The purpose of this study is to understand the relationship between roles of transformational and transactional leadership behaviors, types of a current organizational culture, and attributes of the learning organization in both private and public certified and accredited hospitals. The study has the following four objectives: 1) to test the relationship between leadership behaviors as perceived by administrators and the learning organization and each of its attributes, 2) to determine how much variation and what direct effect leadership behaviors have on learning organizations as perceived by subordinates, 3) to determine how much variation types of current organizational culture (achievement, support, role, and power–oriented culture) have on learning organizations, including both private and public hospitals, 4) to compare variations in indirect effects of leadership behaviors on learning organizations with regard to types of current organizational culture as perceived by subordinates, and 5) to confirm and compare the path analysis of a theoretical model showing subordinates perceived causality between eight roles of leadership behavior, four roles of a current organizational culture, and the development of a learning organization. 	The quantitative study utilized information from eight hundred healthcare professions systematically selected from nine hospitals in both sectors having been certified and accredited with HA since 1995. Five hundred and fifty respondents from different levels and jobs involved with quality improvement programs completed the questionnaire that was sent to them. 	Multiple regression using a stepwise technique was utilized for analyzing hospital’s chief executive perception of the eight roles of transformational and transactional leadership behaviors and to determine variance in the development of a learning organization. The results indicated that chief executives in both private and public hospitals viewed themselves as leaders performing transactional leadership behavior, with the producer role explaining 20% of the variance in the development of a learning organization. Regarding the significant relationship of each attribute of a learning organization, transactional leadership role of producer was a significant predictor of knowledge system and explained 29% of the variation. Chief executives with producer role, thus emphasized the knowledge system, that is, the development of new knowledge and insights that have the potential to influence behavior. The study also conducted semi-structured interviews with the chief executives of the hospitals to obtain their perception on the current organizational culture to gain insight about how the organizational culture has changed over time since they have participated in HA.For the subordinate’s perception of both two sectors, this study used quantitative techniques through a questionnaire survey. Descriptive statistics and structural equation modeling (SEM) based on LISREL methodology were applied to analyze the results. Direct and indirect effects were examined. The private hospitals’ learning organization model indicates that the development of a learning organization was directly influenced by transactional leadership (the director role) and  transformational leadership (the broker role), regardless of the nature of organizational culture. For the public hospitals’ learning organization model, it indicates learning organization was directly influenced by transactional leadership (the producer and director role), regardless of organizational culture. Furthermore, the private hospitals’ learning organizational model illustrates that the development of a learning organization from learning the process of how to initiate and implement hospital accreditation successfully is indirectly affected by leaders using the coordinator role through the achievement culture and the supportive culture respectively. The public hospitals’ learning organization model indicates that the development a learning organization is indirectly influenced by transformational leadership (the mentor role) and transactional leadership (the director, coordinator, and monitor role) via achievement–oriented culture and supportive culture or via achievement–oriented culture and role-oriented culture respectively. Consequently, 42% of the variation in private hospitals’ learning organization model and 49% of the variation in public hospitals’ learning organization model were explained. Finally, the learning organization model in both private and public hospitals was found to adequately fit the hypothesized structural model with the satisfactory goodness-of-fit level. In addition, the results indicate the learning organization would not exist without the two supporting foundations of appropriate leadership behavior and organizational culture. Thus, the findings suggest that leadership behavior influences the organizational culture and is deemed an appropriate starting point in the casual relationship model. It confirms a theoretical model claiming that subordinates of both sectors see causality between leadership behaviors, a current organizational culture, and a learning organization. 	For future research, it is recommended to replicate the study but also include the measurement of a current organizational culture as perceived by the leaders. Thus, the replicated study will be able to compare and confirm two causal models of the development of a learning organization between leader’s perception and subordinate’s perception. With in this regard, the results of the future study will show whether or not a discrepancy exists between them. Moreover, replication of this study in other organizations such as educational institute would be useful. A follow-up study after several years of HA would indicate whether or not the attributes of a learning organization have been sustained in these hospitals. 	The results of the study also point to two important practical implications for organizational policy and human resource management. First, the training program for leaders is in organizational culture management because the development of a learning organization gained from learning how to implement quality improvement will be not sustained, unless culture of hospital change. The culture change process is recommended. The second implication on this study includes a leadership training and development program for chief executives of both private and public hospital.


Dental Health Services Under Universal Health Coverage PolicyThe study of oral health services system to focus “Oral Health Services Under Universal Health Coverage Policy” was conducted during 2001, the first year of the implementation of universal health coverage (UC) policy.  Followings are  major findings and recommendations:Findings:1. Policy to emphasize on prevention is still far from expected.  Almost all of the services delivered by the studied hospitals were pure curative purpose while preventive services accounted for less than 3%.2.  There were 26% increasing of clients in dental clinics of the six government hospitals.  Most of the increasing number were adults and elderly people.  Services for children were comparatively decreased.  More than half of the clients had to pay for the service fee. Among the clients  37% were gold card holders under the UC program.  The total clients were from 6.5 % of the total population and only 1.5% of the total gold card holders.  Most clients visit the dental clinics for only one time and received only one dental service.  More than 80% of the services were under a core-package for example dental filling, tooth extraction, tooth scaling, etc.  Clients had to be on longer waiting list, particulary for denture services.  Preventive activities in the community formerly responsible and carried out by provincial health office were not be able to continue by the regional or general hospitals during the first year.3. Most of the private hospitals, six out of seven, delivered only hospital-based curative services.  Almost half of the patients (43.5%) were gold card holders.  Administrators of the private hospitals were much worry about the financial problem from providing dental health services.  Some administrators closely monitor the expenses and set up additional regulation to prevent financial loss.  However, the loss scenario is unlikely happened in the near future because only 4.5 % of gold card holders used the services.4.  Many private dental clinics are reluctant to apply and enter the sub-contract system in providing dental health services because the UC policy did not effect their business .  In addition, they are afraid of spending time in preparing paper work and uncertainty to have a quick reimbursement of the fund.  Anyhow, some clinics which had experience in getting insurance sub-contract from business companies, expressed different opinions.  They supported the idea that subcontracting from the UC program will result in a  mutual benefit.  The private clinics can gain more patients during the low client period of the day and can maximize their current employee staff performance.	The idea of subcontract out the dental services for the private hospitals depended on the decision of the contacting unit which dental health service might not be at top of the concern for them.  In addition, the idea of subcontract might not be possible in the rural area where dental professional are scare and inadequate.	Although private clinics were ready in the aspects of the service unit and technology but the social readiness such as the handle of patient right to know is important. 5.  The UC policy can ease the financial constrain of the current system but can not trackle the lack of dental health personnel.  Data in 2001, showed 68% of the provinces has under satisfactory ratio of dental health personnel per population.  There is a need to readjust current dental health manpower development not only in term of number but also the new required skill.  For example, dentists in both public and private sectors should be trained to carry out dental public health work in the community while dental public health nurses should be able to work hand in hand with private sector.6.  The first year experience of the dental health service under the UC policy was not fully match the standard set up for the primary care unit especially the coverage and personnel aspects.   Several alternatives can be choose to solve the problem:  a) government employed more dental health personnel.  b) a joint government and private services  c) prioritize the most needed service to meet the standard criteria instead of providing all services as currently.   In principle, the solution can be a combination of these three alternatives with modification for specific area.7. There are also phenomenon in favor of improving dental health services.  Private hospital hired more full time dentist instead of part time and former sub-district health center could start deliver dental health service after transform to be a primary care unit by the primary contacting hospital. Recommendations:1.  The goal of a universal coverage for all dental health services can not be achieved in these near future.  We recommend the strategy for UC policy to focus primary on coverage of particular age group such as children and also focus the coverage in dental preventive and promotive services.  This will yield a high impact to solve dental health problem of the of the population.2.  There is an urgent need to set up a shared information and data bank for both public and private sectors at the local and national level.  Without common indicators and information, it is difficult to evaluate the success of the UC policy.3. The monitor and inspection body for the implementation of dental health services under the policy is vital.  There must be criteria to select the inspection body.   If the provincial health office is choosed to serve as the inspection body, the personnel must be trained to enhance their skill and capability.  In some countries, the government contracting out the management and implementation of the program to local dental health association.4.  One of the major standard criteria for sub-contract  the service is the reach out capacity to the population.  If the accessibility of the population is not satisfy, the contracted units must expand its network.  Detail on how to assess the capacity of the contracted unit and its network must be clearly documented.5.  Dental health promotion in a boarder sense should be introduced.  The real dental health promotion is not limited to clinic-based services or family visit or screening for preventable conditions but should encompass initiating promoting dental health environment. Further study	Carry out this study during the first year implementation of the UC policy pose some limitations in term of the limited number of study hospitals and provinces and the dynamic stage of the implementation. Several problems or issues might have been solved so far.  Recognizing this limitation we also recommend further studies in the following area.1.  Macro-policy study to provide recommendations for the national health system.2.  Additional case study to gain more knowledge in dental health services under the UC policy and context such as:	a) Subcontracting joint public and private dental clinics for delivering services to specific age group or conditions.	b) Effective management and supervision of the service network.	c) Development of key performance indicator and information center for assessing quality of both public and private services.	d) Estimation of average cost and expenses in carry out dental health services in different provinces.


The project   “researching community in development health of 0 – 12 years old children” of Namka village, Moo 1, Payakaew sub-district, Chiangklang district, Nan, has  4 objectives; namely:To solve the problem of lack nourishing food in 0 – 5 years children of Namka village, not over 5 percentage of one level, none in two levels within A.D. 2003.To solve the problem of dental health in 0 – 12  years children of Namka  that has not over 30 percentages within A.D. 2003.To get the form of 0 – 12 years children  health promoting that is suitable for Namka Community.To learn community’s participation process in problem solving of community.Procedure Chiangklang Health Team that consists of doctors, nurses, public health  academic, pharmacist and  dental officers had researched “community in development health of 0 – 12  years children” of Namka community. The community analyzed the problems of 0 – 12 years children in community, found the ways to solving, solved the problems and evaluated by itself. The Chiangklang Health Team gave the supporting about the knowledge and helping in this progress. It’s the good collaboration of community, school, kindergarten and hospital.Community’s participation activity make the community realize the problems, cause of problems and the ways to solve the problems of lack nourishing food, dental health problems and other social problems of 0 – 12 years children, namely;Setting up the environment in the community including school, kindergarten, community stores, must  not have food stall that demolish children health.There is a good culture in anniversary birthday celebration of children. There is no party but it replaces merit making in the temple, and giving a little money as gift.There is teaching in the brushing teeth like brother teaches sister, and parents are care about children’s dental health.There are not candies, coffee and health demolished beverage in funeral.The community has its rule, and punishes the people who break the rule as to fine.Result	After the community do this process, there is health effect, namely;Before this project (June, 2002) in the lacking nourishing food, we found that 7 children have lack nourishing food ( 15.22 percentages), and nobody  has lack nourishing food after 6 months. We follow this project one years later, we found that there is not lack nourishing food of children in Namka community.From June 2002 – December 2003, there is changing in dental health as followingPre-primary	:  	A. level (dental health is good)  from 34.78 percentages a			72.73 percentages.E. level ( dental health must be cured suddenly) from 43.48 percentages as 22.73 percentages.Baby teeth decayed from 82.61 percentage as 72.73 percentages.Primary	:	A. level from 44.59 percentages as 64.94 percentagesE. level from 40.54 percentages as 26.78 percentagesPermanent teeth decay from 29.73 percentages as 15.58 percentages.The result of dental health in kindergarten :No teeth decay from 20.83 percentages as 53.70 bad brushing teeth from 16.60 percentages (June 2001) as 0 percentage (June 2002 – Nowadays)3.	Participated process of Namka community that effects children’s health development as specific, can measure the effect of nutrition health and dental health. That process has success because of good participation, such as, analyzing problems, finding causes, finding the way to solve, including  care the rule that set up by community. The success factor is similar to “Ottawa Charter”, for example, construct public policy, construct an environment that is useful for health promoting, construct the power of community firming,  improving personal skill (especially of community leader and parents) and changing the role of public health officers).4	The important factor of success is the good environment that useful for health development. Moreover , the location of community is fine. Because the Namka community is not too big. It separates from other community that surrounding  with rice farms, so the community can take care each other.Suggestion for improvingHealth construct in organizations should bring “Ottawa Charter” to apply in progress.There should have community in the vicinity of Namka. Its leader has strong power, and the community is ready, realize children health problems. That community can participate with Namka to exchange the idea, knowledge and spread the united front  to take care the children health. If we have a big group, we can have community network for care children health that can make unanimity in our country.For Namka community, there should have enlarging health development in other age level by participation  process such as, drinking problem, smoking problems, etc. Local government organization and municipality  should participate in this process or promote health such as, to except taxes of the stores that participate in this project or give fund to that store or shop. Health promoting is a mission that the community must do, if the community makes this process by itself, the district should support the fund.


Health assembly is one of a mechanism in the process of Thai Health System Reform which is an ambitious movement for total change of Thai health system fromideology to practices; from individual, community, and professional levels, to national level. Assembly is a new mechanism for public participation Thailand. This mechanism aims to bring multi-sectoral cooperation to promote new health system that emphasizes prevention rather than curative health where by the term ‘health’ was defined in a broader term included various aspects of well-being which beyond the realm of medicine. First movement of the health system reform is to launch the “National Health Bill,” that will be a new Thai health constitution, a guarantee for new health system to exist and maintain people participation. The National Health Reform Committee and the National Health System Reform Office, thus, form an ad-hoc committee to mobilize and organize health assemblies in almost 500 districts, 75 provinces, and one national assembly. The ideology behind organizing health assembly is to consider these assemblies as “social innovation” for people participation in the policy making and legislation procedure. Therefore, each sub-committee at all level is allowed to create different procedures to make people participated in this law making procedure as much as possible. The procedures are expected to be acceptable to local cultures and settings. The assemblies, thus, need not be formal, or totally informal; whatever types or forms of social gathering for this purpose is achieved there would be lesson learn to other assemblies that followed. Thus, the provincial health assemblies were organized according to local setting, which in turn gave lesson to the national health assembly. Every procedure is differed depend upon various factors. This study, therefore aims to document and analyze the procedures of the assemblies to see what the primary forces that bringing people participations in different kind of settings. It also aims at understanding the whole picture of people interaction in different kind of stage arrangements. This report also analyze the procedures of health assemblies as a form of social process that scrutinize, on the one hand, instrumental components of social transaction, environment, and tools for interactions; and expressive components of social transaction, emotional reaction, symbolic representation, and exchange of ideas and knowledge. The result of this study revealed numbers of factors influencing people participation in the assemblies, particularly the components of multi-sectoral participants which was a challenge to organizers; the nature of moderators and the dynamic of interactions which could enhance or became a barrier for people participation at the same time; the matter of the contents of the discussion which could bring cooperative or protesting atmosphere; and the formats of the meeting which create a pressures or accommodating nature for participation. On the other hand, this research also found that the assembly (particularly national health assembly), reveal a set of political procedure resemble of neo-communitarianism which emphasize on public/civic engagement of an eclectic group of participants. Even though, health is an agreeable subjects that people could easily accepted the ideas of change for the good will of people, health assemblies, emphasize communicative culture of formal talk and discussion with specific set of rules, people who are not familiar with the procedures could found a resistant to some of the subjects discussed by persons of different background. This study is only able to reflect what had happened at the front stage of communication which left the back stage of communication untouched, and to be further study with cooperation of those who organized the assemblies in the future.


The idea of setting up practical Primary Care System, under changes of health care policies and concepts in structure, methods, tools and operating systems, involved developing health care providers and related field staffs.  This was accomplished through learning and sharing experiences among academics, health care administrators and staffs, local government office administrators and the public.  Based on socio-cultural context of each area, and health care policy changes and reforms, the transformation itself has shown progress in human resource development, tool development, operating method development, and effects of the development management. Roles and responsibilities of nurses for providing primary care services are proposed including 1) overall health care managers, 2) health service providers, 3) supervision and monitoring nurses, and 4) community nurses, to pursue all care activities including providing care for every dimension of the population, creating a health care network, providing continuous care, providing family care, preventing illness and promoting sanitary awareness.


The objective of this project was to search for problems of drug system in Songkhla hospitals, which is major portion of drug system in terms of both expenditure and quantity.   Questionnaire mailed survey was used to collect data from pharmacists who were in charge of drug system in 21 hospitals.  These included both public and private owned hospitals.  Also, focus group technique was used to search for the problems in the drug system.  A total of ten hospital pharmacists sent the survey back and pharmacists from 19 hospitals participated in the focus group.  From all data, the conclusions were as followed	1. Drug Selection	An important problem in drug selection process was the problematic performance of the hospital patient and therapeutic committee (PTC).  It started from the beginning process when the data was gathered for submitting to the committee and continued to the committee meeting.  They had an impact on the performance of hospital drug selection.  Another potential problem was the problem of non-officially listed drugs in the hospitals, which were drug products that were not selected through the PTC but they were available in the hospitals.  It affected the drug system in various perspectives such as equity problems among different patient types of payment or problems of avoiding regular drug selection process.	2. Drug Procurement	Various problems related to the procurement process were identified.  First, the hospitals were forced to buy drug products manufactured by the Government Pharmaceutical Organization (GPO).  Some of the GPO’s products were more expensive.  The GPO also provided poor services such as they did not notify in advance when some products were out of stock.   Second, the human and information resources were scarce for decision making in drug purchasing groups, which was a government policy.  Another problem was the quality of drug products.  Under resource constraint, less expensive products were procured.  They were required the quality assurance at the hospital end.  However, limited resources were available for the hospitals themselves and the number of analyzing agencies were also inadequate.  	3. Drug Distribution	An important problem regarding the drug distribution was the distribution toward the primary care units (PCU).  The pharmacists’ roles at the PCU were ambiguous.  Also, data of drug storage appropriation at the PCU did not exist.Drug UseOther than general drug use problems such as clinical outcomes of irrational drug use, economic efficiency and equity among the different patient types of payment were the problems in the drug system.  For instance, non-essential drugs, which were usually more expensive, were likely prescribed for patients who paid out-of-pocket or were covered by the government.  They eventually created unnecessary high national drug expenditures.In conclusion, this study reflected various problems in Songkhla hospital drug system.  Some of them were long time problems such as the problem of PTC in drug selection process.  However, there were also contemporary problems which occurred from either technological change or government policy change, such as the scarcity of information, the impact from the universal health insurance coverage (UC) and the drug purchasing group policies.


Diagnosis related groups for the low income, development and applicationInpatient services are complex and costly. The US Medicare, the elderly health benefit scheme, had faced uncontrollable expenses in the 1970s because the scheme reimbursed hospitals retrospectively. Diagnosis related group (DRG) was invented in  the early 1980s to be used in a prospective payment system to control the rising cost. After it has been proved successful, DRG has migrated and been adopted into health care systems in  many countries. Some use DRG on a case by case payment basis, some use DRG in a resource allocation formula and some use it to compare the hospitals' activities. DRG is considered  non-foreign to the Thai health care context. Classifying cases into DRGs requires information that is readily available  (diagnoses, operating room procedures, age, type of discharge). DRG can be used to predict the lengths of stay and resources  used to treat patients in the hospitals, so we are able to use DRG for resource allocation, for case-based payment and for comparison between hospitals. Assigning patients into DRGs  requires data on ICD-10 and ICD-9-CM (for diagnosis and  procedure respectively)of individual patient. So far, research activities on DRG in Thailand based on the 10th revision of Health Care Financing Administration (HCFA-DRG). Relative weight for each DRG is estimated by using patient-based costing methodology and cost to charge conversion ratio, then compare the cost mean of each DRG to the average cost of all patients. After reviewing the weights from many piec of research results and with inpatient data from Ramathibodi hospitals, the final version of relative weights to be used in the Thai context is endorsed by the Health Insurance Office. The uses of DRGs are many folds. In 1997, allication of non-salary recurrent budget to 92 general and regional hospitals used the average relative weights to better reflect their case complexity and cost. The second example, relative weights for different schemes of the low income were used to estimate budget requirements if the Thai government were to propose a universal converage scheme to the majority of Thais.  The third example, relative weights were used to evaluate hospital achievements. The future use of DRG within the global budget ceiling in the reform of civil servant medical benefit scheme should be cautiously laid out. Finally, if DRG is to be used in the Thai health care context, it needs to set the system that recalibration of DRG weight can be done systematically. The dataset for hospitals to report for each patient to be examined is the important strategy for continuity of the system. Finally, cost accounting studies in a few efficient hospitals need to be done to tell the true cost of providing care to each DRG.


The purpose of this study are to study prevalence of vitamin B1 deficiency and vitamin B1 intake from diets.  Samples were between 15-50 year’s old, 157 persons from Ban Choochat, Tambon Lue, Prathumratchawongsa District, Amnatcharoen Province.  The samples were selected from the population in Ban Choochat 274 persons by list from the person between 15-50 years old, the sample increased 4 persons so the total samples were 157 persons.  The researcher collected data using questionnaires.  Questionnaires was interview which developed from interview format of the person who had vitamin B1, deficiency by The Nutrition Division, The Ministry of Public Health.  It was divided into 6 parts:- personal data interview; body checklist record; laboratory’s examine record; food eating interview in 24 hour’s interview; and cooking food’s situation interview.  The data were analyzed and interpreted statistical by frequency, percentage, means(x) and standard deviation(S.D.).	The results of the study, it was found that, Ban Choochat, Tambon Lue, Pratoonrachawondgsa district, Amnatcharoen province had vitamin B1 deficiency 73.90%, divided by ETKA found Low risk level 34.40 and deficiency level 3.20, divided by TPPE found Low risk level 21.00%, and deficiency level 52.90%.  From physical examination found that the sample of vitamin B1 deficiency were not show all clinical symptoms in every person.  The amount of vitamin B1 from diets each day, that was under normal requirement (1.2 mg/day), was found in 93.34% of the samples and the nutritional status was found that obesity samples could deficient in vitamin B1 also.  The samples which vitamin B1 deficiency had the risk to be obesity and obesity level 1 about 19.83% and 18.10% and proportion in dietary:- protein : fat : carbohydrate each day=12.03 : 8.02 : 81.10% and proportion in dietary:- protein : fat : carbohydrate each day = 12.03 : 8.02 : 81.00. It was indicated that the habit in eating food is not balance, especially in Carbohydrate which the kind of whiten rice, took in water a night (63.70%) or cooked by water’s change(15.30%), eat raw preserved fish every day (63.70%), eat vegetable which spoiled vitamin B1 and worked hard (agriculture 95.50%).  It should increase using Thiamine to be coenzyme to metabolize carbohydrate for energy and lead to risk from vitamin B1 deficiency.Keywords :  Vitamin B1 Deficiency         Vitamin B1  Volume intake


The Satisfaction Evaluation  on the Re-structured System of the Food and Drug Administration(FDA)	In order to effectively guarantee consumers and clients of FDA the utmost satisfaction, the evaluation on the newly-designed operational system has been initiated and applied to officials in charge and clients involved with the service delivery of  FDA. During October to December 1998, a questionnaire and an interviewing on a level of officials and clients’ satisfaction had been distributed to those targeted groups, evaluated and compared with the former operational system in each individual division,  ranging from Drug Control Division, Food Control Division, Cosmetics Control Division, Medical Device Control Division, Toxic Substances Control Division to Narcotics Control Division.	In general, clients of FDA using the new system of service delivery do content with the re-structuring, especially in Cosmetics Control Division and Toxic Substances Control Division ( the range is between 3.50-4.49). More specifically, when compared with the former system, the results are as follows:The re-structuring is better off by far when applied to the Cosmetics Control Division.The re-structuring is somewhat better than the previous system when applied to Drug Control Division, Food Control Division and Toxic Substances Control Division. However, some possible adjustments would increase more efficiency and satisfaction .The re-structuring is acceptable but less satisfied clients than the previous system was when applied to the Medical Device Control Division.	In sum, the evaluation reflected overall satisfaction on the re-structured system when compared to the former one (the range is above 3.0) but was not as outstanding as it has been expected.  With regard to the level of satisfaction among officials involved in the FDA, a production division and a support division are contented with the re-structuring (the range is between 2.5-3.49). When compared with the previous system, the production division is convinced that the new one is less satisfied and is expected to be developed both in terms of the promptness of coordination and cooperation. With respect to the supporting division, the evaluation also turned out to be negative in which it implies that the new one does need a strong determination from FDA to develop in almost every sense, from coordination, efficiency, responsibility to overall effectiveness and quality of service delivery.


The study of quality indicators of administrative data and hospital characteristic aims to test the 45 indicators of quality assessment of the administrative data in the US whether they can be applied with the existing administrative data in Thailand.Can they use and compare the result of the services in various aspects such as year,region comparison. Will  they be possibility of using some indicators to monitor the quality of services in Universal Coverage of health care scheme (UC)  in the future? 	The methodology is cross sectional study of reimbusement data from 2000-2003.It is two parts of analysis.First,the data is assesed by sampling from year 2001 hospital data to audit the chart with central data.Second,administrative data of three years are test with 45 HCUP(Health care cost and utilization project)  indicators.There are two groups of those indicators provider level and area level indicaor.The provider level consist of 6 Volume, 5 Utilization, 6 inpatient condition mortality  and 7 inhospital procidural mortality indicators. While the area level consist of 4 Utilization and 16 Avoidable hospitalizations and Ambulatory care sensitive condition (ACSC) indicators.The comparison between the various characteristics are studied in this research.	The result of this study showed that the 70% of data was corrected in diagnosis and 62% in procedural coding.The data can rather use for analysis of indicator.For the volume indicator,it can not be evaluated from data because those operations are less in Thailand,Thus,the mortality form them can not be compared as well.   	The utilization indicator which can be analysed in this study was Caesarean section rate while incidental appendectomy among elderly and Laparoscopic cholecystectomy can be used by combining data from three years due to the small number of cases.The useful inpatient condition mortality were Acute myocardial infarction mortality,Congestive heart failure mortality,Pneumonia mortality and Stroke mortality while another two indicators, Hip fracture mortality and GI hemorhage mortality were required to use the total data of several years for assessment. 	For the area level indicators, the service rate of Hysterectomy and Laminectomy can be used while CABG and PTCA  cannot because of the inadequacy of data. Most of the Avoidable hospitalizations and Ambulatory care sensitive condition indicators can be used except for uncontrolled diabetes mellitus since there is no coding in ICD 10. However,some provinces had few data compare to area population so the indicators cannot be evaluated.	Because they are no composite index of indicator,each of them can be applied separately,Using various years of data makes the reliable result of assessment especially mortality indicators. Some of indicators are main indicators for presenting the result of hospital services for example;  Caesarean section rate because there were adequate data in each year and such result of services can be used for comparison. For the area level indicators, this study showed that some provincial area might have less population so the reliability of the indicators might be questionable. This  can be solved by expanding area into regional area.   	Applying these indicators 	in Universal Coverage scheme presently is not likely to be possible because of two factors;the correctness of data and the suitability of the indicators in Thailand data.Moreover, there are many factors involved. For example, cause of illness, treatment or operation and health service system between Thailand and other countries are different. In order to tell which province or which hospital is good quality in inpatient services providing, there must be the development of indicators for Thailand, particularly, the standard of selection of indicators using statistic method. Besides, low standard of care caused by the monitoring organization would make the result of indicator assessment for comparison more meaningful.


Improvement  the continuity of hospital to home-based rehabilitation for stroke patients at Sappasittiprasong HospitalBackground and PurposeStroke management is aimed at facilitating functional independence and community reintegration. Therefore, It would be logical that the sooner the patient can be returned home following stroke, the sooner the reintegration process can commence. The purpose of this study was to improve the continuity of hospital to home-based rehabilitation for stroke patients.MethodsAction research  devised to 3 phases. This study was Phase 1 what showed situation analysis to identify problem. Prospective study  collected data of patients and patients’ family who referred to Physical Therapy Department at Sappasitthiprasong Hospital. The data was collected by interview, indepth-interview,  observation and focus group.  The main outcome measure was Barthel Index (BI) for assessment activities daily living (ADL).ResultsThe problems were identify to problem of co-ordination in interdisciplinary team,   problem of home visit service from home health care system, problem in lack of authority and  problem of patients and caregiver.  The most of patients were in rural area.  There were 8 subjects who came to follow up from 20 subjects. Barthel Index score showed improvement when comparison of hospitalization period and 3 months followed up period (4.8, 12.2, respectively).Conclusion The continuity of rehabilitation system could improvement by the patient’s family member or other caregiver participated in rehabilitation from beginning and improved the co-ordination in interdisciplinary team.


Health Systems Reform in EnglandHistory of NHS	In England, the health system is national Health service (NHS). In 1997, NHS had about one million employees with a budget of 45 billion pounds, making it one of the largest organizations in the world.	 Before the NHS,  health care was in the form of  fragmented services run by various organizations. There was no single main institution responsible for coordinating the services. 	In 1911 the government enacted  the law “ National Insurance Act” with the aim to serve the work force, but the provision did not cover their immediate family members.	In 1942 Sir William Beveridge gave a report which was the start of the policy of comprehensive health care for all people. Anerin Bevan, Secretary of State for Health of the Labour government, succeeded in negotiating with the doctors and brought about the law to start National Health Service in 1946.	 NHS was originated on July 5th 1948.  NHS  is the second institution next to the Monarchy that  the British people take pride in.  Anerin Bevan was the architect of it and was considered the best political achievement  by the Labour party.Problems and drives that led to health care reform	 The principle of  the NHS is free comprehensive health care at the point of use regardless of the status of the people, i.e. equity. NHS is funded by general taxation. The  problems and  drives to reform the NHS can be traced back to the beginning of NHS due to two original conflicts:The conflict between centralized and  autonomous  management of its organization structures.The conflict between the medical profession and the government. The government funds NHS and wants some control but the doctors give service and want professional autonomy without scrutiny from the government.NHS success became its own enemy in a few years of it running. When the government promised to give free delivery of care, the obvious problem was the inability to meet the financial obligations when faced with increasing health care cost and demand. There have been accusations all along that every government has not given enough funding to the NHS.The complaints had increased since Margaret Thatcher came into power in 1979, leading to the radical reform in 1990.	The British government spends less money for health system compared to that of other developed European countries, amounting to 6.6% of GDP whereas other developed European countries spend about 8-9% and the USA, 15-16%. NHS has produced comparative health outcomes to other countries; however, the British people are still not satisfied.Reform Process NHS changed very little during the 1950s and NHS drifted without clear direction until 1962 when strategic management was introduced to guide the development.In 1974, there was the first structural reform, introducing more planning and integration of the services. The reform was apparently unsuccessful. There was no genuine attempts to challenge the medical profession, which was the centre of real power in the NHS. Eventually the conflict between the doctors and management remained. There was no mechanism to get the doctor to account for their work to the management.In 1979, there was another attempt to reform NHS, leading to the second structural reform in 1982. However there were only a few changes to the organization.In 1983, the conservative government brought in successful businessmen as advisers. One of them was Sir Roy Griffith, who was asked by the government to report on the conditions and ways to improve the  efficiency of NHS. The 24-page report by Sir Roy Griffith was very powerful in bringing about huge changes in NHS. General managers were speedily introduced into NHS in 1984, commencing the era of bargaining with the medical profession.In 1988, Magaret Thatcher announced a radical reform, leading to the significant White Paper: Working for Patients, which proposed unprecedented radical reform of health system. It was followed by the National Health Service and Community Care Act 1990 to start the reform.One of Thatcher’s political ideals is that government institutions and bureaucracy are inefficient and need transformation into a more corporate and market system in order to be more efficient.Strategies of NHS reform 1990	The process of change was inevitable  because of mounting public pressures to the government. The main strategies used was managerialism . All kinds of management techniques were used such as quality assurance , performance indicators, management for excellence, etc. Market competition was instituted.	The strategies for this 1990 reform were as follows:Delegation of power and setting up of autonomous bodies such as NHS Trusts and GP fundholdingInternal market.New funding systemDecreasing the power of medical professionStrengthening primary care system by giving importance to GPs and creating GP fundholding.Essence of 1990 reform	 The essence of 1990 reform was the creation of the split between providers and purchasers of health care. Hospitals were encouraged to become autonomous by being a NHS trust, answerable directly to the Secretary of State for Health. At present all hospitals in England are autonomous NHS trusts.	GP fundholding would act as purchasers of health care on behalf of the patient. It received and could manage its own budgets and could enter into contracts with any provider the GP fundholder saw as giving the best deal.. If the money was saved from the efficient management of the budget. The fundholder could use the money left for developing the practice, which was a new power they never had before.	What bound the provider and the purchaser was a contract, leading to an internal market.	The process of decreasing the power of the doctors was done by having systems like medical audit and doctors’ accountability of their actions to the management. The doctors was no longer free to do whatever they like as it may cause purchasers not to buy the hospital services.Human Resources and Manpower DevelopmentPhilosophy of  human resourcesServices and human resources planning have to go together. The policy about human resources in NHS is still not clear in the midst of many changes that are taking place in NHS. Prior to 1970s there had been no clear direction of the services. Each health care  profession  was quite independent of one another. In 1980 the Medical Manpower Steering Group reported that planning for medical manpower was extremely difficult due to the uncertain future of the NHS.Future Medical Manpower	There were 102610 doctors in the NHS in 1996 which was 1.7 per one thousand population.. According to the Medical Workforce Standing Advisory Committee report by the Department of Health, a study on  future delivery patterns and needs for doctors, it  found that 76% of NHS doctors were British graduates. It also recommended that , under the present situations, the chance of  having a surplus of doctors was slim and there should be 1.7% annual increase of the number of doctors. The methods to achieve this aim were as follows:to recruit more overseas doctors.to maintain the number of present working doctors.To produce more doctors byincreasing the number of medical schools expanding the existing medical schoolsincreasing the new intake of medical students by 1,000 per year.Future Direction of Manpower Development	In 1998, the government  produced a document called Working Together: Securing A Quality of Workforce for the NHS, which stated that every  hospital trust and employer would have to complete the manpower planning by April 2000, including the plan for producing and developing  most health care professionals in the NHS   to have a link between the education of  manpower and the delivery of services.	 Because of inadequate data,  planning was very difficult. However King’s Fund had the following recommendation:There must be a long term  and realistic planning , taking into consideration the boundaries between health care professionals so that there may be ways to predict the number of professionals needed.There must be a concrete link between the training of health care professionals and the services requirement in the NHS. There should be emphasis on overall management of the NHS system and the cooperation between the managers and the professionals. There should be a comprehensive analysis and synthesis of data and research on human resources.Technology Control and Regulation	New technology has to be assessed strongly and continually for its cost effectiveness, efficiency , safety and use-appropriateness.	There has been increasing evidence that some technology is unnecessary and misused. Most western developed countries have  a system of intensive regulation of medical technology in four dimensions:SafetyEfficacy StatusEffectiveness in general practiceEfficiency England uses the budgets limit measure to regulate medical technology. An organization, called National Coordinating Centre for Health Technology Assessment at Winchester, is responsible for disseminating information about technology  assessment and distribution. In addition, the Royal Colleges of various medical specialties have their own registration of medical equipment and training of the use of medical technology. The Department of Health also has a committee called Standing on Health Technology Assessment to advise on the need for new technology.	However there is no central body to control expensive medical technology. Nor is there a law for such matter. Only through advice, cooperation, negotiation and peer pressure is control and regulation being done.Consumer Roles and ProtectionPhilosophy and evolution of the relation between NHS and its ConsumersThere are three models for health care system:Market Model: health care is treated as a kind of  goods which is regulated by  market mechanism of  demand and supply. Consumers have choice to choose the goods, but in reality health care does not seem to follow the market mechanism alone.Professional Model: This is based on the fact that doctors know best and should make the decision for the patientsBureaucratic Models: The state must intervene to provide health care  in order to have equality and to protect the best interest of the public.England uses the mixture of second and third models, although it seems that the first model has been in operation since the 1990 reform. In fact the public still have little choice. People have some choices regarding GP and hospital accessibility but once they are with the professional, they are hardly involved in making decision about the care.Compared to other public organizations, NHS lacks direct democratic accountability as there is no public representative  unlike local authorities, etc. NHS has indirect accountability through the House of Commons, which accounts for the public through health ministers.In 1974 Community Health Councils were set up to represent the public so that people and consumers were more involved in health care.In 1983 the Griffrith’s Report greatly affected the relationship between professionals and patients as market mechanism was introduced into the health care system. An example in the report: “ Businessmen have a keen sense of how well they are looking after their customers. Whether the NHS is meeting the needs of the patient, and the community, and can prove that it is doing so, is open to question”.In 1991 the government introduced the Patient’s Charter.Consumers ‘s Roles	There are three issues regarding the role of the consumer:1 Involvement in decision making process the careInvolvement in planning, developing, monitoring and auditing the servicesPublic Involvement	Consumer Protection is a big issue although the government is not very concerned gives little support with no new law. However the Department of Health has established the Centre for Health Information Quality.	In summary the public needs to be more involved and requires further developments.  The culture of “ doctors know best” is no longer acceptable by the people. People want information so that they can be more involved in making decisions.Ways of Public Involvement	1.Community Health Councils	2. Public Opinions	3. Quality Assurance4  Self- Help and Campaign GroupsComplaints and Compensations	There are several ways that consumers can voice their complaints and seek redress:Family Health Service Authorities would accept complaints about general practitioners, dentists, pharmacists that do not comply with the agreement.District Health Authorities have mechanism to accept and monitor complaints about hospitals and community services.In 1979, the Royal Commission on NHS criticized that the complaint pathways were too complicated and there should be a simple system that people could understand and consumers could voice their complaints.       In 1973 Davies Committee proposed a national practice guideline on how to manage complaints in the hospital as well as setting up the independent health ombudsman. The proposal had been ignored until 1985 the Hospital Complaints Act required health authorities to set up a system to deal with complaints. In addition to NHS mechanism, there are professional bodies like the General Medical Council, the United Kingdom Central Council for Nursing, to which people can submit their grievances directly. Ultimately people can go to court to seek redress and compensations.	The House Committee on Public Health is another place where people can voice their complaints on the condition that complainants would not go to court for compensations. The committee would deal with public mismanagement and would not interfere with clinical judgement.	In the past doctors had to pay premium to a Medical Defence Union to cover their malpractice insurance. However since the 1990 reform, health authorities would have to bear the malpractice compensations in case there is a legal case against doctors. There is evidence of increasing complaints against doctors through various organizations.Health Ombudsman	Health ombudsman could deal with any complaints about the NHS services except cases  that are in court. The main “ weapon” of health ombudsman  is publicity. Health ombudsman would publish two reports annually and these would be circulated to various media. The reports will  also be studied by the House Committee on Health with increasing publicity. Which in turn increase the power of health ombudsman. The House Committee could summon the Health Authorities to account for the management and the response to the complaints, which could be quite disconcerting despite the lack of legal power.Complaint Process	Previously the complaint process was quite complicated through several channels such as Family Health Services, General Medical Council, Hospital Trusts. Each channel has different mechanism. In 1996 , a new integrated complaint mechanism  was formally proposed:First Step: Local Resolution.Second Step: Independent Review. If the complainant is not satisfied, he or she can request an independent review.Third Step: Health Ombudsman. If the previous two steps have not brought satisfactory resolution, the health ombudsman could be requested for helpAnalysis	Any health care reform would deal with two issues:Funding mechanismDelivery of the care.In essence, the reform would aim at good quality of care at low cost, which is comprehensive and equitable.. The strategy often used is managerialism.The British government, in response to funding pressure, has brought about a policy: “ The health of the Nation 1992” in order to reduce sickness. The health targets set are such as reducing coronary heart disease and stroke by40%, breast cancer 25%, lung cancer 30%in men and 15% in women, suicide 15% in year 2000. Community becomes more important with emphasis given to prevention as it is more economical.The evaluation of the 1990 reform indicated that the reform did not achieve the objectives. Waiting list remained as long as before. People did not have more choices as promised by the reform. District Health Authorities had not changed their policy of purchasing care due to limited budget.The internal market had created its own problems like skimming, skimping and rationing. Skimming occurred when the purchasers would accept only healthy people because of cheaper investment and hence money was saved.Skimping happened mainly to the providers which want to save the money by not giving full treatment. It especially affected the disadvantaged patients who did not know their right or had no power to voice their complaints, undermining the original principle of NHS of equity. Medical audit and the patient’s charter would be ways to reduce skimping. Rationing was inevitable with limited resources and high demand. The main problem is how to prioritize and who will make decision about the priority. There is still no satisfactory answer to this question.The other objective of 1990 reform was to increase the satisfaction of the health care personnel. This had not happened as there was more resistance from the doctor and other health professional personnel had been demoralized be more and more changes without apparent benefits apart from more paper work.Professor Klein had summarized that this reform had brought about superficial changes in that hospital became more beautiful, furniture was new, receptionists were more polite. He questioned whether there was nay real change in how the doctor treated the patient. However this reform was a good start for people to demand accountability from the doctor, hoping that it would eventually lead to better services.NHS after 1997	When the Labour party took office in 1997, it announced a nee White Paper: The new NHS : Modern, Dependable. GP fundholding was abolished and GPs would form primary Care Groups. However it had not abolished the internal market. Emphasis was given to quality with more cooperation that competition amongst the health care units.Consumers’ Roles	Nowadays consumers have more power through increased information. There are more channels to voice their complaints and  to seek redress. That does not necessarily mean that the power of doctors is automatically reduced. Reduction of the power of doctors is to be achieved by various self regulation, quality assurance, peer reviews, etc.Manpower Training and Development	England still faces the problem of manpower planning and development because there has been no systematic planning since the start of NHS. Only for the last 20 years has there been an attempt for serious planning.. This is an important lesson for Thailand. Technology Control and Regulation	It is noticeable that England has no law to control and regulate technology, but uses the means of budget limits and technology assessment by several organizations with indirect pressure for technology control and regulation.Lessons for ThailandWhat we can learn from the reform in England is as follows:Reform is inevitable due to natural increasing pressures from the society.Reform will take place quicker if political parties are involved and law ensues.Reform will not make everything better but , to be fair, it has not worsened everything.What is interesting is why the British government, whether Conservative or Labour party, still uses general taxation as the main funding mechanism of NHS although other developed European countries use social insurance to fund health system. General taxation has served England well and it is interesting to see the effect if it were to be adopted by Thailand.There must be a systematic future planning for manpower development.There must be control and regulation of expensive technology with consideration of efficacy, effectiveness and efficiency and safety.Consumers and the public have to be more involved through independent organizations and increased information.There must be a simple mechanism for the public to voice complaints and seek redress.Recommendation:To study in detail the history of health system in Thailand.To decrease the power of medical profession and demand their accountability.To increase the power and information of consumers.To use politics and finance to direct reform justly.To raise awareness of health care reform to be a national agenda.To work together for the Health System Reform Law.To research on health economics more thoroughly.To set up an autonomous organization to work with the government for the health system reform.To put into practice what is agreed upon.


The objectives of the study were:To develop a model for occupational and environmental health hazard surveillance which focused on agricultural and industrial sectors,To collect data and information regarding occupational and environmental health at provincial level,To identify health hazard information for the development of surveillance system. In addition, all of this information was used to prioritize occupational and environmental health problems at provincial level.The methods of the study were designed to encourage all relevant organization participation. Six provinces, such as Nan, Uttaradit, Ayutthaya, Srakaew, Amnajchareun, and Yala, were invited to join the project.  The steps of the study included data collection and survey.  The secondary data, e.g., general information of province, number of working population, and number and type of factories, were collected from relevant organizations in provinces. After that, a survey of health hazards in agriculture was conducted by local health officers. A self-assessment health book for farmers from Bureau of Occupational and Environmental Diseases was used as a tool to collect the data. The target population was 150 farmers for each province. The sample was taken by cluster sampling from each household of three districts. Regarding the industrial sector, the information about number and type of factories was collected. Only one workplace from each type of factories was chosen to conduct a survey in order to get the information about workplace information, working process, and health hazards. This information including the data from Workmen’s Compensation Fund was analyzed to set up a priority of the problems in terms of type of factories.The results showed that working population among 6 provinces was about ¾ of total population. Most of them are farmers, e.g., 85% in Nan, and 70% in Uttaradit. Almost farmers are rice-farmers. However, the majority in Yala is rubber gardener. Regarding the industrial sector, the data showed that the leading factories were agricultural industry. Ayutthaya was the province where the number of factories and number of workers were highest. In spite of very high number of target population, there are very few numbers of occupational health professionals who can provide occupational health services in all of those provincesThe data from the survey showing that farmers’ health  hazards include  1) heat and sunlight, 2) ergonomic problems and accident,  and  3) unsafe use of pesticide. On the other hand, there were lots of health hazards, especially chemical, in industries. Types of industries that were  the most important for setting up the surveillance were firework factories (Nan), Auto-body and repair shops (Uttaradit), Shoe-making factories (Ayutthaya), wood factories (Srakaew), rice mill factories (Amnajchareun), and wood factories (Yala).In conclusions, hazard surveillance is very essential and important for occupational and environmental health surveillance system. The system can use all secondary data from several sources in province. Apart from that, a field survey is needed to assist in identifying other hazard information. The problems identified by the study included lack of some data, no system for data sharing, low capacity of local health officers in hazard identification, and lack of cooperation among relevant organizations and workplaces. However, the study showed its promising achievement as a first step for surveillance system development.


A study of group process in diabetic This study is an application of action research to improve diabetic outpatient service at Plapak Hospital, Nakhonpanom Province.	The existing service was run through general outpatient service every Wednesday 8 -12 am.  The regular services for diabetic patients included; weighing, blood pressure taking, fasting blood sugar testing, and seeing a physician for medication. While waiting for seeing physician,  group health education was conducted by health personnel. 	In situation analysis, The first step of conducting action research, limitations of the existing service were defined. Firstly, it took times since patients had to do many stops, this might cause them hypoglycemia. Secondly, health education as such was not  applicable for patients’ problems.	The second stage, 17 insulin-independent diabetic patients were purposively selected to join as research  participants. Group discussion technique was introduced to encourage patients’ participation to share their problems as well as ways to solve such problems.	The following stage was evaluation. Results from research participants were the feedback of the new service system developed. The service system was rearranged as following: diebetic clinic was seperatety set up from general outpatient clinic; the service was run in every Wednesday and Friday morning; and patient-driven health education which based on self-help group concept was used.  The scores of fasting blood sugar, body weight as well as self-care practice on dietary control, pesonal hygiene and foot care, exercise, medication and help-seeking behavior before and after new service system intervention were found statistical  significant at 0.05 level by paired-T-test. Patients’ satisfaction in terms of  having a say and being recognition were much higher.	Consequently, patient were aware that it was their responsibility in living with diabetes. This enabled them to arrange their own self-help group at their villages. The outcome of this  research also provided the lessons for health personnel. They changed their way of viewing patients, listened to them more and worked with them as equal partners.


Thailand experienced a major healthcare reform in 2001 when the newly elected government launched the Universal Healthcare Coverage (UC) scheme, which is also known as the “30 Baht Healthcare Scheme.”  As the UC scheme is an entitlement program, the government has responsibility to provide such program and maintain the quality of the program to meet the standard.  Under the limited budget and commitment to many public programs, the government may have to find extra funding to finance the UC scheme.  There are at least two possible directions for the UC extra funding: reducing the cost of the program by transferring people who are eligible for the UC program (e.g. spouse and children of insured persons under the Social Security scheme) to a preferable healthcare program (e.g. Social Security scheme), and raising government revenues by increasing tax rates or healthcare co-payment.During the period of 2005-09, we estimate that there will be 50-52 million UC eligible people. In 2005, the capitation cost required to maintain the standard of healthcare services is Bt2,000.  When the capitation cost is indexed with the growth of public employee’s salary, the total cost of the UC scheme will be Bt100-136 billion in 2005-09.  Compared with past budget allocation (when capitation rates were much lower), the extra funding required to finance the UC scheme will be Bt31-46 billion.When transferring spouse and children of insured persons under the Social Security or SS scheme (who are currently under the UC scheme) and allowing retirees of the SS scheme and their spouses to be under the healthcare program of the SS scheme, the total cost of the UC scheme would reduce.  With the capitation cost of Bt2,000, the extra funding to finance the UC scheme would reduce to Bt17.6 billion in 2005 and Bt27.5 billion in 2009.The government can also raise extra revenues by increasing the commodity tax rates (e.g. taxes on alcoholic beverages and cigarette as recommended by many policy makers).  When the excise tax rate on alcoholic beverage increases by 40 percent in 2005, additional government revenue raised from excise taxes will be Bt25 billion in 2009.  In the same period, if the excise tax rate on fuel and gas increases by 30 percent, additional government revenue raised from excise taxes will be Bt45 billions.  An increase in the tobacco tax rate by 70 percent will raise additional government revenue on excise taxes by only Bt20 billion.  The additional tax rate on tobacco does not raise a large sum of government revenue because the price elasticity of consumption on taxed tobacco and cigarette is high.  About half of the cigarette consumption was untaxed.  In addition, an increase of value added tax (VAT) from 7 to 10 percent would raise Bt140-200 billions of VAT revenue during the period 2005-09.To raise tax revenues for the UC scheme, the government may choose to raise some combination of commodity tax rate just enough to cover the extra spending on the UC program.  However, this study has shown that, under the existing commodity tax structure, the government should increase tax rates on entertainment, fuel and gas, and clothing.  The marginal cost of public funds for alcoholic beverages and cigarette are high.  Raising their tax rates will further distort the prices and deteriorate efficiency of resource allocation.


Criteria, Guidelines, and evaluating tools for the promotion and transfer of public health civil servants (Administrative personnel level 8-10 and technical personnel level 9-10)The recommendations propose strategies for personnel  assessment based upon the meri system whereby the scope of application will be limeted only to administrative personnel level 8-10 and technical personnel level 9-10. The proposed  merit system encompasses 4 components as follows : 1.criteria, qualifications and career ladder ; 2.procedure of assessment ; 3.responsible agency for evaluation ; and 4.assessment tools. The first three components could be readily put into action  while the last one or the assessment tools suggest experimental  models which could be further developed in detail for future  application. The salient feature of the recommendations could  be summarized as follows : 1.criteria for assessment and career ladder are clearly designated to spell out the basic qualifications of the personnel to be assessed and steps of professional growth 2.open opportunity for concerned personnel to submit their work history and future plan propused to implement in the desired position, including open opportunity to apply for recruitment in the desired position. 	3.existence of an agency to screen essential information and data before submitting to policy makers for consideration through the 3 essential steps : step 1 : the evaluation committee considers the evaluation forms and grades them on a regular basis ; step 2 : the searching committee screen out unqualified  personnel, evaluate the applicants and makes recommendations for futher      consideration ; step 3 : the selection committee proposed the short list of appropriate applicants to be considered by the responsible policy makers. The Permanent Secretary and Director General will take part in the selection process as well as designate policy for the three  foresaid committees. 	The overall recommendation were made under close cooperation of high level administrators, expens and  technicians concerned and they were proposed for open critique and comment by health personnel level 8-10 who will be directly affected by this undertaking in a consultative meeting before final submission. This paper is in short the recommendations for establishing a sound merit system in personnel administration which proposed detailed guiding principles for implementing the system in its early stage. It is noteworthy that the establishment of the merit system requires continuing endeavours in organizational development, interdepartmental cooperation, development of tools and database for personnel assessment which, in the long run, could be evolved into an effective Personnel Assessment Centre.


The  purposes of this research were to: 1) study the scope and implementation of the One Tambon One Product (OTOP)1 policy at the provincial and sub-district levels. 2) study the impact of the OTOP policy on the physical, mental, social, and spiritual health of local fabric weaving groups in the Northeastern or Isaan region, Thailand and 3) provide guidelines for related policy makers to improve the implementation of the policy in order to increase positive and minimize negative health impact. The OTOP policy is aimed at promoting the production of local goods by using local wisdom and resources in order to distribute them to national and international markets, thereby raising the economic living standard in Thailand, particularly in rural areas where income levels and consumer demand are low. There were 4 groups in this study, which comprised of 1) local fabric weaving groups (126 participants) 2) government officials, members of tambon administrative organizations, village headmen/village committees (23 participants) 3) middle men (5 participants) and 4) the consumers of the local fabric (5 participants). A variety of qualitative methods  were used to gather data, namely focus groups, informal interviews, in-depth interviews, participant observation, and field notes.  The data were analyzed by using quantitative and qualitative methods.The results of the research indicated divergent levels of understanding amongst local fabric weaving groups, government officials, middle men and consumers of traditional fabric. Additionally, the OTOP policy had both positive and negative impact on the physical, mental, social and spiritual health of the four - group participants as follows: 		1. Local fabric weaving groups There were both positive and negative health impact to these groups. The positive impacts were gaining new knowledge about dye, weaving fabric, and business management. The themes also appeared in the increase of learning  about society in big cities, using local wisdom to create new pattern of fabric, and teaching the culture of fabric weaving to their children. Furthermore, the themes emerged center on the increase of the family members’ relationship, the opportunity to access health care services and the opportunity for their children to study in universities or colleges Also, the themes showed the decrease number of burglars. Regarding the negative health impact, themes emerged center on the unfair treat on local fabric weaving groups by some government officials who are responsible for OTOP. Moreover, themes appeared  the increase of physical illness. Additionally, the themes showed the deteriorate of spirituality; the feeling of losing the culture and heritage of their ancestors’ fabric pattern.  Concerning the congruence of positive and negative health impact, themes appeared the increase of   both  income and debt,  well-being and struggle in wandering to sell products, unity and conflict, and happiness and anxiety or stress. The themes also emerged center on the decrease number of immigrants but increase number of wandering merchants.  2. Middle men The positive impact was that middle  men appreciated local people had jobs and earned money from them. The negative impact was that their own business were regressive after the OTOP policy has been introduced. 3. The consumers of the local fabric Most consumers appreciated that they had better products both styles and qualities. However, they were upset about the local fabric weaving groups that these groups were unable in management marketing.  4. 	Government officials, members of tambon administrative organizations, village headmen/village committeesSome government officials, members of tambon administrative organizations, village headmen/village committees delicated themselves for work by paying their own budgets to run  this project for serving the local weaving groups. Additionally, they had the problem to deal with some government official groups who took advantages and selected their own people to sell the products. These problems affected the succeed of OTOP policy. The suggestions from this study  were 1) the government officials have to use integrative approach and  management  to reduce the repetitive jobs, work loyally and stop taking advantage from the local fabric weaving. 2) the Ministry of Public Health and Ministry of Interior have to enhance staffs’ knowledge about the health impact of OTOP policy on local fabric weaving groups in the North-Eastern, Thailand. 3) staffs who were responsible for OTOP policy at the provincial health care agencies should take responsibility for not only food standard but also  for  the negative health impact on local fabric weaving groups from OTOP policy. These findings contribute to a more nuanced understanding of the impact of OTOP on the village level, as well as provide guidelines for policy makers, for example the government should welcome the opinion of grass root people for better problem solving to improve the implementation of the policy in order to encourage the positive outcomes of the program, particularly in under-developed regions in Isaan.


Research Title	Institutional preparation and capacity building for 	Thailand’s adoption of Clean Development Mechanism (CDM) 	ProjectResearcher 	Suthawan Sathirathai, et al.Funding	Health Systems Research InstituteYear	2004AbstractThe objective of the research report entitled “Institutional Preparation and Capacity Building for Thailand’s Adoption of Clean Development Mechanism (CDM) Project” is to present Thailand’s strategy for implementing the CDM project especially in the field of laws and regulations. This will be used as the main database for negotiations and a basis for decision-making concerning the selection of the projects for the benefit of the people and country. To carry out the study, the researchers organized fora for the exchange of views and knowledge on CDMs both in the public and private sectors. Other research methods used consist of the review and analysis of related laws as well as the collection of data on CDMs in industrialized countries.  	The outcome of the study shows that the implementation of CDM has enabled Thailand, which enjoys great potential for attracting foreign investments, to increase her capability of achieving sustainable development in line with the requirements of the Kyoto Protocol. Two main issues to be considered are, firstly, the fact that Thailand may have legally-binding targets for reducing greenhouse gas emissions in the future; secondly, the country may also lose other opportunities, should it expedite the implementation of CDM without careful consideration. It is therefore imperative to establish a basic guideline relating to the selection criteria for CDM projects to ensure that there are sound modalities and procedures as well as clear rules on the rights to issue Certified Emission Reductions (CERs) as far as national entities and CDM project owners are concerned. Besides, these rules should enhance the reliability and transparency of the CDM implementation process as well as provide the CDM process with institutional mechanisms to check the performance of related agencies and organizations.


The health promotion and disease prevention is the important issue in Ministry of Public Health that has been developed and progressed for a long time.  While, the public health system changed from the Universal coverage insurance policy has also impact on changing in the heath promotion and disease prevention by taking the result of this budget allocation, health personnel allocation, managing administration, achievement evaluation.  The purpose of research is for studying the impact of Universal coverage insurance policy on these health promotion and disease prevention aspects.  Moreover, the result for the quality of health promotion activity in Universal coverage insurance policy by studying in four provinces, which are Surin, Phang-nga, Lumphun, and Nakonsawan emphases on the qualitative method collection from the central hospital, general hospital, and PCU/heath center.	The result of the research found that there are various models of budget allocation in each province in 2002.  Some problems in the system occur from them.  Method in budget allocation was changed in each province in 2003 such as to setting the minimum budget that have to allocate to PCU/health centre.  The directly budget allocation from provincial health office makes administration management in PCU/health centre more flexible in health promotion activity.  The model of budget allocation that helps personnel expect should emphasis on making motivation in health promotion activity in the level of PCU.  The budget allocation in paying out for handling project plan should make it well organizes, and must have strongly monitoring and evaluation unit in CUP level.	The health personnel allocation to health center/PCU is not successful in attempting to have doctor or nurse in PCU.  Perhaps, the cause is the salary budget allocation changed from capitation, which included salary in CUP level in 2002 to included salary in provincial level in 2003. The CUP’s board system also has a problem about personnel administration, health officer especially, in PCU or health centre have the confusion about the line of command and direction of policy, which do not go in the same way.  The health officer is not sure in doing their activities.  However, the Universal coverage insurance policy has not impact on number of health promotion activity, but the impact of quality cannot summarize.This research allots the health promotion and disease prevention activity analysis into 2 groups.The group that has policy and method after having the Universal coverage insurance policy such as family folder, and health examination in risk group.The group that has policy and obvious method before having the Universal coverage insurance policy such as home visit, mother and child care, EPI program, and family planning activity, and health promotion in community.	It found that there are the factors, which has impact on the quality and quantity of health promotion activity after the Universal coverage insurance policy in service provider aspect; example of, the budget allocation form, consistency and supporting factor, resource planning, participating setting same goal in the CUP, continuously monitoring demonstration, supervising, and evaluation, adjustment of attitude in health care personnel in new paradigm of health promotion, making relation with the health volunteer, and efficiency of health report systems.


A Community Survey of Musculoskeletal Pain and  Management In Namphong District, Khon Kaen ProvinceObjective: Studying of incidence and cause of muscleskeletal pain and epidermiologic of Ya-chud in Namphong district, Khon Kaen Province.Study design: Descriptive survey studyLocation of study: Rural community in Namphong district, Khon Kaen Province.Sample Population:Distributor of Ya-chud  in 12 villages  of  Namphong  district  which  simple random sampling amount 86 distributors.Population  in Namphong  district,who age over 15 years-old,lived in the villages amount 685 persons which clustur random sampling.Methadology:Surrogate  survey and open survey on distributors in the villages. Analyted component of  Ya-chud and compared  between two-way.Interviewed sample population in musculoskeletal pain and self-care,then examination in sample who had musculoskeletal pain recently on 7 days before interviews to diagnosis caused of musculoskeletal pain by American Rheumatism Association.Result: Groseries in rural villages had Ya-chud and surrogate survey had directed sale Ya-chud amount 18. Total Ya-chud which surveyed have 51 types. Analytical component in each type,10% had corticosteroid only,16%  had NSAIDs only,71% have corticosteroid plus NSAIDs. Corticosteroid  had dexamethasone since 1 to 3  tablets in each set. Almost NSAIDs had indomethacine and/or phenylbutazone. 74% of population used to musculoskeletal pain; 43% had pain recently 7 days before interviewed. Cause  of musculoskeletal pain refered from work.Examination in patient who had pain recently amount 264;54% is LBP, 25%  is soft- tissue rheumatism,17% is myofacial pain syndrome,17% is peripheral osteotitis,prolong  treatment is 9%. Caused of LBP from back  muscle  strian and L-spondylosisInterviewed on population who had musculoskeletal pain 508 and 58%  used to use Ya-chud for pain  when they had pain syndrome; 12.5%  used to use Ya-chud and ¼ used every day. 95% of population had known side effect from health worker and advertising ,68% used to treatment when they had pain syndrome and 33% choose to used Ya-chud because of convenient and low price. Impact of decision to treated from experience and household.Excepted Ya-chud  they had massage and hot compress.Health facility has popular too; 6.7% choose to go to health center because nearly house.Conclusion and dissicustion :Ya-chud had dangerous component and community problem ;they had distributed in general of rural community of Thailand. Population bought freedom from groserlies, although they  known side effect from Ya-chud. Musculoskeletal had refered from work and short-course therapy. Chronic rheumatism disease which prolong treatement had few in community. When they had pain symtom,they choose to low cost treatment, comfortable and related daily life. Solved of Ya-chud is present convenience treatment , low price ad effectiveness, such as massage, compress  and develop health worker of health center to treat simple musculoskeletal diseases in community.


According to the advanced technology information, varieties of information are increasing disseminated on the Internet. In particular, health information is contained in web site in order to gain knowledge, give opinions from experience and advertise health products and clinics. Although those webs are rapidly increased on the Internet but there is no guarantee that how credible the health information or health web is. Thus the purposes of this research were 3 folds: to (1) survey the credibility of Thai health webs, and (2) analyze the process of health web development. This study was employed 2 research approaches: (1) survey approach by examining credibility of 255 webs, based on study criteria from 1,888 Thai health webs. These data were analyzed by using frequency and percentage (2) qualitative approach by interviewing 30 webmasters regarding how to develop health web. The qualitative data were analyzed by using content analysis method to explore the process of web development. The majors’ findings were as follows: 1. Findings from the survey, twelve criteria of a web credibility were used to examine the webs. There were 99.20 % of health webs via the Internet proposed health information with legal or/and ethical contents. There were 77.30, 71.80, and 71.80 % of health webs giving an e-mail address of a webmaster and contacting channel for users, and provide successful links to other sources respectively. However, few health webs (9%) were given a disclaimer. Other criteria including date of creation, date of last update, references, and authors were disclosed on the webs only 12.20, 13.70, 32.20, and 33.30% respectively. 2. According to interviews, webmasters reported 7 steps of web development: (1) Beginning with individual interest, the initiation of developing a health web was started with an interest to create Thai health web after exploring health webs from other countries via the Internet. (2) Learning to create web, webmasters learned how to create a web by asking experts or self studying. (3) Letting aims and target group, some webmasters developed health webs for providing health information to public while some wanted to advertise their health products or clinics. Thus, the target groups of those health webs are general people and health care personnel. (4) Developing web patterns, some webmasters created a web by themselves whereas some hired experts to develop it. (5) Searching information, webmasters used variety of sources, such as individual expertise, experience, and other experts, and so on to collect health information. (6) Transforming data, after collecting enough health information, webmasters would transform those data from using technical terms to be general terms for people understandable in the patterns of new articles, cut and paste articles, and questions and answers column. (7) Updating information, this step, webmasters would regularly or irregularly update their health information. Comparing data between from survey and interviews, it was found that most webmasters less realized to show the credibility of health information and health web. In addition, some webs were not screened inappropriate language and or disconnected contents before posing new information on the Internet.


Drug price comparison between Thailand and the United StatesThe price differential of drugs, calculated by item, group and purchasing power parity (PPP), was conducted to compare drug price between Thailand and the U.S. The 209    samples accounted for 34.9 percent of the total import, or 12.9 percent of the total import and manufactured. The comparison by item showed that 17 drugs in Thailand were more  expensive than in the U.S. The total import of the 17 items was 17,491,517 US dollars. Of these drugs, four of them were AIDS/virus drugs and five were antibiotics. The comparison analysis by therapeutic group showed that AIDS/virus group were priced 6percent higher in Thailand than in the U.S. where ones of antihypertensive drugs, phychotropic drugs, anticancer agents, miscellaneous group, cardiac drugs, antibiotics, vasodilating agents and antiinflammatory agents were(percent) 18.7,  24.3, 28.1,  45.0,  49.2,  47.5,  73.1 and  73.6  differences respectively.   Comparison by registration type demonstrated higher price of the new drugs over the old drugs category with percentage of differences at(percent) 20.0 and 44.4 lower in Thailand than in the U.S.  Comparison by dosage for did not show significant differences among groups of injection, tablet and capsule; and other form which were 38.0,  37.4 and  34.4  lower in Thailand than in the U.S. respectively. Comparison by using the 1995 PPP (Thai PPP=28 and U.S. PPP=100) indicated that most imported drug were charged more in Thailand than in the U.S. expect antiinflammatory drugs and vasodilating agents.


Surgical Blood Use in Sappasittiprasong Hospital with Application to the Maximum Surgical Blood Order Schedule	This study was descriptive study that collected data of surgical experience of Sappasittiprasong hospital in anesthetic and admission record retrospectively and analyzed each surgical procedure by transfusion indices [Crossmatch percentage, transfusion percentage and Crossmatch transfusion ratio (CT ratio)] 	In 1997 , 6,757 anesthetic procedures were done but we could collect data of 4,693 elective surgical patients from anesthetic and admission records (69.4%) and classified 106 surgical procedures into 4 groups. 	The operation with crossmatch percentage and transfusion percentage greater than 30 was categorized in group 1.  There were 25 surgical procedures in this group. The operation with crossmatch percentage greater than 30 but transfusion percentage less than 30 was categorized in group 2. There were 31 surgical procedures in this group. The operation with crossmatch percentage less than 30 but transfusion percentage greater than 30 was categorized in group 3. There were 6 surgical procedures in this group.  The other operation with crossmatch percentage and transfusion percentage less than 30 was categorized in group 4. There were 44 surgical procedures in this group.  All  4 groups had CT ratio 2.57 : 1 , 8.95 : 1 , 1.82 : 1  and 10.73 : 1 respectively.Group 1 was high risk group of transfusion so we set number of blood unit for each procedure in “MSBOS”.Group  2 and  4 were low risk group of transfusion so “Type & Screen” should be appropriate for   these procedures.In group 3 , the transfusion  indeces showed that preoperative crossmatch of these procedures had been appropriated


The guidelines and legal measures relating to the older persons welfare in Thailand  	This research aims to study the legal measures of older persons and found that : the right of older persons has been recommended by the International Law on Human rights as a fundamental right enacted in the Universal Declaration on Human rights by which every state has to follow. The United Nations International Action Plan on the Older Persons has been set up to improve their life and begin clearer when the United Nations declare the International Year of Older Persons in 1999 and recognize the right and policy to respect older persons equally.


The child-center’s system, mechanism, effectiveness and efficiency for both public and private.	This research aimed to study the child-center’s system, mechanism, effectiveness and efficiency for both public and private.	The research process included a survey of 149 child centers in 6 provinces, namely, Bangkok, Chiengmai, Songkhla, Khonkhaen, Chonburi, and Loburi. The questionnaire was constructed and sent to  776  teachers and teacher-assistants and 2,073 parents. The questions focused on the system, mechanism, effectiveness and efficiency of the centers. The survey results indicated the indept-interview of selected centers. Thus only 19 child-centers of 2 provinces namely, Bangkok and Loburi were chosen due to the complete information and cooperation.	The indept-interview of 19 child-center’s administrators, 195 teachers and teacher-assistants and 842 parents were done. The results showed that:only 9 out of 19 selected centers were considered to have good system, mechanism and more effective.more private child-centers tended to have better system, mechanism and effectiveness than those of public ones (6 out of 9 private centers versus 3 out of 10 public centers)more public child-centers tend to have more efficiency than those of private ones.


The National Health Security Law of B.E. 2545, in Chapter 1 stated that the right to receive public health service is assured and in section 5 the people’s right are indicated to receive an efficient public health service of high quality. In section 6 it is stated that people, who intend to use their rights according section 5, must submit an application for registration to the unit or office, which they want to choose for their regular health service: The unit they want to choose had been identified by the National Health Security Office. Those who are registered must comply with regulation procedures and conditions defined by the Local Health Committee. Convenience and needs of individual’s will be considered. It is obvious that the Act intends to open an opportunity for people to make use of their rights for universal health care coverage and that they can choose where to receive regular health services according to their needs and convenience. But there is still the opportunity of the Committee as well as the respective unit to define by themselves proper criteria and condition which health service unit should be chosen based on the convenience and needs of a given individual. The Ministry of Public Health and the National Health Security Office decided to conduct a pilot project which did allow people to make use of the right within the universal health care coverage scheme, also named 30-baht scheme (golden card), to choose their regular health care unit by themselves on a voluntary basis. The project was conducted in the provinces Prae, Saraburi, Surin, Songkla and the Pravej district of Bangkok Metropolitan. The corresponding offices in each province issued a regulation in October 2545 by defining the period of 2-3 months while the people could contact the offices in case they want to change the main or sub-main health service unit they previously had been allocated to, to select another one according to their needs. At the start of the project people were allowed to use the services at the defined health service unit since late 2545 up to present. This study project was divided into 4 sub-projects for the purpose of monitoring and evaluating. The main results and significant findings are summarized and concluded in this report. Recommendations are made for policy formulation and project management. The model tested, in which the people could choose the health service units according to their needs will provide guidelines for consideration of the National Health Security Office and related units or organizations at local level. 1. The needs of people to change the health service unit 2. Model for choosing the health service unit on a voluntary basis Main health service unit3. Project management of the rights of people to choose health service units on a voluntary basis Project management


Informal Working Conditions and Health Problem:A Case Study of Industrial Home-Based Work At present, most of informal jobs employed in Thailand are mainly in the group of manufacturing industries.  The majority of these informal jobs are putting-out system, i.e., the subcontraction some parts of the manufacturing work to private homes.  As a consequence, the health of the workers in these home-based industrial work is at risk.  The case study of these informal jobs are bronze work, seed-making, fishing-net, hand-weaving, garment and gem-cutting	The result of studies found that the manufacturing process of these industrial works cause the health hazard to the workers and their family members as well as some environmental damage of their communities.  The level of health risk ranging from the highest are the following: bronze work, seed-making, fishing-net, hand-weaving, garment and gem-cutting.  In regard to the health problem, most of the workers’ illness are believed to be due to the working condition.  Most significantly, the result from the diagnosis of some doctors reveals that these industrial work are dangerous to the workers’ health and are the main cause of the illness of their family workers.	Aside from the health problem, another interesting point is that these home-based industrial workers have to invest on their own capital expenditure but earn lower wage than the minimum wage rate.  They have to face the health problem without the responsibility of their employers.  Therefore, the best solution in to set up a health insurance system for these informal home workers.  The system which is run by the community organization.  Their employers and the government have to share the responsibility.