrete through the learning process of the whole communities.  The communities started to have some concerns and gave more opportunities to PALs and other disables.  To reach the solution, attitudes and skills of the disables needed to be changed towards self-reliance.  Learning process and participation of the whole community i.e. PALs, disables, families and community leaders are the key factors towards the success of community based rehabilitation.  To sustain the disables’ capabilities and groups development, empowerment and support from the government and non-governmental organizations together with community paticipation have to be forth coming on a continuous basis.


Family Violence State of the Art Review and Research Promoting System in the Future. This paper reviews research on domestic violence internationally and nationally and suggests the direction of research promoting system in the future. The analysis of this literature considers historical context, methodology issues, concepts and theories related to domestic violence and situational reviews on wife abuse, dating violence and child abuse. As domestic violence is emerging as a significant social problem all over the world, there is a growing body of multidisciplinary research on domestic violence. However there are key issues of controversies in the study of domestic violence including definition, method of measuring and data sources. The review suggested to create the structure and the process of domestic violence research. It is suggested to develop a National Research Center that could collect, process and disseminate reliable information, which can support policy and practice efforts in the field. It will develop data from practice and return it to practice. The Center will cover several areas of study including violence against women and all forms of spousal violence; child abuse and neglect and dating violence.


Roles of municipality in health developmentThe objectives of this study were to examine the implementation of health and health related activities undertaken by municipality according to the roles and  responsibilities defined by law, to examine the readiness of health resources in the health and health related activities, and to gather municipality administrators/personnel opinions on municipality roles towards health development. A survey research design was used and mail questionnaires were sent to 149 municipalities and Pattaya City in Thailand. The response rate was 78.7 percent (118 municipalities). There were 538  municipality personnel responded to the survey questionnaires on municipality roles. The majority of the municipalities  agreed on the present organization structure of the  municipalities of provide health and health related activities to their populations, 57.9 percent and 74.2 percent by muang and tambon municipality respectively. However, 45.5 percent of  nakorn municipalities suggested that the organization structure should be changed to a higher level. Moreover, the analyses were based on 1) roles according to Municipality Law B.E.2496;  2) roles according to Ministry of Interior's regulations B.E.2535; 3) activities in which more than 50 percent of the municipalities could perform 4)municipality personnel opinions towards the roles and activities in reality and decentralization in health activities. The finding shows that most of the municipalities could perform activities in sanitation and environmental health, solid wastedisposal, prevention and communicable disease, health education, nutrition, family planning, immunization, prevention and control of non-communicable diseases, primary health care, dental health, veterinary medical car.  The results show that there were some activities that only few municipalities would do such as medical care after the office hours, inpatient care, surgery, delivery, specialized care for specific diseaes, mobile medical and dental clinic, medical laboratory and diagnosis, toxicology microbiology laboratory, occupational health, antenatal and postnatal care, mental health, and waste-water treatment and quality control. The majority of municipality personnel (75.1 percent) agreed that it was appropriate to decentralize the role and activities in health care to municipality and the resources were moderately sufficient. The opinion on building  municipality hospitals was 38.9 percent and medical centers  95.9 percent. However, the utilization rates at hospital/medical centers were very low : nakorn municipality 65 patients/day, muang municipality 14 patients/day, and tambon  municipality 7 patients/day. Moreover, if health problems  according to important health indicators (Basic Minimum Need : BMN) were considered, they were quite good. However, there are still many problems in which lack of resources especially human resources for health, lack of clear policy, roles and activities, management, and cooperation of related agencies and people were problems in implementation of majorhealth projects.The implications from this study were suggested as follow : 1)Municipality should have the major role in taking care of the health of the population in the municipality area. 2)Municipality should emphasize on health promotion and disease prevention more than curative care and should provide a proactive service by focusing on purchaser's role more than provider's role. The municipality should let other potential public and private facilities being providers.3)Expansion of hospital and medical center should be undertaken only with the case of insufficiency of health care facility, resource capacity, and the need of local people. 4)Municipality should promote and support people to be partnerships in health  and health care for individual, family, and community.      	5)Central gevernment should allocate resources and promote municipality to increase sources of income. 6)In the future, government should fully decentralize authority to municipality      and empower community organizations and people. 7)Futher studies should focus on qualitative and quantitative aspect to cover the areas and health facilities including general population on roles of municipality on health development.


Genetically Modified Organisms have a great potential in national economic development. However, the global market acceptance is presently yet quite limited. Intellectual property, ecological risk, organization, rule and regulation as well as economic analyses indicated that Thailand should impose the so-call “Safe Use of Forefront Technology” policy on GMOs issue. Prior to the acceptance of the technology for the enhancement of the country competativeness, the enacting process to have a complete legal system on biosafety must be accelerated in order to have the system fully implemented within 3 years. Capacity building for government officials who will responsible in controlling GMOs must also be urgently executed. The knowledge on the risk from using and consuming GMOs as well as the responsibility of GMOs developers and producers should be disseminate nationwide. Policy organization and regulatory organization must be permanently established to oversee the GMOs issue. The component and the role of these organizations must be stated in an Act. The above action has to be fully in place before the policy organization starts working. The policy organization will consider and determine the national direction on research, study and utilization of GMOs, especially in an open system. For the time being, capacity building in science and technology must be emphasize on biosafety management. Other research works must aim to obtain a patent able result as well as to serve the demand of Thai society and her markets. A unit in the Ministry of Natural Resource and Environment should be assigned to implement the biosafety regulation. The expense arising from GMOs utilization shall be born to the producer, on polluter – pay principle. The above suggestion is based on the present evidence that cannot yet confirm that GMOs do not pose higher risk than ordinary organisms.


A review of the management strategies of alcohol-related disordersHeavy drinking and alcohol dependence are major public health and social problems in Thailand and worldwide. The alcohol-related problems may arise as a result of a single bout of drinking, alcohol abuse and dependence and may affect not only the drinker but also the drinker’s family, friends and associates as well as others with whom the drinker comes into contact. The enormous social, medical and economic costs of alcohol use and its related disorders have urged a lot of efforts to improve prevention and treatment techniques for alcohol-related disorders worldwide. Both alcohol consumption and alcohol dependence exists within continua, i.e.; consumption and problems range from abstainer without any problem to heavy drinker and alcohol dependent with substantial or serious problems. Likewise, there is a continuum of response to alcohol-related problems, ranging from primary prevention, secondary prevention to specialized treatment. The public health paradigm of prevention should concern the interacting elements of agent (alcohol), host (the drinker) and environment. Therefore, the prevention strategies should include measures taken to modify the environment and to change individual behaviours. The overall management components are consisted of prevention activities directed at drinkers in general, problem drinkers and those at risk for developing alcohol abuse and dependence, early identification and intervention of nondependent drinkers and treatment approaches for those with alcohol dependence problem.The purpose of this review was to analyse international scientific papers on existing prevention and treatment programs for persons at risk for developing alcohol-related problems and persons who already have had such problems. It aimed to provide an overview of the current state of the research on the effective intervention and management measures of alcohol-related disorders for general practitioners and other health professionals, for researchers, for non-health professionals and those responsible for making policy decisions on health care expenditure. The review was divided into five chapters: 1) Definitions and terminology of alcohol-related disorders and impact of the problems, 2) Primary prevention strategies, 3) Prevention strategies for alcohol-related traffic injuries, 4) Secondary prevention strategies, and 5) Tertiary prevention strategies.Primary prevention focuses on general population including non-drinkers, hazardous and harmful drinkers and alcohol dependent individuals. The comprehensive prevention policy of alcohol problems has three principal components; control, education and the provision of alternatives. Control measures comprise legislation and laws on the alcohol advertising and media portrayals of alcohol, alcohol beverage container warning labels, alcohol sales and price of alcoholic beverages and the minimum drinking age. Education measures include school and community-based programs and mass media campaigns aimed at changing individual behaviours.Prevention for alcohol-related traffic injuries is composed of four strategies; general deterrence, specific deterrence, community-based prevention programs and mass media campaign. General deterrence is based primarily on enforcement and publicizing of laws concerning driving under the influence of alcohol such as legal blood alcohol limits for drivers, zero tolerance law, random screening of drivers and administrative per se laws. Specific deterrence is based on changing the behaviours of those drivers who have been identified as driving under the influence of alcohol. The drivers’ behaviours are controlled to a certain degree by the imposition of a penalty like fine, loss of license, mandatory jail or remedial treatment. Examples of specific deterrence are mandatory jail, certified driver intervention program and alcohol ignition interlock. Other strategies used in the prevention of drunk driving are alcohol server training program to promote responsible beverage service, mass communication campaigns to increase the general public awareness of the risk of drunk driving accidents and change individual behaviours, designated driver and community action programs.Secondary prevention emphasizes early identification of those at risk for alcohol-related disorders and problems and providing appropriate intervention before they become dependent on alcohol which treatment yields unfavorable outcome. Early intervention is a proactive measure, composed of early detection of the problems by means of screening instruments such as questionnaires or laboratory methods and brief intervention for those detected as hazardous or harmful drinkers. The commonly used screening questionnaires for alcohol dependence and hazardous or harmful use are Michigan Alcoholism Screening Test, CAGE and AUDIT. Laboratory methods can be used to identify markers for recent alcohol intake (blood alcohol concentration), heavy or hazardous drinking (gamma glutamyl tranferase and other liver function tests), alcohol-related liver diseases and susceptibility to alcohol dependence (mitochondrial ALDH genotype). Brief intervention is a clinically based, cost effective, time efficient intervention designed to counsel nondependent problem drinkers about strategies to reduce their alcohol consumption. The ultimate goal of brief intervention is to prevent future alcohol-related health problems and injury. The principal components of brief intervention include 1) Feedback, 2) Responsibility, 3) Advice to change, 4) Menu of strategies, 5) Empathy, 6) Self-efficacy.Tertiary prevention includes treatment of the alcohol dependent individuals and a long-term management program to prevent their relapse to drinking.  Treatment process can be divided into four phases; 1) preparation phase including history taking, physical and mental examination and laboratory tests, 2) detoxification phase as an out- or inpatient case, 3) rehabilitation phase and 4) post-rehabilitation phase when patients return to their families and society. Pharmacological treatment of alcohol dependence has five main objectives, i.e. reducing alcohol withdrawal symptoms, reducing alcohol intoxication symptoms, reducing alcohol consumption and preventing relapse, preventing alcohol craving, and treating co-morbid psychiatric illness. There are several methods used for psychosocial intervention of alcohol use disorders, including 1) cognitive behavioral therapy, 2) supportive psychotheray, 3) behaviour therapy, 4) community reinforcement approach, 5) psychodynamic/interpersonal therapies 6) brief intervention, 7) marital and family therapy, 8) interactional group therapy, 9) family psycho education and family therapy, 10) aftercare service, 11) Self-help group (Alcoholic Anonymous and Alanon).


The Development of Public Health Budget System for Efficiencyand Equity of Budget Allocation and Administration at the Policy Level	The current public health budgeting system is largely determined by the Budget Bureau, the Ministry of Finance. Its obvious weak points are the existence of budget ceiling which responds neither people’s demand nor needs, lack of outcome-based activity evaluation, and the use of historical base budgeting system in which new activities are less likely to initiate. Two main objectives of the public health budgeting system should be on improvement of resource use equity and efficiency. It is suggested that health services be grouped into their hierarchies to lessen the existing current problems in addition to using health service information for categorizing such services.


Samut Sakhon, a small province in Central region has three districts, Muang, Banphaeo and
Krathumbaen. Banphaeo hospital, the first autonomous hospital in Thailand through Public
Organization Act, 2542 BE. will be financed through capitation according to population size in the
district. This will have significant changes to financing mechanism at provincial health office and
health centers in the district. The objective this study is to assess unit cost (covers labor and material
costs, excludes capital depreciation costs) of services provided by health centers in order that
Banphaeo hospital could fairly purchase care from health centers. We assess operating cost in fiscal year 2542 BE., among all health centers in the province. Staff time allocation survey was done to
allocate labor cost to various key activities of health center, material cost was directly collected for
each activities. Cost from general administration and reporting function were allocated to service
activities using simple allocation method.
Results: operating expenditure per capita population at health center was 120 Baht per year, (110
Baht from health centre and 10 Baht from District Health Office). Annual operating expenditure was
834,136 Baht per health centre, of which 56% was labor and 44% material cost. Each health center
was staffed by 4.16 health workers. Time allocation reported 22% contributed to curative services,
27% to administrative function, 18% on health promotion activities and 30% community based
services. Curative services consumed 40% of total operating expenditure, most were drugs and
supplies. Unit operating cost for curative service at health center was 59 Baht per visit (range 53 to
65), health promotion and mother child health services was 100 Baht per visit (range 88 to 120). If
cost from District Health Office was included, unit cost would increase by 9%. Unit cost was
influenced by staffing intensity, magnitude of labor cost and productivity. Unit cost is one of several
tools for proper resource allocation.
This study provides evidence on how hospital could purchase services from health center that reflects
operating cost. Several options are capitation base on population size, total cost inclusive for each
group of activities, or unit cost per service rendered. It depends on how to stimulate proper service
behavior by health center. However, current funding available at health center from central
government and local administration should be taking into account to purchase services from health
centers.


Objective: To establish a national registration of acute coronary syndrome (ACS) registry in Thailand in order to study clinical epidemiology, determine the demographic, management practices and in-hospital outcomes of patients with ACS.Methods and results: Thai ACS registry is a multi-center prospective project of nationwide registration in Thailand. The enrollment of the patients started in August 2002. After one year, records of 3025 patients were collected from 16 hospitals. The patients were classified as ST elevation myocardial infarction (STEMI) (38.9%), non-ST-elevation myocardial infarction (NSTEMI) (35.6%) and unstable angina (UA) (25.5%). The mean age was 64.5 years old with 59.8% of male and 40.2% of female. The cardiovascular risk factors were 44.8% of diabetes mellitus, 62.1% of hypertension, 68.9% of dyslipidemia, and 31.9% of smoking. About 52% of the STEMI patients received reperfusion/revascularization therapy. The median time of door to needle was 100 minutes in patients received thrombolytic treatment and only 11% of them were received within 30 minutes after admission. The most complication of congestive heart failure was found 42.1% in ACS group. The total mortality rate was high in STEMI (16.2%) followed by NSTEMI (11.7%) and UA (3.1%) respectively. The mean length of hospital stay was 10 days.Conclusion: Thai ACS registry provides a detail of demographic, management practices and in-hospital outcomes of the patients with ACS. These data may have an impact on our health care system and alert the government to make a policy for these problems


This  study  is  an  action  research  phase I :  situational  analysis.  The  objective   is to    study   about   the   inappropriate   behavior  to  injection   between   a   provider  and patients at  out  patient  department  of  Rasrisalai  District   Hospital.  The  study   units are  composed   of  6   doctors,   5  ER  nurses ,  and   403   patients  who  got    the  1  out  of  12  common  injection    drugs and 517 oatrenh who did not get injected dngs.  Data  collection   had  been   corrected    since   1 st    April    1998  until  30th     November  1998. The  instruments  are  the standard  criteria  for   12  injectable  drugs ,  questionnaire, medical  record  and  the  treatment  assessment  format.  Data  analysis tool are  percentage ,   mean  and  Odd  Ratio.         The  study  shows  that  48.9 %  of   the  providers  (doctors  and  nurses) have the  inappropriate  injectable   behaviors.  Gentamycin   and  Vitamin  B  complex  are  the  most  common   drug   to  be  use  (92.3%).  Over   use    is   the  most  common   pattern.  Patients  have   the  good  attitude  for  injection ;  for  instance  rapid  action  and   recovery,   comfort  and  clean.          The   study  indicate   that  there  is  the  overuse  of  injection  drug in  Rasisalai Hospital .    So  we  should  have  the  standard  process  to  treatment assessment ,  in order to   get  the   basic   data  to   change  for  good behavior.   In  the  same  time ,  we   should  create   same guidelines  to  change  the  patient, s  belief  and  value.


This study provides preliminary estimates on effects of the 30 Baht Scheme and the universal health coverage program on households cost savings and on poverty reduction. The estimates employ data mainly from two nationwide surveys-the socioeconomic survey (SES) and the health and welfare survey (HWS).	In terms of poverty reduction the study compares over time the percentage of those who were impoverished because of health care expenses using data from SES. The figures are drawn from the households that had per-capita income more than that of the poverty line, but had after-health-care income (gross income after subtracting households health expenditure) that fell below the poverty line. We find that percentage of these impoverished group had been declining from 2.15% of total households in 1992 to 1.84% and 1.53% in 1994 and 1996, 1.1% and 1.3% in 1998 and 2000, and 0.7% in 2002. The early declines could be attributed to the expansion of Health Welfare Program for the Low Income Group to cover the elderly and children in 1994 and its subsequent financing reform toward per-capita budgeting that took place between 1998-2000. The recent decrease in 2002 is most likely results of the 30 baht scheme (plus a small effect of the coverage expansion of the Social Security in mid 2002). Based on these figures, the impoverished households that were caused by health care burden decreased by two-thirds as a result of the coverage expansion toward universal coverage. The above finding is similar in all regions but are more pronounced in the rural areas.	We also measure number of households that become impoverished because some member were hospitalized. We find, however, that number of this types of households are rather small—ranging from 1/7 to one fourths of those were impoverished because of health expense. This finding suggests that a comprehensive universal coverage scheme that also covers major outpatient expense would still be crucial if poverty reduction is considered a main objective of the universal health coverage program in Thailand.


Consumer protection in health insurance system intends not only to facilitate the benefiaciries to efficiently utilize their health benefits but also to indirectly expedite the quality of care. The study aimed to summarize the existing situations and make the policy recommendation to improve the consumer protection system in health insurance system in Thailand that comprises three main health insurance schemes including National Health Security, Social Security and Civil Servant Medical Benefit Scheme.  The scope of consumer protection system in the study has covered on five issues of people’s rights as follows: the right to access to needed care through health insurance, the right to access to quality care, the right to access to complete benefit package, the right to participate in health insurance management and the right to access to necessary information.  Focus group discussion, questionnaire survey and documental review were used for data collections.  Focus group discussions were employed to collect the current situation of consumer protection in target groups as wll as to suggest policy recommendation.  The people’s opinions toward health services quality under the National Health Security were collected by using questionnaire survey. The documental review was performed to gather the information needed for people to efficiently utilize health services in their health insurance schemes.  Preliminary data was also sent to community representatives in Provincial Health Security Sub-committee to make comments before finalizing the report.  The results show that there still have been several problems regarding the people’s rights such as the problems of uninsured groups due to no ID Card, low people’s confidence in quality of care and medications especially for high cost care and medications, the problems of specific groups of people who could not access to health benefit package such as the disability, patients living with HIV and AIDS and the informal sector workers, lack of or inadequate information database for general people, and low level of people participation in health insurance system. The crucial policy recommendations to strengthen the consumer protection system covered in the report are: 1) actively searching for uninsured groups by cooperating with civil groups or not for profit non-governmental organizations, and financial supporting to hospitals that are responsible for these uninsured; 2) accelerate the process of external accreditation in all levels of, and both public and private health facilities, 3) people have to participate in all levels including policy formulation, health insurance management by acting as local purchasers and hospital committee, service providers especially health promotion, monitoring service quality and the completeness of benefit package provided, managing complaint, and disseminating the essential information to people especially in the remote areas by getting financial support from the government to help people in communities to set up “Community Health Insurance Center”; 4) the essential information that needs to be widely distributed are composed of the information for selecting the hospital, the information for deciding whether or not to receive some controversial health services or second opinion and the information to increase basic knowledge about health insurance and health service utilization.