The evaluate of the allowance for the elderly	The study of structure of the subsistence allowance for the elderly has the purpose that to evaluate the execution of welfare service for the elderly in the allowance project including the study the problems in the past in qualitative and justice in the society and seeking the guideline to development the desirable pattern of the allowance projects in the future. 	The method of study is the qualitative by interviewing the relevant groups i.e. the elderly who are allowance recipients and non-recipients, family members of the who are allowance recipients and non-recipients elderly including the committees of allowance recipient selection in the village (committee of the village welfare assistance center) and the responsible persons of the allowance in the provincial public assistance. That is the data collection together with the quantitative data collection from the exemplars of 360 persons in 9 provinces (19 districts) i.e. Chiang Mai, Tak, Nakorn Ratchasima, Nong Bualumpu, Phra Nakorn Sri Ayudhya, Trad, Nakorn Srithamarat, Satun, and Nakorn Pathom, by analyzing the data in description with the statistics.	The project of allowance has been paid interested highly as the government is trying to change the pattern of services from the institutional case to the deinstitutional care and make an effort to have the community participate in solving the community’s problems with the concept community-based. The project of allowance has started since the year 1993 under the responsibility of the Department of public assistance with the budget yearly not less than 1,440 Baht for 400,000 persons of the elderly by selecting the poor relatives without relatives and supporters from village 5 persons qualified to receive the allowance. The results of the study are as following.1. the elderly recipients of the allowance can be classified into 3  categories as below1.1 the poor elderly but looked after by descendants, not left lonely, still supported by the family, living at the center of the village. Moreover, the relationship with the village committee They are the group that received the allowance the highest. 	1.2 the elderly with the descendants, not so miserable with  the middle-class income, mostly are close relatives  of the village committee or the head of the village. This group will get the allowance high next            1.3 the poor elderly, miserable without relatives or descendants who left to work elsewhere, mostly living alone by themselves far away from the village center, not participating in the activities of the village, sometimes  looked after by others who sympathized them , mostly will  not receive any social welfare service. As they are regarded as  the “peripheral group” in the community, they will  get the allowance the least	2 the concept of management of the allowance to arranging the allowance for the community is community-based by decentralizing so the community can cope with their own problems, but in the practice it is found out that it lacks the effort in encouraging the real participation of the community. Even the elderly as the residents in the community do not participate in deciding, assessing the   problems of the community by themselves. Therefore,  the village welfare assistance centers  with an aim to considering the allocation of allowance has been established in quantity, lacking the methods to develop, strengthen the centers as the operation of most of the centers is regarded as the additional task, lacking the monitoring and assessment of the problems.	3. the thought in its operation is still based on individual affairs as it is arranged to the poor elderly in the residual welfare model only. However, in the real operation it is not decentralized to the target groups thoroughly. The rules in selection of the elderly still lacks the standard, fairness, and the consideration based on the principle of means-test  	4. the authority’s mind is still attached to the patronage system. The providing the allowance  is unduly considered based personally on intimacy, the intention to expand political power.  While the selection process lacks the investigation, monitoring, the consciousness building of welfare among the selection committee. The unfair allocation of social resources will cause the conflict rather than the stability in the community.	5. the problems of disembursement of the allowance, caused from the unfair process of allowance management i.e.the amount and the period of providing the allowance not regularly counted. The reduction of the allowance as the transportation fee in traveling to get the allowance payment, the lack of knowledge in opening the deposit account at the bank in one’s own names, causing them unable to check the account books by themselves and protect themselves. The lack of the assessment and investigation about the fairness and transparency of  its operation and the support of information system can be raised as the reasons.	6. the accomplishment of diffusion and expansion of service of the elderly i.e. increasing the number of the allowance recipients has been counted in quantity rather than the quality. Even though, the poor elderly still cannot benefit from this increasing  number of allowance recipients   	7. the satisfaction  the elderly are satisfied with the allowance even the amount of the allowance is not enough for their real living. For the real poor elderly, they feel as they have been more socially guaranteed, credited with dignity. The such amount of allowance can respond to their social value, belief and culture as well. 	8. the appropriateness and justice   the welfare allowance is provided in form of the diffused payment as the temporary assistance. Meanwhile, it is used in continuation, cannot fix the period, has no guarantee in the expenditure plan. Moreover, most of the target groups who receiving the allowance are not so qualified, thus this project cannot serve well to solving the social injustice.	9.the participation in operation  it still lacks the process of seeking and mobilizing the participation to help all levels of its operation, including the promotion of welfare consciousness among the concerned persons, that discouraging and weakening the dedicating spirit for the community	10. the self-reliance and sustainability of the project   the pattern of the welfare service cannot sustainably empower and strengthen the elderly for long, as it function as the public assistance only, lacking the reinforcing process or pattern of coordinating  with other organizations, that does not result the desirable self-reliance. Moreover, as the welfare service of public assistance is conducted individually based, it will encourage the individualism rather than complement to the collectivism or communality


Korea is one of OECD countries in Asia, which had high economic growth and could achieve universal coverage of health care shortly, only 12 years of development by setting limited benefit package in addition to low contribution rate. Rapid expansion of insurance coverage and benefit package was accordance with country’s high economic growth. In addition, political context is also crucial for the achievement, conflict between the North and South Korea and military regime tried to obtain legitimacy in the process of gaining political power, furthermore, integration of insurance schemes was succeeded during new popular political party become a government.	Legislation is the main mechanisms of reform in Korea in addition to strong political commitment.  Strategies of reform included expansion of insurance coverage and benefit package, redeployment of health resources, quality improvement, structural reform of insurance system, reform of payment mechanisms and separation of drug prescribing and dispensing role, and increase investment in health promotion.  Even Korea succeeded in achieving universal coverage some problems remained. For the recent reform, there is not enough evidence to show success and it’s still too early to evaluate. Success in reform is determined not only by appropriate designed of the reform but also political factors, especially, political factor in the health sector.


The Health Status Researcher Network Programs, one of the Health Intellegence  Network programs, are immensely supported by Health Systems Research Institute, Thailand. The objective of this programme is to generate linkage among researchers, health experts and those who are interested in interlinked network collaboration, but organize independently, on the basis of data characteristics and their applications.	The program, initiated in July, 2001 is of reviews for selecting suitable health status measures for Thailand. Further developing these indicators for use at the local and national levels is the program’s next step.	It is proved that the importance of measures for assessing health status of population becomes ever greater. Firstly, findings from the process for preparation of REPORT on HEALTH of THE NATIONS,Thailand  2000 ,clarified that data were available but these scattered data are not systematically well-organized for shared usage. Data generation and analysis, besides data collection, is relied mainly on each individual organization or researcher’s interest, which leads to lack of overall consistency and reflection. Secondly, Thailand is currently in the midst of transitional environments such as devolution and health system reforms. Inevitably, such changes  affect on national, provincial and local restructuring that encourages operational mechanisms of such levels to be more autonomous. The decision making process, therefore, requires locally specific data in order to manage to its fullest capacity. Also, preparing provinces or other subnational-levels for sufficing their own data for measuring health status, disease burden and system performance is needed. Lastly, standard concepts and definitions, most importantly, applied in the context of health care reforms, are needed to make a clear aligned understanding in describing or measuring health systems, health promotion or disease and injury prevention, which, in various countries, are currently adjusted for policy efforts. For instance, health promotion has become a critical procedure in monitoring public policies. In the new health systems, new tools are needed for making development at both national and local levels. The objectives of this program are toSearch for indicators measuring health status of Thai populations utilized appropriately at the  national and provincial levels.Establish researcher networks for developing a consistent and sustainable system of population’s health status assessment.Develop local- area researchers through capability buildings and establish extensive networks at all levels.Generate a health status assessment manual that is for use at the provincial level.Disseminate health status and related reports periodically.The first phase of this program centers on reviews of global and national health status indicators, having consistently been developed, thereby, presenting proposed indicators that are appropriate for Thailand at the provincial and national level application. Moreover, such measures can be used for inter-country comparisons for overall and sub-level reflections by age and geographic distribution.Such reviews include 1) consideration of concepts, theories, definitions, advantages and disadvantages of each indicator used for measuring health status of the population, problem prioritization, cost-effectiveness, and equity. 2) consideration of data sources in respect to systematization and reliability. 3) consideration of feasibility of the indicator application at the local level.  Based on researcher team’s expertise and indicator characteristics, the reviewed measures are broadly classified into 3 categories; namely, Basic Demographic Measurement, Negative Health Measurement and Positive Health Measurement.Basic Demographic Measurement, of which is not only themselves the fundamental indicators in directly reflecting the health state of population, but also the basis for calculating rate and other substantial health status indicators, in particular applied for use at sub levels such as the health service area or the provincial area. Quantitatively, ample data gathered from each sub area will be further aggregated into the national measures. Difficulty of sub-area measurement is a lack of data quality and reliability; therefore, development of database together with data generating agencies, such as Central Registration Office and National Statistics Bureau, is tremendously urged. Proposed indicators include number of population classified into size, age- sex structure , life table, infant mortality rate, maternal mortality rate, age-sex-specific-mortality rate, birth rate,total fertility rate, which are all presented at the provincial and national level.Negative Health Measurement defined by World Health Organization encompasses many different dimensions of health and functioning, and complex interaction with environment. At present, dynamic environmental transformation has brought greater evolution from single indicators to composite index and summary measures of population health, broadening area of health measurement. These measures are reflection of the unfinished health agenda and identify area where health gains can be made. This assists the national, as well as sub-level policy makers to make use of health policy and planning, including further determination of proper intervention. Proposed indicators regard cause-specific-mortality rate by age and sex, Year of Life Loss(YLL), incidence rate, prevalence rate, case-fatality rate, duration of disability, and natural courses of diseases and Year Loss due to Disability(YLD). Disability-Adjusted Life Years, the aggregate measure of YLD and YLL, and Disability-Adjusted Life Expectancy are included. 3. Positive Health Measurement mirrors the dimension of positive health in response to a paradigm shift in health system reforms from “cure-oriented health” to “promotion-emphasized health”. Life Expectancy or life longevity is not sufficient to measure life with good health. As a result, World Health Organization proposed Healthy Life Expectancy; that is, DALE or HALE in World Health Report 2000. In addition, developing indicators for measuring good health state of Thai persons at the individual level is necessarily encouraged in light of fully reflecting well beings covering physical, mental, social and spiritual dimensions, and, more importantly, being optimal for Thai society. This will result in accomplishment of health promotion policy. These developed measures are eventually called Healthy Thai indicators.The next step of this programme is to develop and test the proposed indicators, to develop health information system database in the targeted provinces, to establish local researchers and create extensive networks, to disseminate reports and data for interrelated communications among researchers and health experts, and to  institutionalize of knowledge pools of measurements for assessing health status of Thai population.


Influence of business on child care center and parents: Potential impact on early child healthThe objective of this study is to investigate the potential impact of the relationships among business-child care center-parents on health of young children. Parents of the under 5y-old children and directors of child care centers were interviewed. Data collection was conducted in the Muang district and the vicinity of Khon Kaen, Chiang Mai, Songkhla and Bangkok during November-December 1999. The studied variables included: general information on children, parents, director and child care centers; marketing activities, product brand name and type of activities; opinions on relationship between business and child care centers; and impact of these activities on parents' choices. The designed questionaires were reviewed by the experts and pre-tested. Descriptive statistics were used to analyse the data. Possible impacts on child health of the product named by the interviewee were derived from the experts' opinions. Four hundred and thirteen parents, 90 nursery directors and 145 kindergarten directors were studies. Most of the interviewee were mothers. Twenty-two percent of the studied parents had a university degree, more than half had a monthly income over 10,000 baht. Most of the child care center's directors were also female, got a aniversity degree and have worked more than 10 years. Nine percent of the studies parents sent their children to the family day care.Over the past year, the child product business has organized various marketing activities at the king dergarten 2-3 times more frequently that at the nursery. At the nursery, the businesses which most frequently used direct sale promotion with children and parents were those selling dairy products(23 times), supplement food/breakfast(16 times), and vaccines (12 times). For direct sale promotion to children and parents at the kindergarten, the businesses frequently and this chammels  were supplement food/breakfast (94 times), dairy product(48 times) and soap (41 times). Child care centers had a great influence on parental choice of child products. Sixty nine percent of parents have ever been adviced. For the top ten products recommended by the child care centers, 46.2-88.9% of the advicee consequenthy used them.  They were baby powder, tooth paste and soap, respectively.  Most of these products are appropriate for child use and not harmful to health.  Two items narmely chicken pox vaccine and chicken essence soup, are not necessary for young children, and the other two items including crispy snacks and anti-bacterial soap are not appropriate for long-term useResults of this study demonstrated the high influence of child care centers on parental decision of child product choice, the influence of giving free samples in change of parental consumption behavior and the acceptance of business marketing activities of child care centers. Measures and regulations should be set up to control business activities in child care centers for the benefits of young children.


This study was aimed to study the health promotion and disease prevention (HP-DP) service for children from birth to five years old, and the health service behavior of children under universal health coverage policy.  Descriptive design with indepth interviewing was used for data collection.  Subjects were documents, 1000 parents who brought the children to receive HP-DP service,  12 health care providers, and experts.  Data were obtained by using questionnaires and interview guidelines.  Findings were as follow:	1.	All levels of health care service, university, regional and community hospitals and primary care units, have provided HP-DP service in the settings both before and after the institution of the universal health coverage policy.  New institutional policies, guidelines, manpower allocation, staff development or resource allocation were not implemented to support the national policy.  Service was extended to the community as well.  However there was limitation of personnel and time.  Many health care providers did not know about the new benefit package for children from birth to 5 years old.  In addition they had limitations in developmental assessment, developmental stimulation or promotion, developmental promotion corner arrangement and providing recommendations on child rearing.  Thalassemia screening for children whose parents showed traits or had the  disease, and hypothyroid hormone testing for children with indicators,  were rarely done.	2.	The old and new benefit packages for health promotion and disease prevention in children from birth to five years were not much different.  However the services recommended in the United Kingdom and the United States included family history; genetic history; vision and heaving testing; mother-child interaction; details for parental advice for child in each age group concerning food, oral care, accident prevention and developmental promotion; and empowering parents in child care.  The recommended activities were consistent with the recommendations by the Royal College for Pediatricians and experts.	3.	Children’s health service behavior or parents’ behavior in coming for HP-DP service.  Mothers were found to be the ones who brought the child to the well baby clinic more than other persons.  Most mothers were workers, housewives and public servants.  They selected to receive the HP-DP service at the hospitals because their children were born there and they were rear home or office.  Most received services were weight and height measurement, and vaccination.  Developmental assessment and advice on child rearing and developmental promotion were limited.  The health service behavior of children both before and after the universal health coverage policy was not different.  About 53.3 percent of parents felt the same level of satisfaction with the service provided.  The services on height  measurement, vaccination, developmental promotion, health assessment and advice treatment when the child was ill were found to differ statistically significantly  at p <.001


The objective of the study on solving anemia in pregnancy living in Sriratana hospital’s catchment area is to decrease iron deficiency anemia in pregnancy through operational research using participatory group process. Data were collected by means of questionnaires, weight and height scales, antenatal care record, record of group process and laboratory investigation including packed cell volume (hematocrit) and screening for thalassemia (DCIP-KKU clear test, Osmotic Fragility test). Various medias were used for disseminating basic knowledge, control and prevention of anemia and related issues in group discussion. All pregnant women living in villages in the catchment area were participated during November 2000 to October 2001. The results showed that using participatory group process to perceive iron deficiency in pregnancy and to formulate solutions has an effect on correcting knowledge, attitude, and behavior to prevent and control iron deficiency anemia statistically significant. In addition, 11 programs had been generated to make other iron food sources available, to disseminate knowledge of iron deficiency anemia and motivate pregnant women attending antenatal care service at first trimester. The outcome of intervening programs indicated that 41.2 % of pregnant women attended first ANC at pregnancy age less than 12 weeks. And, 76.5% took iron tablets regularly according to the prescription. These findings consistent with the increasing of mean packed cell volume from 33.3% (95%CI: 32.3-34.4%) at first attending ANC to 36.8% (95%CI: 35.9-37.6%) at pregnancy age 28-32 weeks. Anemia in pregnancy also decreased from 36.8% to 16.7%. It is concluded that participatory group process in perception of anemia in pregnancy will decrease anemia in pregnancy and results in cooperating between health facility and community.


Need and want analysis for public health information servicesThe purpose of this study is to explore the needs and wants of nine target groups in using health information : the massmedia practitioner, the public health personnel, the teacher, the housewife, the factory worker, the community leader, the teenager, the working adult, and the elder. The study employed the qualitative research method. The data was colleccted by the technique of in-depth interviews and small focus-groups access  745 key informants who were  members of nine target groups and lived in Bangkok and Chiengmai. The results of the study were as follows : 1.All nine target groups felt more the need for health information concerning various types of deseases than for of health information concerning good health. 2.The finding indicated different purposes using health information among the nine groups. The mass media practitioner, public health personnel and the teacher used health information for their professions. The houswife's purpose was to  both take care of herself and others in the household. The teenager and the elder used the information just for themselves. The working adult and the factory worker did not pay much attention to health information. The community leader was the  only group which  wanted to develop their capacity to use health information.3.The importance of needs and wants in using health information depended on the relationship that one has to the care of others  ; for example, nurses have to take are of patients, teachers   have to teach students, housewives have to take care other people in the family. 4.The proper way to respons to the needs for health information is to start first by creating attention/interest in health information. Then, by using the communication strategies which are compatiable with the target group, to associate the information with their previous understanding.  It is important as well to use the medium as which target groups indicated as their preferred source of health information.


การเกิดซ้ำของหินน้ำลายและเหงือกอักเสบในนักเรียนประถมศึกษาที่รับการขูดหินน้ำลายโดยเจ้าหน้าที่สาธารณสุขระดับตำบล  อำเภอโชคชัย  จังหวัดนครราชสีมาRecurrent of calculus depositions and gingivitis in primary school student that scaled by healthworkers at District Health Centers inAmphur Chokechai Nakhonratchasima provinceThe aims of this study were to compare the recurrent rate of calculas deposition and gingivitis in primary school children aged 10-12 years between a group of schools that performthe systematic tooth brushing after lunch program (implementation group; imgroup) and a group of schools without the systematic tooth brushing after lunch program (Comparison group: Cm group)  in Chokechai district. Groups of 4 schools with 141 and 147 schoolchildren were proposively selected from the related criteria. Every subjects received calculus scaling by trained health workers. Data collected by oral examination with Volpe - Manhold Index for calculus, and gingival Index for recording gingival status, 5 and 8 months after scaling by 1 examiner. The results showed that the recurrent rate of calculus deposition between the implementation and comparison groups were significantly different at both 5 months and 8 months after scalling (p=0.1, 0.2). The percentage of subjects in Im group who had no calculus deposited at 5 and 8 months period were 45.4% and 27.0% respectively. While the rate in Cm group were 30.6% and 19.0% respectively. Gingival status between two groups were not significant different at both 5 and 8  month period (p=0.25 and 0.94). It was found that only mild and moderate gingivitis were observed with out any subject with severve gingivitis. The results indicated the low effectiveness of the actual scaling campaign in primary schoolds.


According to the present constitution, the standardized and efficient health information service through information structure is the one required for the public equally.  The information infrastructure that is an alternative for providing public health information consists of three network; telephone, cable TV, and internet.The research team considered four alternatives in providing health information to the public using telecommunication technology and the internet.  The four alternatives were: Information service via Web site (one-way communication via internet), Consultation service via Web board (two-way communication via internet), Information service via audiotex (one-way communication via telephone), and Consultation service via audiotex (two-way communication via telephone).  The target group of the first two alternatives was teenagers, media, working people, doctors and public health officers whereas that of the last two alternatives was major population of the country.The study showed that the unit cost of the four alternatives in the year 2005, ranging from the least to the most, was Information service via Web site, Information service via audiotex, Consultation service via telephone, and Consultation service via Web board.  The difference in cost depended on three factors: frequency of using services, the necessity of using staff to provide information, and the cost of supporting equal information to all target groups.Before providing services to a full scale, it is recommended that the Ministry of Public Health (MoPH) evaluate the outcomes of each service provided at present as to how beneficial it is to the public, whether the service is provided right to the target group, and what the problems/obstacles are.  The MoPH should also play an important role in carrying out or promoting the services using three guidelines: providing direct services by the responsible unit, supporting the community in providing services, collaborating with private sectors and media, as well as developing network similar to Canadian Health Network and apply it to best suit the Thai situation.


The steering committee of health policies and strategies development for health manpower was appointed by the National Health System Reform Committee in May 2003. The committee secretarial tasks done by the Health System Research Institute and researcher team. The mission of the steering committee is to develop and present policies and strategies of health manpower under the changing situations of the Thai health care systems and its context. The secretarial team is carried out process were the documentary reviews and structured interviews, including various sub- committee meetings. The spotlight of the contextual changes in all aspects are described in the introductory chapter which focus on issues that needed carefully consideration. The main report describes results and recommendations with major principles for developing policies and strategies on health manpower. Three main topics have been discussed and concluded, these are:Components to be achieved on policies and strategies for health manpower;Initial plans for further action and;Short- term and long- term mechanisms for system development on health manpower should be based on concert efforts of various organisations. Such mechanisms are to be  functional units that linked with accumulated knowledge and national policy development. By summary, the future proposals for action should be pragmatic and relevant to the governmental policy toward the national policy on universal coverage. Under the contextual changes, health manpower policies and strategies should be grounded on the "demand driven" idea and responsive to basic and specific health needs of the entire population.


The main focus of this qualitative research was to explain folk and popular health care systems concerning promoting health of the middle-aged women residing in Lanna society. Study settings included an urban community, a semi-urban were 55 women, aged between 40 and 59 years old, and nine practitioners working in folk medicine. Data were obtained through the use of focus group discussions, in depth interviews, and participation and non-participation observation. Data were analyzed using content analysis, indicating the main themes, categorization, and mapping the connections. The major results of this study indicated that there were three alternative health care systems for middle-aged women: popular, traditional, and modern health care systems. Regarding the definition of health, the middle-aged women defined ‘health’ as a multi-dimensional aspect including the dimension of physical, mental and physiological function. Therefore, good health, according to these women, was referred to the state of physical fitness, being free from disease, good and happy mind, and being able to function activities. It is also interesting to note that marital status and child bearing was indicated to influence women health. In the period of middle-aged, the women preferably called as “golden age”, a period of various changes had been occurred physically, mentally and emotionally. Some women might call this age as “confusing age” because of uncertainty concerning whether the way they acted was appropriate. Further, the middle-aged women perceived that their age was high risk of developing disease and was irritability. Regarding the management of the physical changes, it was found that the management was depending on the severity of the symptoms. For mild symptoms, there was no special activities performed. Some women used daily activities, traditional herbal sauna, and Thai traditional massage. In case of having severe symptom, the women preferred to seek help from modern health care services, either public or private sector. It the treatment was unsatisfied or ineffectiveness, they would further seek help from traditional practitioners. Concerning the management of mental and emotional changes, almost all middle-aged women stated that they preferred to do mediation, hobbies and listen to Buddha teaching. It worth to note that the concept of health promotion among the middle-aged women was not clearly defined. Nevertheless, they pointed out many activities leading to good health. These were taking good nutrition, exercise, doing leisure activities, and taking tonic medicine or folk medicine. Hence, the results indicate that to promote health of the middle-aged women, it is of great important to modify health care service policy from curation to health promotion and disease prevention. This is anticipated to develop the concept of health responsibility among the middle-aged women. The modern health care services, therefore, should focus on primary or secondary prevention rather tertiary prevention, and such services should be in accordance with culture, beliefs and lifestyle of middle-aged women.


Current Problems of Controlling TB (Tuberculosis) in Thailand	Two major problems of controlling TB in Thailand were lack of new vaccines and drugs development and increasing phenomena of TB drug resistance due to inconsistent drug taking by most patients. Controlling TB by DOTS (Directly Observed Therapy, short course) was a new strategy determined by most international health organizations. One of the DOTS was simply to have the patient’s helper who monitors his or her drug consumption so as to keep continuity of drug taking. The helpers may be the TB official, the health official at a health center, the health volunteer, the community leader, and the family member. Current situations and problems of controlling TB in Thailand by the DOTS were reviewed in this study. The DOTS coverage was found 34.1% of all districts by December 1999 while its operation was lower than the WHO target and likely to decrease. Its effectiveness was found better than the conventional based on the RCT study whereas no significant difference was found under the non-RCT study. Most operations at district level did not have quality monitoring and evaluation process while a number of the patients’ helpers were not trained. 	The problems of DOTS operation in Thailand were regarded into firstly, policy level at which policy makers gave relatively low priority of TB controlling than many communicable diseases, secondly, a number of personnel dealing with TB control neither trained nor interested in getting trained, thirdly, less motivation in health officials to put forward the DOTS operation in their own areas, fourthly, poor reliability in performing the DOTS by family members, and fifthly, lack of based-cohort study to illustrate levels of success or failure in addition to less qualitative study on this topic so far. Establishment of research networking on the DOTS and its policy-based research were recommended. The research topics should be on the DOTS efficiency, the DOTS model development, factors related to its success and failures, and criteria for the DOTS performed by family members.


Community Participation in Government Hospital Administration	The primary purpose of this study is to explore the current situation of community participation in government hospitals in Thailand. This concerns community participation in the context of hospital development and management, as well as its underlying factors. The methods of data collection include both quantitative and qualitative.A nation-wide mailed questionnaire survey was carried out to determine the extent of participation in government hospitals with at least 60 patient-beds. The questionnaires were mailed to the total number of 212 eligible hospitals and 209 completed questionnaire were returned, or the response rate was 98.8 percent. The qualitative data collection aims at in-depth investigation of the process and underlying factors of community participation in hospital development and management.                        		The survey result indicated that community participation in any specific health program organized by the hospitals has been developed at a certain level, but not in the hospital administration except Ban Peaw community hospital in the central part of the country.  The most popular form of participation reported by hospitals is community leaders participating as hospital consultative committee members.  The main activity of the committee is to help fund raising and mobilize local resources for hospital development. On the part of hospitals, the reported significant reasons underlying community participation development was to strengthen hospital accessibility by the community they served (89.8 percent).  The other important reasons reported included inadequacy of the government budget (47.4 percent) and communities’ interest (43.0 percent).  The majority of hospitals (95.9 percent) appeared to recognize the importance and benefits of community participation. About one-third reported no problems in hospital development as a result of community participation, and about one-fourth had plans to reform the administration to become autonomous hospitals.		Four hospitals experienced with community participation in development and management including 3 government community hospitals and one private-non profit foundation hospital were purposively selected as case studies for qualitative data analysis.  The hospital administrators and key staff members as well as community leaders were given in-depth interviews.  The major findings are that the communities have competence in hospital development and management in the direction they need. The four major existing forms of community participation include 1) community participation in the decision making process of hospital development plans and policy formulation for the health service system, 2) community participation in hospital management of infrastructure and non-medical activities, 3) community involvement in health care service implementation, and 4) community involvement as coordinators to bridge gaps between hospitals and communities. The factors facilitating community participation are threefold: 1) hospital related factors, 2) community related factors and 3) quality of relationship between hospitals and communities they served.  The crucial hospital related factors are the policy of community involvement expressed by the hospital administrators, the competence and leadership of hospital administrators, the inadequacy of the government budget for hospital development, the hospital administrators’ expression of his or her sincere welcoming of community members to participate in hospital development/ administrative/consultative committees, as well as strategies for mobilizing local resources through the integration of religious beliefs held by the community. On the part of community, the critical factors are community health needs, community competence, community faith and trust in hospital administrator, sense of belonging to hospital, and community satisfaction with the services provided. Lastly, but very important, is the good relationship between hospital administrators/staff and community members.   		To sustain effective community participation, the government sector, including government hospitals should construct communities’ social and economic conditions to facilitate community participation in government hospital administration. The concepts of civil society, good governance based upon democratic ideology, equity and patient’s rights, and sense of belonging to government hospitals are recommended as strategies to be promoted in the communities.  In addition, the health promotion hospital policy of providing out-reach health promotion services should be strengthened. To empower community members with sufficient potentiality to actively participate in hospital administration, the government sector and government hospitals should promote  comprehensive development projects, both health-based and community-based economy, based in the communities they serve.  This should be coordinated with the existing community organizations, both government and non-government, including community temples.To facilitate community power in decision making in hospital administration, the present hospital administrative structure needs to be reformed.  All, or at least more than half of the total number of the administrative committee members should be selected from among the representatives of community members. Practical rules and regulations for community participation, for instance, the composition of the hospital administrative committee members, the characteristics of eligible representatives of the community members and selective procedures, should be developed and considered through the process by which the community has equity participation in decision making.


Health is a dynamic self-regulating process in a living system that is interrelated with its greater ever-changing environment and ecology in which it depends. Physical and mental health of an individual closely correlates with that of its society and ecology. This subtle and complex interconnection has been discovered and articulated in modern science. According to the ecological worldview and deep ecology, to heal ourselves is to heal our relationship with the earth. Our modern human culture is now facing a survival challenge, amidst the postmodern absence of absolute ideology and value system, to come to terms with the realization that we are parts of the whole, and the whole is within us. Without changing in our perception we have towards life and nature, our behaviors will remain unchanged, unhealthy and worsen the condition of this living planet, which in tern will have much greater effects on human health. However, in Thai society as well as in other countries, there have been emerging social and ecological movements that try to cope with this modern sickness from different perspectives and historical backgrounds. This study is to explore the philosophy and practices of deep ecology movement that can contribute to the paradigm change in the way we think about and relate ourselves to the issues of health. We hope that some insights and realizations gained from this research can be of useful and inspiring enough for readers to critically and thoroughly reexamine the way we live our lives as well as and the socio-economical structure and conditions we maintain that shape our present health condition. The local traditional wisdom obtained on a practical basis showed in this study have affirmed that ecological worldview is nothing new but have already been existed and available in its own unique cultural and ecological context. To recognize such endangered local knowledge as invaluable and relevant to our modern needs is the beginning of the healing process towards the restoration of the wholeness and health of this living planet and her members.


This study aimed to explore the health status of older people, their health behaviors and needs of health care services. Also it explored the potential and readiness of community participation and investigated strategies for providing health services under the condition of community participation and meeting elderly’s needs. Data were collected from older people who lived in two rural villages in Songkhla province. Participants were 95 from older people, 59 from village A and 36 from village B. Questionnaires, interviews, audiotape focus group meeting and home visits were used to collect relevant data. Data were then analyzed using content analysis. The results showed that among the 95 older people, thirty-seven percents were males and sixty-three were females. Ages ranged from 60-84 years with the average age were 71 years. The average age for male older people were 67 and for female were 72. All participants were Thai ethnic and Buddhist. Most of the participants, had primary school educated and living with their spouses and children. They perceived having adequate incomes and perceived their health as “equal or at the same level of health” as compared to other older people in their age group. Sixty-one percents of the older people perceived that they had some health problems. The three most common health problems were a. knee joints/back pain (30%), b. hypertension (27%) and c. heart disease (16%). Health promotion behaviors of the participants were practicing followed the medical advice, exercise, and eating useful food. In their perception of needs of health care services, they reported that they wished to be healthy so that they still can be able to keep working and keep performing self-care. As they were healthy, they did not expect help from their children or from the community. However, when they were ill, they would like their children to help taking care of them or accompanying them to see doctors and paying the bills. They indicated their needs to meet other older people as a social group and having organized group activities such as exercise, health education, group relation, dinning together and offering medications when getting a minor illness such as catching a cold. In surveying of the readiness, potentiality and community participation needs, the data revealed that the studied communities had economic readiness as the people felt their children could find jobs and gain adequate incomes. There were group gathering of housewives and teenage representatives to performed activities. After discussed with key persons involved in caring for older people including elderly themselves, to identify a health promotion model that involved community participation and meeting the needs of older people. Firstly, the community agreed to enhance the local wisdom projects to treat the main health problems of elderly, for example, the use of herbal medicines and massage to treat the arthritis/ joint pain of the older people. Second, the community agreed to arrange a group gathering of older people to run the health promotive activities. The activities would function under the guidance of the health professionals in the design and conduct of various programs. An exercise program would be initiated and instituted by the health professionals. Funding support would have to come from the local government so that the programs can be perceived as governmental support and co-operation for local initiatives. Thirdly, the children and housewives group were agree to support and take care the older people when they get into late older and got sick. Two factors influenced the success of implementing the health promotion program for elderly were the leadership and the attitude and expectation of older people to the group gathering.


Unmet Need for Drug Therapy in Hospital-Visited Patients	This research aimed to analyze the issue of unmet need for drug therapy in hospital-visited patients.  Methods used in the study varied from physician interview, hospital policy survey, analysis of hospital databases, individual patient evaluation, to medical chart review.  Based on opinions of prescribing physicians, the unmet drug need problem tended to focus on expensive or newly marketed drug products, which were considered the target group in this study.  	Results from the hospital survey showed that some of the study drugs were not covered in drug formularies of several hospitals; whereas some were listed in restricted formularies.  In ten therapeutic drug classes, hospital database analysis revealed that out-patients under Low-Income Scheme were less likely to receive and to continue receiving the drugs as compared with those covered by Civil Servant Medical Benefit Scheme.  Disparity in the unmet drug need across patient payment schemes varied widely with respect to the drug classes and study hospitals.  This study confirmed adverse consequences due to inaccessibility to certain therapeutic modalities.  A case study on patients with end stage renal disease found that accessibility to renal replacement therapy by the Low-Income patients was much lower than in the Civil Servant Medical Benefit recipients, thus the former group faced a higher mortality rate.  Inaccessibility to appropriate choice of antibiotics would increase risk of death due to the fatal infectious disease like melioidosis in another case study. 	Four major policy recommendations were generated from this study.  First, standard data sets for drug prescribing and dispensing as well as drug coding harmonization should be developed.  All three health care financing agencies: Civil Servant Medical Benefit Scheme, Social Security Scheme, and Universal Health Care Coverage Scheme should set common structures of electronic files for recording drug utilization data.  Second, prior to use of the stored information, a set of criteria for drug use quality based on up-to-date medical knowledge should be established.  Information on the quality criteria could lead to an agreement among medical communities on variables needed to be specified in the standard data sets and on the way to measure quality of care.  Third, for the issue of health equity monitoring, this study showed high feasibility to assess the extent to which a need for drug therapy was unmet, especially for the drug products that were proven in their effectiveness and efficiency.  Lastly, it is possible to evaluate a policy aiming to increase health care productivity in the future.  The approach used in this study should be disseminated through hospital networks in order that results generated from analyses of drug use databases can be used for quality of care development.


Populations’ Suffering from Health Care Utilisation	The Thais’ suffering as a consequence of health care utilization was studied in order to set up recommendations for improvement. Quantitative and qualitative study was used during August to October 1998. The sampled health care facilities were the university hospitals, both public and private hospitals, and health centers in totality of 1473 facilities. Their suffering and dissatisfaction were grouped in terms of cause natures as following: health providers, patients’ illness, environment of health facilities, medical equipment, facilities’ management and administration, patients’ profiles including their socio-economic status, services features and health insurance schemes. 	With regard to health providers, conflicts among health providers were often found possibly leading to poor quality of care while insufficient providers made long waiting lists. Lack of informing the patients and unavailability of patients’ consensus were also an important issue. Patients’ dissatisfaction led by either crowding or dirty OPD was linked to their uncertainty of how well the facilities did infectious control.  Those insured by the Public Health Assistance Scheme did not feel confident in care quality given. Most of the Thais subjectively related good quality of care to high technology based medical instruments, comfortable OPD space, warm welcome reception, and care provided by specialists. The study viewed that financial resource was not the sole answer to reduce the patients’ suffering.


This study aimed at exploring the situation of dental health service management since the first launch of universal health insurance policy, and to determine the impact of the policy on utilization and provision of the treatment service including the dental benefit package of the hospitals as well as health promotion and prevention program. The result is used partly for further implementation and for policy recommendation on dental health service. Three provinces : Payao, Pathumthani, and Yala were selected as target areas of which universal health insurance policy was implemented since 1 April 2001. This study includes 1 regional/general hospital and 1 community hospital in each of the 3 province, making totally 6 health facilities in this study. The data on treatment service was secondary data collected, by statistical package program, from the daily client’s record attending the dental clinic at the hospitals in the workdays of odd numbers in April - December 2001 and 2002. The data on health promotion derived from interviewing dental health personnel in each province. The data was then processed, analyzed, concluded and reported. The result on treatment service revealed that the number of hospital visits at the 6 health facilities has increased by 26.6 %, and the number of clients has risen by 20.2 %. In overall, the service coverage was 6.36 %, the regional/general hospitals coverage was 5.44 % and the community hospital coverage was 9.06 %. In regional/general hospitals, the population group with highest increasing rate of hospital visits at 30.2 % was those over 60 years of age who received basic health care service not the dental care. The proportion of those aged over 60 years having hospital visits was about 6 – 7 % of the total population, while the visits was declined to 6.0 % among those aged 0 – 4 years and 5 – 9 years. The percentage of those shifting from buying health insurance card to the gold health insurance cards in this project and receiving hospital service has somewhat increased from 9.1 % to 10.2 %, while the percentage has risen from 1.5 % to 22.2 % for community hospitals. Those shifted from the low income card to the gold cards have increased hospital visits from 15.4 % to 18.5 %, of which have increased among the low income group and the elderly. However the percentage of visiting community hospitals has reduced from 46.0 % to 35.2 % among the disable, the elderly, and those aged 0 – 12 years. Regarding repeated dental health service, it was found that the average visit of one client is 1.29 and 1.35 times in 2001 and 2002. The proportion of those having only one visit somewhat reduced from 81.2 % in 2001 and 78.0 % in 2002. The increasing rate was higher among the old patients than the new ones.With respect to the service types provided, the first 3 types of dental service provided were the basic service, i.e. tooth extraction, tooth filling, scaling, and the proportion of each type has not changed during 2001 and 2002.Considering the service types received at each visit, the percentage of those receiving only dental check up has increased about 41.1 %. If the dental check up is not regarded as a type of service, then almost 80 % had attended only one service type at each visit which was 31.8 % higher than the last year rate.The type of services under the health insurance benefit package was classified by population groups : pre-school age (0 – 5 years), school age (6 – 12 years), youth and working age (13 – 59 years), and the old age (over 60 years). The result suggested that there has been an increase of all types of basic service, i.e. tooth extraction, tooth filling, scaling, (including periodontitis treatment in the clients aged over 13 years), accounting for more than 90 % of the services under the benefit package. Whereas other services such as wearing acrylic base denture, root canal treatment presented less proportion. For dental health promotion and prevention service, the dental section of each hospital provides oral check up for pregnant women at ante-natal clinic and well-baby clinic, included in the dental health program for the target groups continuously implemented since before 2001. Each hospital does not change this activity but differs in implementing methods and duration. Regarding pre-school age service in Amphur Mueng, all hospitals have not yet implemented dental health promotion in the child development center and in kindergarten classes of primary schools. For school age children service, prior to 2001, primary schools were included in responsible area of various health service facilities. After the launch of universal health insurance policy, regional/general hospitals remain their responsibility to those schools under the catchment area of the hospital but cover more numbers of schools. These hospitals accept and commit health promotion and prevention as hospital functions. However, regional/general hospital personnel thought that school health promotion and prevention should be implemented by dental workers. In the areas outside Amphur Mueng, the dental health section of some community hospitals did not implement dental health promotion and prevention program in child development center, however, all of them have carried out dental health surveillance and prevention program in primary schools covering the same numbers of schools and activities during 2001 and 2002.Regarding home service and visit, the dentists working in the dentistry group and dental health section did not involve in preparing family files. These health facilities did not arrange certain service activities that support self reliance of the people. According to the findings, the treatment service is 6.36 % coverage of the total population. The analysis suggested that since the first implementation of dental health project in the 4th National Economic and Social Development Plan, it would yield 10 % coverage. Considering the service access classified by age, it was found that the proportion of children and the elderly receiving dental care, comparing to the total population, is less than those of other groups. Thus, it should be taken into consideration on the issue of service management that identifies specific targets with suitable proportion. Taking into account the needs and desire for treatment service in comparison with the service result, and the data on human resources, budget and time, the guidelines for identifying direction of dental health service system at provincial level could be developed particularly on the output standard of dental health service benefit package. It is noted that regional and community hospital have different patterns of providing service types in the benefit package. It is thus recommended that dental health service system assessment at national level is to be undertaken to monitor and reflect the actual picture of the service to the province and the administrators. An outreach preventive implementation at community level is a crucial answer to effectively solve the dental problem of the people. Hence, service system management without focussing on the community and prevention cannot stop the rapid increase of the problems.


Health Care Financing for Low Income Population in Thailand	The present study investigated a current public health care policy for low income population in Thailand on the financing and expenditures as well as evaluated the post-policy implementation outcome of the current system of health financing for the low income population aiming at the satisfaction and perception of health care providers, the poor who have enrolled in the free medical care project (FMCP) and the poor who have not enrolled in the free medical care project (NFMCP), but received free care or paid partial expenses. The study also tested the hypothesis of differences on the satisfaction and perception between the FMCP in the provinces that have the highest utilization rate of free medical care enrollees at health centers and the FMCP in the provinces that have the lowest utilization rate of free medical care enrollees at health centers.The secondary data on number of free medical care project enrollees, budget and health care expenditures revealed that the increasing number of enrollees in each year did not correspond to the total number of the poor in the country. Although the budget allocation for each region harmonized with the number of the poor in each region, the ways the budget was set for every group in the government welfare programs together has not reflected the real expenditure for each group, especially for the poor. Each region and each level of health facilities also experienced different patterns of changes in the health expenditure for the FMCP. The health expenditure for the NFMCP was in a high level compared with that of the FMCP. However, unlike the FMCP, the inpatient expenditure of the NFMCP still increased.	The analysis on primary data collecting from 10 provinces in the north, northeast, central, east and south regions showed that both providers and poor patients mostly satisfied with and agreed to the health policy for the poor. The assessment of the impact of the policy for the poor on the providers showed that most providers satisfied with the policy, practice, expenditure calculation in health facilities. The providers also mainly satisfied with the work and job related to the poor in the workplace. Nonetheless, most providers did not satisfied with the budget and the ways the budget was allocated in the provinces. Most providers also agreed that the poor should pay a proportion of total health expenses or a proportion of health expenses on some types of services.	By assessing the satisfaction and attitude of the FMCP on the health policy for the poor, the results depicted that most FMCP satisfied with the policy and service received. However, some FMCP patients misunderstood or did not know about the right and benefits of being enrolled in the FMCP. Furthermore, most patients agreed that the poor should pay a proportion of total health expenses or a proportion of health expenses on some types of services. The hypothesis testing of differences on the satisfaction and perception between the FMCP in the provinces that have the highest utilization rate of free medical care enrollees at health centers and the FMCP in the provinces that have the lowest utilization rate of free medical care enrollees at health centers showed that the high (low) utilization resulted in lower (higher) patient satisfaction.	By assessing the satisfaction and attitude of the NFMCP on the service received, the results revealed that most NFMCP satisfied with the services, providers and facilities. Some NFMCP were previous FMCP, but the free medical care cards had expired. Some NFMCP had requested for the free medical care cards, but they did not get the approval. Part of the NFMCP did not know about the free medical care project or knew about the project, but lack of some important document. Most NFMCP also agreed that the poor should pay a proportion of total health expenses or a proportion of health expenses on some types of services.


This report had three objectives. Firstly, it aimed to review the existing knowledge and analyzed about system, structure, and mechanisms of healthy public policy development in 5 case studies: namely, health promotion policy, healthy child development, anti-tobacco policy, AIDS policy, and anti-Amphetamine drug and its derivatives policy. The cases were both from domestic and international experiences. Secondly, it intended to study about community involvement and participation along policy process in each case. Lastly, structure and mechanisms of development were synthesized and proposed as options for Thailand. Case studies shed light lesson learnt at least in 6 areas as follows: 1) re-organization or re-structure is essential to establish with new health promotion approach in the Ottawa Charter. New management, through the concept as health is cross-cutting issue, would give advantage of working together, co-ordination, and collaboration between and among the sectors, as well as strengthening the communities and people participation. 2) appropriateness and relevancy of policy measures depends on health promotion view of the leader / administer and wherter such measure is based on correct knowledge 3) mechanisms for good health information development and transfer, knowledge establishment, research and development, and monitoring and evaluation are required. 4) Law enactment for health promotion, besides justice purpose, need to be enhanced and law enforcement needs to be strengthened. Paradigm to draft such a law for supporting health promotion activities like Thai Health Promotion Fund have to be changed. 5) As key success factor, health promotion activities are central to have partnership involvement and people participation. therefore, effective management and good information exchange are crucial. Appropriate knowledge transfer and awareness of self and community care would alert and call for impact assessment as well as healthy policy measures and transparent decision-making. 6) The government should act as a collaborator to link each partner to assist people and communities to formulate their action plan for health promotion. In summary, development of health public policy needs to change policy process which enhances all stakeholders involvement and participation. To formulate public policy, policy-makers have to think about the impact that might be happened after implement process. Decision-makers should be responsible for mistakes if negative impact occurs. Therefore, it is required to establish new organization with new health promotion approach and good mechanisms for information and knowledge transfer, as well as monitoring and evaluation process.


Vision and Direction toward Health System Reform:views of civil aging societyThe participatory research aimed to understand the following aspects which are related to aging issues in Thailand: a) the existence and situation of network of community based agecare organizations; b) roles, capacities and strategies of community based agecare organizations; c)  vision and mission toward improvement of quality of life of older people in Thailand.  The information fed by the participants, most of whom were older people from rural poor areas throughout the country, through participatory discussion that included A.I.C, focus groups techniques.  There were 127 participants from non-governmental age related organizations, indigenous group of older people. 	Comparison of the image of Thai older people in future compare to current situation (2000), it is revealed that about half of the participants (55%) indicated that the living condition of the older people would be better than present because aging issues is being campaigned and well-recognized by public increasingly.  The participants of all four regions stated that the aims of organizing activities are similar in terms of achieving the objectives of the establishment of the elders' clubs which aim to encourage older people to live with their families in communities as long as possible.  However, the types of activities are different in accordance to the needs and preference of the older people and the conditions of the areas.  The recommendations presented by the participants are similar which can be concluded as followed:All cares and services provided by the government sectors need to be reviewed, particularly actively provisions, instead of passively ones.  Such provisions should be accessible by all older people and equally.Health promotion measures should be sustainable and should emphasis on health information for community and self health care. Prevention and control of diseases measures should go along and make sure that it can be brought to practice effectively.


According to advance technology now the patients who suffered from hematologic malignancy can be cured or at least live longer with better quality of life. However the standard treatments that were used internationally are costly and it is impossible to give best treatment to every Thai patient who suffered from hematologic malignancy due to shortage of budget and man power involved in this problem. In routine practice there are variation on investigations and treatments depend on the patients socio-economical status and health insurance scheme leading to difference cure rate and survival time of the patients. The suitable clinical practice guideline (CPG) for treatment of this group of disease in Thailand can not establish at present because of lacking basic data about the situation of these disease in our country. To establish disease registry of hematologic malignancy would give the information about epidemiology, variation of practice and clinical outcome which is useful for developing suitable CPG for treatment of hematologic malignancy in Thailand.The study was performed by establish the network of hematologist form 9 leading institute in Thailand who deliver treatment to this group of patients working together to create case record form. System of data collection and quality control concurrent with development of web base data entry system was done in the first 6 months of the project, starting on January 15, 2003. Then the process of data collection and data entry on web was performed during July 1, 2003 to March 30, 2004. The quality controlled and monitoring was performed concurrently. It was planned to register the patients and follow up them for at least 3 years.During the first 9 months of data collection there were 1,124 patients registered to the system. The diagnosis were malignant lymphoma 51.2%, acute leukemia 20.3%, CML 10.7%, multiple myeloma 7.7% . About the expense of treatment, 56.5% of the patients using universal health coverage or “30 baths” scheme, 26.3% using government welfare, 6.8% under social security scheme and 8.7% pay out of pocket. The patients who are under government welfare have tendency to receive more effective and expensive treatment than patients under other scheme. There is an interesting data that 12.2% and 8.3% of lymphoma patients infected by viral hepatitis and HIV consecutively.There are some problems about using web based data entry system. Even though it is good to get data on real time but it is rather difficult to manage because the internet system and local network of the participate institutes were attacked by virus computer several times. And some research assistants are not familiar to computer program. After first phase of study, the data entry will be changed to sending case record form to the center fordata entering instead of using web base system.


HIV  Infection  and  AIDS  in  ThailandThe Acquired Immune-deficiency Syndrome(AIDS) was recognized in 1991 when a cluster of pneumocystis carinii pneumonia was reported in the United States. Disease surveillance systems were sets up in several countries including Thailand so that the first case in Thailand was reported in 1994. Because the epidemic was confined to special groups ie. Homosexual men, injecting drug users, and commercial sex workers during the first year, health authorities misunderstood that AIDS was disease of the foreigners and interventions for the Thais were not necessary. Control measures started in late 1980's, from Veneral Disease (STD) division using epidemiological data to propose justified control measures. The AIDS Division was extablished in 1990 to coordinate national activities. During the 1990's, the epidemic expanded to general population through heterosexual people especially those who visited commercial sex establishments and through casual sex later. The median infection rates among women attending ante-natal care (ANC) clinics and 21 year old Thai men were 1.5 The essential control measure now is to reduce risk per act among sex and drug related population through condom promotion and needle exchange with bleach supply. Long term goal is to promote and maintain safe behaviors which will enable individuals, families, and society to protect themselves and their society. Biomedical, epidemiological, and social research studies allow as to understand patterns and determinants of the epidemic that there had been two distinct  epidemics among sex and drug acquired populations. Studies also allow us to learn the difference of normal ranges of CD4 between Thai and Caucasian people. More studies are in great need for rapid and effective control measures.


ความสามารถในการจ่ายค่ารักษาพยาบาล และสภาวะเจ็บป่วยจนล้มละลาย ของผู้ป่วยในที่จ่ายค่ารักษาพยาบาลเอง ในจังหวัดสงขลา	การศึกษานี้มุ่งวิจัยเพื่อนำผลการศึกษาไปสู่การพัฒนาการจัดระบบประกันสุขภาพที่คุ้มครองการเจ็บป่วยจนถึงขั้นล้มละลายทางเศรษฐกิจของครอบครัว  (Financially catastrophic illness- FCI)โดยมีวัตถุประสงค์เพื่อพรรณาถึงความสามารถในการจ่ายค่ารักษาพยาบาลของครัวเรือนที่ไม่มีหลักประกันสุขภาพ หรือ ครัวเรือนต้องจ่ายค่ารักษาพยาบาลเอง (pay out of the pocket) หาความสัมพันธ์ระหว่างความสามารถในการจ่ายค่ารักษาพยาบาล กับปัจจัยทางสังคม เศรษฐกิจ และประชากร วิเคราะห์พฤติกรรม วิธีการจัดการทางการเงินของครัวเรือนเมื่อประสบกับภาระในการจ่ายค่ารักษาพยาบาล และผลกระทบของการเจ็บป่วย และภาระการเงินต่อครอบครัว ศึกษาลักษณะโรคที่พบบ่อย ค่ารักษาพยาบาล วันนอนโรงพยาบาล วงเงินสูงสุดที่ครัวเรือนสามารถจ่ายได้ของผู้ป่วยที่ต้องจ่ายค่ารักษาด้วยเงินในกระเป๋าของครัวเรือน ในภาวะทั่วไป และเมื่อเผชิญกับภาระค่ารักษาที่เข้าข่ายสภาวะเจ็บป่วยจนล้มละลาย  คาดประมาณอุบัติการณ์ของการเจ็บป่วยจนล้มละลายในจังหวัดสงขลา	 การวิจัยนี้ ได้ออกแบบโดยแบ่งเป็น 2 งานวิจัยย่อย งานวิจัยแรก เรียกว่า FCI-1 Study เป็นการสำรวจเก็บข้อมูลผู้ป่วยในรายใหม่ที่อาศัยอยู่ในจังหวัดสงขลา ที่ต้องจ่ายเงินค่ารักษาพยาบาลเอง เป็นผู้ป่วยที่มานอนรักษาในโรงพยาบาลทั้งรัฐบาลและเอกชนในจังหวัดสงขลา ตั้งแต่เดือนพฤศจิกายน 2541 จนถึงเดือนเมษายน 2542 โดยการสัมภาษณ์ด้วยแบบสอบถามที่ผ่านการทดสอบแล้ว  งานวิจัยที่สอง เรียกว่า FCI-2 Study เป็นการสำรวจผู้ป่วยในอาศัยอยู่ในจังหวัดสงขลาที่ต้องจ่ายเงินค่ารักษาพยาบาลเอง และมีปัญหาในการจ่ายค่ารักษา ต้องขอรับการสังคมสงเคราะห์ของโรงพยาบาลภาครัฐสองแห่งที่เลือกอย่างเจาะจง ระยะเวลาที่ศึกษาคือ เดือนพฤษภาคม และมิถุนายน 2542 	ในการวิจัยทั้งสอง ใช้ทั้งวิธีการวิจัยเชิงปริมาณและเชิงคุณภาพ  เพื่อให้ทราบถึงวิธีการจัดการกับภาระค่ารักษาที่โรงพยาบาลเรียกเก็บ และความสามารถในการจ่ายของครอบครัว โดย เจาะลึกถึงแหล่งที่มาของเงินที่ครอบครัวใช้ในการจ่ายค่ารักษาพยาบาล ในการศึกษาวิจัย ได้ออกแบบเก็บข้อมูลเชิงคุณภาพ เสริมการวิจัยเชิงปริมาณ ดังนี้คัดเลือกผู้ป่วยในรายใหม่ที่ต้องจ่ายค่ารักษาพยาบาลเอง  ประมาณ 10% ของตัวอย่างในแต่ละโรงพยาบาลที่คัดเลือกในการวิจัยเชิงปริมาณใน FCI-1 Study แล้วติดตามผู้ป่วย  ตั้งแต่วันแรกที่นอนโรงพยาบาลจนถึงวันจำหน่าย สัมภาษณ์และเก็บข้อมูลทุกครั้งที่มีการจ่ายค่ารักษาในระหว่างที่นอนโรงพยาบาล วิธีวิจัยเก็บข้อมูลนี้ เรียกว่า  time-series data collection  เก็บข้อมูลเชิงคุณภาพ ประมาณ 40 ตัวอย่าง ซึ่งเป็นผู้ป่วยในที่จ่ายค่ารักษาพยาบาลเอง และมีปัญหาในการจ่าย ต้องขอสังคมสงเคราะห์ในโรงพยาบาล   โดยวิธีการสัมภาษณ์เชิงลึก (in-depth interview)ในหอผู้ป่วย ร่วมกับการเยี่ยมบ้าน เพื่อเสริมกับข้อมูลเชิงปริมาณใน FCI-1 Study งานวิจัยแรก: การสำรวจความสามารถในการจ่ายของครัวเรือนที่ต้องจ่ายเงินเอง (FCI-1 Study)	การวิจัยเชิงปริมาณนั้น พบว่า ผู้ป่วยที่ต้องจ่ายเงินเองที่อาศัยอยู่ในจังหวัดสงขลา และเข้าหลักเกณฑ์ในการศึกษา คิดเป็นสัดส่วนร้อยละ 4-38 ของผู้ป่วยในทั้งหมดที่นอนโรงพยาบาลในช่วงที่ทำวิจัย แสดงว่า ผู้ป่วยที่เข้ารักษาตัวในโรงพยาบาล ในจังหวัดสงขลา ส่วนใหญ่มีหลักประกันสุขภาพครอบคลุมอยู่แล้ว เพียงส่วนน้อยที่ครัวเรือนต้องจ่ายค่ารักษาพยาบาลเอง ในการศึกษานี้สามารถเก็บตัวอย่างได้ทั้งหมด 1731 ตัวอย่าง ความสามารถในการจ่ายของผู้ป่วยมีความแตกต่างกันในระหว่างโรงพยาบาล ผู้ป่วยที่ไปใช้บริการที่โรงพยาบาลเอกชน เกือบไม่มีปัญหาว่าจ่ายค่ารักษาพยาบาลไม่ได้เลย ขณะที่โรงพยาบาลรัฐ พบว่าผู้ป่วยที่มีปัญหาในการจ่าย คือไม่สามารถจ่ายค่ารักษาได้ทั้งหมดหรือบางส่วน แตกต่างกันตั้งแต่ร้อยละ 23.8 จนถึง 36.8 โดยร้อยละที่พบจะแปรผันไปตามศักยภาพ หรือขีดความสามารถในการดูแลผู้ป่วยของโรงพยาบาล จากการศึกษาพบว่า ปัจจัยทางเศรษฐกิจและสังคมหลายตัวแปร มีความสัมพันธ์กับระดับความสามารถในการจ่าย ได้แก่ ระดับการศึกษาของผู้ป่วย อาชีพ รายได้ของครอบครัว และจำนวนผู้ที่ก่อรายได้ให้แก่ครัวเรือน เมื่อวิเคราะห์ว่า กลุ่มตัวอย่างสามารถจ่ายค่ารักษาได้มากน้อยเพียงไรด้วยวิธี life-table method ปรากฏ ว่า ณ ค่ารักษาที่ 14,700 บาท ประมาณครึ่งหนึ่งของประชากรกลุ่มตัวอย่างจะประสบกับปัญหาจ่ายค่ารักษาไม่ได้  ครัวเรือนส่วนใหญ่ร้อยละ 89 จะใช้เงินสด หรือเงินออม เป็นแหล่งเงินแรกที่สำคัญในการจ่ายค่ารักษา ขณะที่ประมาณร้อยละ 8 ต้องใช้การหยิบยืมเงินเป็นแหล่งเงินแรกในการจ่ายค่ารักษา และร้อยละ 21 ของประชากรในกลุ่มตัวอย่างต้องใช้แหล่งเงินจากเงินยืม เป็นส่วนหนึ่งของค่ารักษาพยาบาลครั้งปัจจุบัน และพบว่าร้อยละ 1 ของตัวอย่าง ต้องให้เด็กออกจากโรงเรียน สืบเนื่องจากจ่ายค่ารักษาในการเจ็


The prospective study was conducted at Kutchum Hospital during April 2000 to January 2001.The objective was to determine the effectiveness of holistic health care that provided to type 2 Diabetes mellitus ( type 2 DM ) by health care team. The health care team were consist of a pharmacist, a nurse, a dietition , a doctor, a patient and other related. person who take care the patient. The effectiveness were determine by comparing of patient compliance,chronic complication and individual problems before and after interventions. The subjects were intervenced after visited a doctor.Patient counseling was the most important instrument of interventions. There were fifteen out-patients without chronic complication were included,11 females and 4 males.Average age was 40 – 50 years old. They were diagnosted as diabetes around 1 – 5 years ago and nine cases had diabetes relatives. Most of them were farmers and also had health cards. The compliance to prescribed medication, usage of appropriate diets and self-care behaviour were increased from 2 to 8 cases, 3 to 13 cases and 9 to 15 cases, respectively. In addition, we found no report of their complication and trend of their individual problems had been decreased after forcing interventions. The result indicated that holistic health care in diabetic mellitus by health team should be applied to make the patients taking care their health according to their basic conditioning factors and health care demand.


“Khao Phanom Pha” located in the area of Ban Khao Phanom Pha, Village No. 7, Nong Pra Sub-district, Wang Sai Poon District, Phichit Province, is a little hill with the height above the mean sea-level of 50-155 meters, covering the area of around 200 rais, considered as mixed deciduous forest and commercial forest with houses scattering thoroughly. Most local people earn their living by doing agricultural work and general wages during the dry season. The area of Wang Sai Poon District and Phichit Province are situated in the basin of Nan River with canals and branch rivers. In the rainy season, it is usually flooded, on contrarily, in the dry season some areas face the problem of water short and cannot be used for agricultural advantage.In 1999, gold ledges were surveyed and found. This caused lots of trespassers from both the province and the neighborhood into the area of Khao Phanom Pha to search for nuggets and this led to the problem of natural resources and environment destruction, injury and death due to landslide. Though the prohibition of trespass was announced, sneaking mining of nuggets still continues.Phichit Provincial Administrative Organization receives the concession to mine nuggets in the area of Khao Phanom Pha in order that the local people can have mutual benefits in mining. This can solve a degree of some problems. Anyway, it cannot respond the people since the amount of nuggets is incomparable with the investment. The sneaking mining of nuggets in private lands in front of the mine of Phichit Provincial Administrative Organization still continues. The nuggets are washed to remove dirt out along river, natural canals. Some people dig ponds and build concrete wells to separate, wash and select nuggets.From the study, it is found that the activities involving nuggets mining are at two places: the mine of  Phichit Provincial Administrative Organization (PAO) and the private land (A famous temple). Both areas are immediate but the excavation in the latter is illegal, lacks of facilities, measures or regulations. Garbage, wasted, refuse occuring are not correctly executed and natural resources and environment do not receive any protection. This may cause problem in the future.The three effecting areas to health and environment are considered as follows: 1) serious effecting areas where the possibility of injury and death from landslide is acute and serious are the area of Khao Phanom Pha including its vicinity, gold mine of Phichit PAO, the area of Wang Sai Poon District where people separate, wash and select laterite for nuggets  2) intermediate effecting area namely all areas of Wang Sai Poon District where no activity of gold mining is found  and 3) low effecting area namely all areas of Phichit Province excluding Wang Sai Poon District.The impact can be summerized as follows:  the private area is excavated until it becomes a huge hole for dumping waste. Its size increases and it probably collapses and is harmful to excavators. It may also damage the hedge of the neighber and the dispute may arise. Excavated soil or stone are piled up in many places without covering or are contained in decayed sack. Separated, washed and selected soil or stone piled up throughout rice field, garden, yard and other areas cover the ground surface until the abundance of soil and landscape are destroyed. There are new careers such as separator, washer, soil porter, excavator, soil seller or queue seller, mill worker, workers who use mercury to select nuggets, nuggets buyer, vender etc. All expect to have higher income, to have enough money for their children’s education, to have additional income, to discharge debts, to have a free-lance profession without going to work for wages in Bangkok, to gain rent from gliding area, to sell land, to get free soil for filling up and to develop their land to be tourist attraction. The economics will be better. Tools and equipment used for selecting nuggets, grinder,driver, scooper are invented and modified. This indicates the history of nuggets searching.The way of life is changed from that of agricultural society to that of struggling for exercise from the morning till the evening. Each lives in each own way, show a clean pair of huts, has no time for others. Society is broken and family loses either life, injury or freedom. Criminal problem occurs. There are problems of drug addiction. People do not consider the right and the wrong not even their own health. In addition, we can find other changes in the community. The old location of Kha Phanom Pha Temple was bought and the temple was moved to another place. People are distant from temple and monk. Only a few people go to make merit at a temple except in funeral or when gamble is made. Cooperation becomes less. Soil and stone in some areas of the temple are grinded for nuggets. Some little students have to take their younger siblings to school since their parents go to work in the mine. Most children do not continue their higher education because they have to help their family in the mine. People or community rarely participate in policy directing. They are not interested in meetings which are left to be the duty of local administrative organization or official units.Mercury is a toxic heavy metal introduced for the process of gold separation from contaminants. It is weighed 40.09 grams a day and 1,202.7 grams a month. The real amount of mercury could be higher since it is used in every area of gold separation, wash and selection.People who separate,wash and select nuggets are often sick with symptoms of asthma, hypertension, headache, anxiety, insomnia, leg pain and most of them also develop a symptom of itchiness and skin disease.  This is due to their long hours of work in water.  They find and buy medicine to treat themselves.  Most of them rarely have interest in taking care of their own health, overtax themselves and do not take enough rest.  Also, they eat unuseful food such as, coffee, energy-added drink, and beverage with mixture of alcohol and liquors etc. Some of them work until they forget their appointment and also forget to take their children to receive vaccination or forget to have pregnancy check at public health center.  A trend of health status is deteriorated or not favorable.  The disease/symptom that are expected to become problems of the area in the future are those derived from food and water, accident/disease from occupation, disease/mental symptom.  The environment changes in hardship and deteriorated direction.  The plan to restructure natural resources and environment in the local level of every area also lacks clarity. No operational plan/project to support the problems are mentioned by Nongphra Subdivisional Administrative Organization, the district where is the source of nuggets and where the nuggets selection is mostly performed.The separation, wash and selection of nuggets from Kao Phanom Pha will be proceeded continuously with relations to an individual, enforceable law and a large numbers of administration and management systems.  There are also other factors.  The arising problems are complicated and have linkage to one another. Phichit PAO cannot entirely solve the problems due to a small quantity of nuggets,complicated rules and regulations, brokers and inefficient services provided, etc. in comparison with a private area, where lower investment is required and no regulation is determined.The way of life, thinking system, household/community economics, various kinds of behavior, health status of people, natural resource and environment administration and management system, pollution, public participation and others are affected in both good and bad sides.  In regard to public health, some people died due to the landslide, some become crippled and some suffer illness from hard work with a lack of enough rest.  There are several types of impact on health.  That is to say 1) A direct impact, such as, accidents, arising illness. 2) An indirect impact, such as,  impact  on changes in the community or ecological system.  3) An accumulated impact, such as, that of chemical substance used in the process, the accumulation of tension and weariness from work and occupationFor the strength of government organizations and agents, there is a lack of major department or organization to solve the problem and the officials are not sufficient. Cooperation from public is also enough. Local administrative organizations is also short of clarity in solving the arising problems as well as short of cooperative plan with relevant agents in order to prevent and solve the problems, promote and improve every matter.The evaluation of impact on health is considered a procedure for building and promoting the occurrence of body of knowledge and measures in taking care and protecting one’s own health, the health of family and community health from factors or provisions that shall affect such health. Also, there is an adjustment of oneself to survive in the changeable society.  The procedure for evaluating health impact should be promoted in terms of knowledge, public and community participation as well as individuals and relevant units in order to be as the same system.  Due to the fact that the study has been done in a short time by methods of surveying, inquiry, interviewing and conversation and each of them has been done in a short period of time, it cannot provide enough knowledge, understanding and explanation of such matter to public. Moreover, it cannot cause the occurrence of public organization as a studying unit or operational units for evaluating the impact on health from activities, projects, policies or others.The study should determine the scope of academic content covering all details for the view of linkage in various factors, by determining which factors should be studied firstly or lastly.  Also, it should cover the extent of area because it is involved in the levels of severity and relations or pursuant to the types of impact.Nevertheless, this studying still consists of several defects which may cause an incomplete study. The improvement and correction of this study should be as follows: the determination of low or basic index which is suitably applied to the explanation of impact on health, the condition of work and the quantity of concentrate mercury in environment and living creatures should be examined, the local administrative organization should issue regulations enforced in local or some private areas of nuggets excavation, any entry to execute any activities should be approved by the landlord and local officials, such as, Governor, District chief and Chairman of Subdivisional Administrative Organization should exercise their rights pursuant to the relating law in order to suppress any events that may have caused danger to lives and properties of public.Local administrative organization that has been affected should cooperate to issue studying approach and seek impact control measures, support and promote the observation of public health and environment quality.  In terms of human resources,  curriculum concerning the impact of nuggets separating, washing and selection activities and toxicity and danger of mercury should be determined.  The monitoring and evaluation should cover all levels of affected areas.  It is also required to arrange strategic plan and operational plan for the administration, prevention, improvement of natural resources and environment.  The emphasis should be made in all sectors in order to create community, strength and evaluation system on health impact in the region should be promoted and other careers should be provided and planned in case that nuggets come to the end to reach the option and lead to the sustainable problem solving.


Health Service System for Emergency Conditions in Developed countries	Health service system for emergency conditions in developed countries was originally built in attempt to reduce life lost from road accident. Early response to injuries was a principle of reducing death and injuries especially in working group. Later, the system was extended to cover other injuries especially heart disease and considered as social safety net. To quicken the service provision, mobile service was made possible to reach the situation area and available for 24 hours. The system could be activitated by anyone either involving or seeing the scene. The study was carried out by reviewing the systems of the US, France, Australia and Sweden. 	The system of the US, Australia and Sweden had central call centres and mobile emergency team some of which had physicians for example the French and the Swedish while the US and the Australian had advanced emergency staff. The US, the Australian and the Swedish had doctors who had specialty in emergency care The provision system, patients’ right to emergency care and emergency team were legislated in all studied systems. Medicare, Medicaid, private insurance and special service contracts covered emergency care in the US. In France, Australia and Sweden, local government budget and national health insurance supported the emergency care. 	The development of the emergency system in Thailand should focus on the system of call centres and its reporting, mobile service, emergency room and referral system. Integrating the system into the health care system should be done for efficient use of resources. Community participation in all process should be strengthened. Legislation, budgeting, personnel development and research were important issues to support the system. Equity principle should be considered and put into practice.


Family and community care system for persons with HIV infection and AIDS: a review in Northeast Thailand	This study reviews the present situation and implementation of caring for persons with HIV infection and AIDS at home by their families and the community. The study also examined the factors related to the care of persons with HIV infection and AIDS as well as studying methods and forms of activities for implementing the care of persons with HIV infection and AIDS at home. The study looked at the problems and obstacles arising in the management of the care of persons with HIV infection and AIDS at home by their families and the community in the Northeast social and cultural environment. It is hoped that the results of the study can be used as directions for developing care systems for persons with HIV infection and AIDS at home by the family and community, appropriately and in line with the social and cultural environment of the Northeast in the future. The present student was carried out in 3 stages. Stage 1 This stage involved synthesis from documents concerning research into the management of care of persons with HIV infection and AIDS at home by families and the community, as well as various project reports conducted both by the state and the private sector but only in the 19 provinces of the Northeast. The synthesis was from documents, research reports and 19 postgraduate theses. Stage 2 This stage was a field study in the research area and the target population to study the forms and mechanisms for implementation of the work of the various organization from both the state and the private sector, choosing 4 provinces and six areas, being the provinces of Khon Kaen, Kalasin, Surin and Roi Et and using in-depth interviews, group discussions and participant observation.Stage 3  This stage involved a critical brainstorming of the results of the research, as well as offering suggestions for policy by 20 academics, implementers and researchers, as well as those with experience, knowledge and those implementing the care of persons with HIV infection and AIDS. The research results were also sent to 2 experts for their criticism and for suggestions. The body of knowledge was then improved. Conclusions and lessons learnt from the study. 		The overall results of the study were that the form of care for persons with HIV infection and AIDS at home by the family and the community under the environment of the Northeastern society and culture at present has 3 major forms:		Form 1 The form of care performed by the people This consists of the form of care by the family, the form of care by the temple and the form of care of persons with HIV infection and AIDS by themselves. In these forms people organizations are the main source of care systems, along with coordination in approaching for concrete help and service from state organizations operate activities which are responsive and operate according to their duties and responsibilities. In this form a few of those infected with AIDS and their families approach private organizations for help, but most attach importance to the state organizations. 		Form 2 The form of care performed by the state or Government Organization  This consists of the form of care offered by medical services at all levels divided into those places which have a duty to serve such as Health Centres, Community Hospitals, and Central Hospitals, and units which have the duty to coordinate and promote, such as District Health Offices, Provincial Health Offices and Regional Communicable Disease Control Offices. In general this form of care is operated according to the central policy, with the type of operations being responsive. Implementation according to the policy depends on the readiness of the administration and the working team of the unit. There are only a few units that offer and offensive type of operation and coordinate clearly with the private sector.		Form 3 The form of care operated by the private sector or Non-Government Organization  This consists of the form of care given by private organizations for the public good, the form of care by foundations and the form of care by religious organizations. In this form of care, organizations in the private sector offensively  make contact to give assistance to various groups in the population. There is a clear and concrete operating system. Public organization have not approached or coordination with state organizations in some parts.