Ronpiboon subdistrict, Ronpiboon district, Nakorn Srithammara Province, Southern Thailand consists of 16 villages. These villages are well known as high prevalence of well water contaminated with arsenic.  The piped water supplied among this area were from 5 lines: Provincial Waterworks Authority, village artesian, Wangsilaruk, Khlong Khunpung and Ronna-mountain piped line, respectively. The aim of this research is to analyze the rainwater and piped water quality in high-risk area of arsenic poisoning in the Ronpiboon district.  Arsenic levels in every piped water system in village 1,2,7,12, 13 and 15 were examined.   In villages 2, 12 and 13, 50% of households were sampled, while in villages 1, 7 and 15, 25% of household were sampled.  The samples were collected 3 times a year and examined for arsenic level by using AAS at Ronpiboon hospital.  Quality control and assurance was performed by the Medical Science Department, Ministry of Public Health .  Data were analyzed using Epi Info version 6. The contamination of arsenic levels in drinking water were followed the standard criteria according to WHO definition (< 10 ppb).	There were 904 samples collected, the majority was from rainwater (97.8%). In this study we found that arsenic levels in all samples of rainwater, from Provincial Waterworks Authority, Khlong Khunpung and artesian piped water was not higher than the standard level while all samples from Wangsilaruk and Ronna-mountain piped water were found to have arsenic levels higher than the standard. 	In conclusion, rainwater, Provincial Waterworks Authority, village artesian and Khlong Khunpung piped water was safe for drinking.  Mountain and Wangsilaruk piped water were found to be not safe for consumption.	The implementation from this study is that the government and local administrative organization should cooperate to set up a plan for water use of the villagers. These including having piped water areas and plateau areas which hold containers for collecting rainwater that are big enough to last for a whole year.  Villagers should be informed of water testing laboratories in their area which can examine arsenic levels especially when changing to other sources of water


Scoping for assessment of health impact among farmers from using  agrochemicals in Chiang Mai and Lamphun provinces aim to 	1. To identify scopes for assessment of health impact among farmers from using agrochemicals in Chiang Mai and Lamphun provinces.	2. To establish participatory process among stakeholders in agricultural policy of using agrochemicals to increase productionsMethods : Study methods included (1) gathering preliminary data on agrochemicals used and health problems from farmers and stakeholders from 2 seminars, (2) collecting quantitative data using interviewed questionnaires, (3) collecting some additional information from focus group discussion, (4) presenting the research summary to farmers and stakeholders for validation in the seminar.  In the preliminary data collection, 2 seminars were held.  First seminar was held in Chiang Mai City to gather data from cabbage and kale growing farmers and stakeholders including academia, consumers, government officers in public health and agriculture, traders in agricultural produces, 108 participants in total. The second seminar was held in Lamphun City to gather data from longan orchard farmers and stakeholders, 61 participants in total. Quantitative data were then collected by interviewing farmers using present study constructed- questionnaires.  There were 33 kale and cabbage cultivation farmers from 5 districts of Chiang Mai Province including Saraphi, Mae Rim, Mae Cham, Doi Law, Chom Thong, and Mae Wang districts, and 26 farmers from 2 districts of Lamphun Province including Muang Lamphun and Ban Hong Districts.  Furthermore, there were 28 longan orchard farmers from 3 districts of Chiang Mai Province including Saraphi, San Patong, and Hang Dong Districts, and 29 farmers from 4 districts of Lamphun province including Muang Lamphun, Pa Sang, Wiang Nonglong, and Ban Hong districts. There were 116 farmers in total including 59 farmers from kale and cabbage cultivation and 57 farmers from longan orchard.  Some additional information was collected from 4 focus group discussions conducted in farmers growing cabbage (one group), kale (one group) and longan orchard (2 groups). The final seminar was held in Chiang Mai City in order to present the scope of health impact assessment among farmers using agrochemicals to farmers and stakeholders for validation.  Of 121 participants, there were 70 farmers and 51 stakeholders attended the seminar.Results: Most farmers used mixed agrochemicals or cocktails in order to reduce time and labor cost. Both vegetable and longan farmers confirmed that they could not decreased using all kind of synthetic agrochemicals because they were not sure to obtain produces as targeted. The most use of agrochemicals in vegetable cultivation was chemical fertilizers and animal manure. Chemical fertilizers were reportedly used in longan orchard as much as in vegetable cultivation


Diabetes is a common chronic disease world wide. Its long term complications both microvascular and macrovascular lead to increased medical expenses, hospitalization and death in diabetic patients. It is proven that intensive control of diabetes and its comorbidities prevent or delay its complications, and the standard of care for diabetes has been established and widely accepted. Therefore, it is important to document the current status of diabetic care and complications in Thailand. We conducted a multicenter registry in diabetic clinics of 11 tertiary centers in Bangkok and major provinces. The registry collected data from April-December 2003. There were total of 9419 diabetic patients. The majority of patients were older than 40 year-old (91.7 %) and 65.9% were female. With respect to socioeconomic status, more than half of the patients had only preliminary education or less and not currently working, nevertheless more than 70% had health care coverage. The registry comprised of type1, 4.5%, type2, 94.6% and others 0.9%. The data also showed that 38.9% of the patients had diabetes more than 10 years, and almost 80% were non-smoker. For glycemic control, more than half had inadequate control: 61.8% had fasting plasma glucose > 130 mg/dl and 69.34% had HbA1C > 7%. The analysis of lipids profile revealed that 63.3% had LDL > 100 mg/dl, interestingly only approximately 32.2% had levels of HDL and triglycerides out of the recommended ranges. With regard to complications, the data showed prevalence of retinopathy of various degrees in 23.3%, but 24.4% of the registry did not received evaluation. Almost half of the patients also had not been adequately assessed for nephropathy, for those who had evaluation, 34.9% had some degree of nephropathy. 5.9% of the patients reported a history of foot ulcers, and 1.6% had had amputation. The prevalence of coronary disease, stroke, hypertension and dyslipidemia were 8.2%, 4.4%, 63.6% and 73.3% respectively. Medication usage data showed that 29% of the patients use insulin. The most commonly prescribed regimen was a combination of sufonylurea and metformin (37%) for hypoglycemic agents, and ACE-I and diuretic (6.5%) for antihypertensive. Lipid lowering drugs were prescribed in 54% of the registry which would reflected that 74.5% of dyslipidemia patients received treatment. Non-prescribed herbal preparation was used at one time in at least 33% of the registered patients.Conclusion: The majority of the patients in this registry had unsatisfactory control ofdiabetes and other risk factors for development of long term complications. Screening for early retinopathy and nephropathy also was insufficient. There should be additional process or system to improve care for diabetes.


The aim of this research project is to look into the possibility of using the hospital
quality improvement and accreditation process (HA process), which has been well accepted
by a large number of hospitals in the country, to help develop health promotion (HP) in
hospital setting. A study was conducted with two-fold objectives: (1) To study health
promotion in HA accredited hospitals, looking for the relationship between HA process and HP
and other factors including concept of HP, and (2) To form a learning network of hospitals to
clarify the above relationship in order to utilize it in facilitating the HP movement in hospitals.
Soft Systems Methodology fits the purpose of this study. It is an action research
methodology that involves developing “a learning system” (Model) to be used as a tool of
inquiry, with declared world-views (the HA process, the Thai HPH standards, and the
empowering core strategies from the WHO Working Group). The model was used to study 8
selected HA accredited hospitals.
The findings included: (1) Traditional health promotion services and activity-based HP
were evident in all hospitals. None of the hospitals used the concept of empowerment in HP.
However, they realized that some parts of HA overlap with HP such as the issues of “Health
of personnel” and “Environment”. Those hospitals which determined to become HPH obviously
put much greater effort into program-based HP activities. (2) None of the hospitals was aware
of care-based HP. However, quality development of patient cares was evident in all hospitals.
Health or quality of life of patients was used as target. The process used was empowering,
including self-care and self-help groups; patients, family and even community participation.
These were obviously health promotion but never referred to as such. This finding should be
crucial for establishing a link between HA process and HP. 3) Hospitals were confused as to
their roles in health promotion. Clarification regarding care-based HP could lessen some of the
problems particularly among tertiary-care hospitals. Other issues, such as the definition of
“community” that includes “group of people having same characteristics or same purposes”
would help hospitals realize that they are already providing HP in many areas, and could see
them as their meaningful and satisfying roles. (4) PDCA, a tool provided by HA was used only
in isolated CQI projects. Promotion of its use for “learning by doing” could be expected to
connect HA process to HP. (5) HP activities were carried out sporadically and unrelated to one another. System thinking was another concept from HA that could be expected to help
HP.
A learning network was formed during the last phase of the study to include a
volunteered group of 11 hospitals (main target group) and 29 associate members which were
willing to join the learning process. The majority of the hospitals appreciated learning by doing
within the network. The most important lessons learned were the concept of health promotion
and empowerment. They became comfortable with the use of care-based HP. This subjective
assessment was confirmed objectively by a large number of presentation of programs that
emphasized “empowerment’, and later “empowerment and PDCA” to epitomize the
connectedness between HA process and HP. It is recommended that care-based HP should
be the starting point to use HA as a tool to develop HP in hospitals.


A mobile membrane filtration unit was installed for 3 months at Moo 2, in Ronpiboon
District, Amphur Ronpiboon, Na-korn-sri-tham-ma-rat Province, from January to March,
2005. It was to produce arsenic free drinking water, serving 550 families in the area. The unit
comprises of 2.2 kW pump, 1 microfiltration unit (0.5µm), and 1 nanofiltration membrane of
4x40 inch. made from polyamide thin film composite. Water supply for the unit was from
rain water reservoir at the Ron-Na Mountain nearby the district through pipeline system. It
was found that arsenic level in the pipeline water gradually increased from 0.10 to 0.16 ppm.
during the period and water pH was between 4.5-5.2, slightly lower than the accepted level
(6.5-8.5). However, no water treatment was made, except caution was taken during rainy
season, due to some fine sand being flushed into the pipeline system.
 The filtration system produced arsenic free (<0.01 ppm) drinking water at 208 L/h at
the beginning and gradually declined to 198 L/h and the end of the project. The decline of the
production rate indicated some fouling on the membrane. After 2 hour washing, the
production rate was resumed. About 10,000 L of drinking water was produced, which was
rather small compared to the number of families. Questionnaires collected by an NGO in the
area revealed that only 34.6% out of 283 families utilized the water. The major problem was
the distance and most families well prepared during the year by having sufficient water
reserves. However, under water shortage only 42% consumed commercial water. Some
families obtained reserved rain water from their neighbors and others still used water directly
from the pipelines, due to poverty. On 0.50 Baht/L bases, this community spent about 11,000
Baht/mth for house-whole use and 97.5% of the questionnaires preferred to own a filtration
system for community health reason. The estimated cost of drinking water was 0.15 Baht/L,
assuming 10 hour operationg/day at 100 Baht/day wage. This was based on 5 day work/week
in 52 weeks/year.
 This community seemed to be alert on health quality and management. There is SubDistrict Committee meeting monthly, where problems can be raised and solved. It is envisaged
that if the community reaches some support from District Committee, clean drinking water
should be available sufficiently for everyday consumption. Towards the ending of this
project, the sub-district community leader in Moo 2 has sent in a request of 200,000 Baht to
the District Committee for a community drinking water unit. This, in return, an amount of
money will circulate in the community, which should benefit finally to everyone under good
management.


This was an initiative by local researchers, with an emphasis on putting the NHA system in place.  Two work steps were involved; first, tracking the flow of funds from ultimate sources of finance to financing agencies and second, analyzing the use of funds by financing agencies.  Five ultimate finance sources and twelve financing agencies (7 public and 5 private) were identified.  Use of consumption expenditures was listed under four main categories and 32 sub-categories.	The results from NHA1 in 1994 estimated a total health expenditure of 128,305.11 million baht; 84.07% represented consumption and 15.93% capital formation.  Of total consumption expenditure, 36.14% represented purchasing care from public providers, 32.35% from private providers, 5.93% on administration and 9.65% on all other public health programs.  Public sources of finance were responsible for 48.79% and private sources of finance for 51.21% of the total 1994 health expenditure.  Total health expenditure accounted for 3.57% of GDP (consumption expenditure 3.00% of GDP, capital formation 0.57% of GDP).  However, NESDB estimated 1994 consumption expenditure to be 180,516 million baht or 5.01% of GDP, of which private sources were dominant (82.17%) and the public source played a minor role (17.83%).  The discrepancy of consumption expenditure figures between the two estimates is 2.01% of GDP.  In addition , there is a big gap in the public and private proportion of consumption expenses; 46:54 in NHA1 and 18:82 in NESDB.	From this NHA2 study, the researchers estimated that health care expenditure in 1996 was increasing when compared to the GDP in that year.  But in 1998, health expenditure was decreasing when compared to the GDP in that year.  This was due to the economic crisis in Thailand.  The main decline in health care expenditure was experience by the private sector with a 21% decline., but the expenditure from the government side was still increasing by 10%.  This showed that the government played a big role in protecting people’s health during the economic crisis.  Another finding indicated that individuals tended to spend less on services from both public and private health providers.  They went by themselves to pharmacies and bought medicines to treat themselves.  Although the government increased health care expenditure in general, it decreased its own spending on health prevention and promotion because, due to the economic crisis, the government needed to put more emphasis on treatment and curative services than preventive ones.	In conclusion, a sustainable NHA and utilization of NHA for planning and policy development is a major national objective.  Having a strong NHA structure will enhance the demonstration of how the country’s health resource were spent, what services were provided and who paid for them and will further facilitate international comparison, especially with members of the OECD countries.


The Model Development Of Safety Promotion In the School Buses at Chiang Rai Province	The purpose of  this participatory action research was to develop the model to find out the suitable strategy  to develop the safety promotion system for the school buses in Chiang Rai province by the process of actively participation from all related sectors in Chiang Rai included :- the Police Units, Transportation Offices, schools/colleges, Public Health Offices, Mass media offices, and Chiang Rai School bus Club. The study population were 388 school bus drivers who were the members of the Chiang Rai  school bus club. The study period took one and a half year long from March 2001 to August 2002. It was divided into 2 phases. In the first phase, 213 school bus drivers were random sampling for interviewing by questionnaire to identify the important problems related to the safety of the school bus. The focus group discussion with the key members of the school bus Club were conducted to provide the qualitative data related to the same problems. Surveillance for the risk behavior, brain storming and setting up the action plan were developed. In the second phase, all school bus drivers were invited to participate in the action plan for promoting the safety condition in the school bus transportation such as training program on safety driving, checking up and improving the school bus condition to meet the standard requirement, educational media production, driving behavior surveillance, campaigning a good behavior driving competition, etc. The study tools included : structure questionnaires, guideline for focus group discussion, behavior observation of drivers, accident report of schools, hospitals, and the school bus club. The percentage, mean and standard deviation were used as the descriptive statistics for data analysis. 	The results of this study in Phase one showed that 87.7 % of the school bus drivers were male, 51.1% had completed a primary education level, 11.7% had a history of smoking, 8.0% had a history of alcohol drinking, 42.7% had a regular physical check up, 52.1% put on seat belt during driving, 90.1% of the school bus was a van-type, and 93.0% owned the school bus. By average, the cars were used for 9 years, the experience in driving a car was 14.7 years and driving a school bus was 6.2 years. One school bus carried the students around 4.9 schools per car. One year before this project started, there were 16 vehicles (7.5%) got the traffic accidents.  A number of activities were introduced to solve the problems. A training course for all school bus drivers was organized. The 16 standard conditions for the school bus were applied to check all 257 school buses and 39.7% of them could not pass in the first round but after improving the vehicle conditions within one month, all school bus were met the requirement. All school bus drivers received the health examination from health personnel. The results showed that 6 drivers (0.3%) had hypertension and all of them had gingivitis. Urine test for amphetamine was done for 301 drivers. Twelve (3.9%) of them found positive by the screening test. Confirmatory test was rechecked and only 1 (0.3%) urine specimen provided positive result for amphetamine. The system development for safety promotion of school buses was quite success by the collaboration of public and private sectors in Chiang Rai. Many things had much improved such as better driving behavior follow the traffic regulations, improving the school bus condition, taking care of their health, development of injury surveillance system, driving behavior observation, referral system for emergency and accident, and educational campaign for traffic safety promotion through public medias. During the study period, 3 school buses had accident [0.8%], 10 students were injured, and nobody died. These number of accidents was much less when compared with the previous year. 	This new approach model which actively participate by all sectors had showed the great impact for preventing the accident caused by the school buses. The lesson learn from this study should be used as a prototype for other provinces to modify for solving their own problems.


Epidemiology of traffic accident in Nongkhai province 1994-1995All of accident cases attended in the provincial hospital and all community hospitals had been interviewed and recorded in a nearly formalized form since June 1994 until May 1995. The one year records of 22,918 accident were classified into 12  categories. There were 25,863 injured cases and 269 fatal cases. 36.6 percent of total accident of 8,388 incidents were traffic accidents, those included 11,236 injured cases and 193 fatal cases. They were calculated as 43.3 percent of total injured cases (1,597.8 per 100,000 of total provincial population) and 71.7 percent of total dead cases. (24.4 per 100,000 of total population) respectively. Number of injures in male was more than in female 27.2 time, most of the cases were in the group of 10-49 years old similarly the number of dead in male was more than in female 4.6 times. The statistic of 61.6 percent of dead cases among the male were commonly in the group aged 10-49 years. Females died in a high percentage of 79.4  were the group aged below 49 years. Farmers, laborers and students (in school and collages) were the groups of high risk.  Most of traffic accidents occurred in the central district (Maung      District) and the second high were located in Phonpisai  District. The number of injured cases increased with in the duration of December to April and abruptly decreased in the duration of May to September and then gradually increased. The dead incidents were less during June to September, 16.00-19.00 hours of Saturday was the hazardous period while the accidents usually  accrued. Slippery road, sliding and fall doing of the motorcycles caused the number of accidents, 87.4 percent of the vehicles involving in the accident had no insurance and 90.3 percent of the drivers had no driving license. Among injured persons and fatal persons (include motorcycle and other automobile) there are 4.2 ,  1.7 percent of driver and 1.7 , 1.8  percent of passenger respectively were antiknock helmet or safety belt (upon kind of vehicle). But smell of consumer alcohol were datable from 28.8 percent of injured person' s breathing. The lesion of injury were commonly found in the extremities, head and face of the injured cases. The first aids before transferring to the hospital seemed to be very scarce.  This study leads to the development of data collecting system and would be useful for accident prevention planning.  Moreover, further study should be done to find out for factors affecting the accidents.


Social and Health Problems of Thai Construction Workers: a Qualitative StudyThe qualitative study of the Social and Health Problems of Thai Construction Workers aims to describe the construction  workers life and analize their social and health problems based  on the finding. Phenomenological study was used in both big and small construction sites of 6 provinces, including Cheing Mai,  Khon Kaen, Bangkok, Chonburi, Songkla and Phuket. Observation,  interviews, and focus group discussion that were conducted  during July 1994 - February 1995 and October - November 1997,  were used for data collection. Key informants were construction  workers, foremen, company manager, and government officers. 	The  major findings are as follows: 1.Construction workers were in  a vicious circle situation. 2.Context of construction workers  were lack of skills, uncontinuity, uncertainty, and lack of  supporting organization. 3.Working safety was the most outstanding health problem that caused construction workers  sickness, injury, disability and death. 4.Social and health  problems of the construction workers are caused by the lack of  social awareness, lack of worker power, the weakness of law utilization and the problems of labor relations. 	Recommendation emphasizes on the social management, and competition in global society.


This study aims to examine the capacity of civic groups that work on issues related with violence against women and children from the macro and micro levels. The scope of the study covers the situational analysis on civic groups that work on issue related with violence against women and children covering their origin, concepts, principles, development, roles, and patterns. The study also focuses on factors that promote or inhibit their potential to be effective.  The analysis of the civic group’s capacity is done according to three components of civic groups including civic consciousness, civic organization, and civic network which considering socio-cultural, economic and political context at the global, regional, country and community levels. This study has utilized qualitative, documentary and case study research designs. The research methods used are mapping, documentary review, internet search, telephone interview, in-depth interviews, focus group discussion, key-informant interviews, and observation. Data analysis is based on concepts of civil society, feminism and critical theory.We found that there are 89 civic groups that work on the issue related with violence against women. They are Non Governmental Organizations (NGOs), community-based organizations, media, radio stations, and business enterprises. The concepts used for their motivation are human rights, women’s rights, child’s rights, and gender mainstreaming. The strategies they use are based on community-based, integrative and interdisciplinary approaches.  Their work covers policy formulation, advocacy, legal reform, societal campaigns for attitude change, prevention and providing support systems that are women-centered and gender-sensitive as well as helping battered women to return to live in society with dignity.Factors that influence the capacity of NGO civic groups that are working experience, development approach, the women’s movement at the global level, policy and support from the government.  Factors that influence the capacity of community-based programs are social structure and cultural system of the community, which includes patriarchy system, kinship system, seniority system, patron-client relations, social class, political system at different level and the bias toward the respect for the formal political structure. An important factor is the community belief of the myth that violence against women is a private issue, not a societal issue. These factors promote or obstruct civic groups in working on issues related with violence against women and children. Moreover, the processes by which various NGOs support communities to work on this issue influence the capacity of civic group at the grass root level, especially the processes of raising community awareness and mobilizing various groups of community members to work on the issue.Recommendations at the Policy LevelWorking on issues related with violence against women and children requires working together on issues related  to structural violence Campaigning against  violence against women and children  at the societal level requires an emphasis on the concept that: 1) violence against women and children is gender-based violence;  2) violence against women and children is not a private, but a public matter;   3) battered women and children have a right to life and to live without violence as well as to seek  helpIn order to work on the issue of violence against women and children, we should integrate our work on this issue with other social problems that occur in the communities. This is because most  social problems share the same root causes and they are connected to each other. For example, the campaign on the issue of violence against women and children should be done together with campaigns on HIV/AIDS, drug abuse, and unwanted pregnancy among the youth. The campaign should based on a gender perspective, which will help us to be able to successfully solve the root causes of these problems To determine principles regarding rights, welfare or safety of community members in order to support civic groups that work at the community levelTo promote other civil societies to work on issues of violence against women and children such as the  taxi network, business women’s groups in various provinces, media, press, advertisement enterprise, creative companies and  radio stations.Recommendations at the Community Level Principles: To mobilize community members to work on the issue of violence against women and children is to work with every sector in the community including village leaders, volunteers, and all other community members, both men and women. An effort must be made to close the gap of knowledge among community members and raise the potential of both males and females, leaders and non-leadersTo form a civil society on the issue of violence against women, we should start with getting the community to analyze their own views regarding gender-based violence including situation, magnitude, forms, types, myths etc. This should include an attempt to raise consciousness on the relationship between patriarchy and violence against womenTo work on  community-based programs require the networking of other organizations  in both  the private and government sectors. These sectors require  clear and specific tasks and roles that complement each otherTo form civil society on violence against women, we should utilize the social and cultural capital that exists in the community, i.e. various forms  social relations existing in the community.Strategies:To form a civil society on violence against women, we should start work with persons who have a clear understanding of gender issues and persons who are most concerned with   working for societal benefit. We can organize community-based programs on violence against women with both types of people, which is considered social capital for us. However, we should try to change the consciousness from the non-gender one to gender perspectiveTo create a strong awareness of the gender-based violence problem, the stage of problem analysis by the community members and the mobilization of broad-based participation from different groups of community members are important community awareness-raising. We should thoroughly consider the community’s views on violence, socio-cultural context that promotes or inhibits community participation and the formation of civil society to address violence against womenTo create an awareness needed to form civil society for violence against women is to deconstruct and reconstruct the consciousness and myths related with gender-based violence. The process of deconstruction and reconstruction can utilize both formal and informal methods including formal training by volunteers and chatting in everyday life conversation. Gender issues must be embedded in content of the messageTo do awareness raising on gender-based violence problem, to deconstruct the production and reproduction of patriarchy and myths related with violence against women that exist in Thai society is important.  The deconstruction process should also involve the production of new set of knowledge on women and gender system, including roles of women in the family and society, human right and gender equalityTo expand the network among various civic groups by sharing and exchanging the working experiences regularly is the key mechanism to strengthen the potential of civil groups to work for violence issue.


This paper concerns the conceptualization, the ideology and the practice regarding the community in the HIV/AIDS responses in Thailand. It reviews the community-related HIV/AIDS research, articles, seminar proceedings as well as documents regarding national plans and policies that have been made available since in the early 1990s. Its main aim is to see how the community was conceptualized, understood and utilized by the Thai government, medical community, academic, NGOs, social activists and people living with HIV and AIDS to fight against the impacts of AIDS both at the national and community levels. In particular, it also investigates the community concepts in discourses regarding the home and community-based care’s policy and practice which were recommended for Thailand in the early 1990s in response to the changing AIDS situation.The paper primarily argues that the sets of concept and discourse concerning the community in the HIV/AIDS responses are problematic and are made and remade over times. It reveals that in the course of AIDS responses, Thailand had utilized several approaches ranging from epidemiological-behavioral approach to good governance and civil society approaches in order to alleviate the negative consequences of the epidemic. Throughout this course, two major community concepts were conceptualized and imposed. The first concept necessarily sees community as the social unit encompassing geographical, administrative and social structures such as formal community leaders, informal leaders, temples, schools and other interest groups at a local level. The latter concept understands the community as the process in which individuals voluntarily come together, and through collective actions they resist the oppressions of others and the external forces that affect their lives negatively. Finally, the paper points out that the application of the community concepts at any stage of the HIV/AIDS responses necessarily contributed to the constraints and effectiveness of the home and community-based care approach which has been robustly encouraged by the Thai government since in 1997.


Survey of risk behavior, risk environment, health information, health information perception: second issue, utilization of health care systemThe purposes of this survey are to illustrate experience of people who have used health care service provided by government compared with private ones and to find out expectation from government hospital development. 2156 people from all parts of Thailand are our population. Cluster and area sampling is used.  A seven part questionnaire has been used and data is collected  through individual interview. The data then was analysed by QPS, and persented by frequency, percentage, mean and standard deviation. Information from open end questionnaire is also  analysed. 1.Type of Service Used. Most of the population make use of health services provides by provincial/district public  hospitals. Medical clinics are their second choice and  traditional this medicine in the least used. Medical annual expense is mostky between 501-1,000 baht. By average they spend about 5,413 annually for medical treatment. For health care  which included medical care is between 501-1,000 baht. By average the health care (medical care included) expense is 6,215 baht per year. For minor illness, they buy medicine from  drugstores. Medical clinics are their second choice. If they make use of public hospital when they encounter minor illness of health problem, their reasons are low price and closeness to their residences. The most frequent diseases are those gastro intestinal disease and respiratory diseases.  They find it is difficult to go to private hospital of clinic in case of severe or surgery cases because of high  price and uncertainty about type of hospitals. Female  population also spend more on medical care and health care  (medical care included) than male. Highest spend for medical  treatment per year in Bangkok population is 7,940 baht and the  population in the North spend the least which is 3,799 baht. The highest spend for Bangkok population for health care (medical care included)is 8,758 and the lowest is in the North  which is 4,365. 2.Opinion Toward Medical Service. At present  public medical centers provide good service except period of  service and time consuming. Doctors' capability is ranked first  and their skill in treatment and prescription ranked second. Female population are slightly more satisfied with health care system than male. The population in the North expressed the highest opinion. Health care system provided by private  hospitals is found to be satisfactory except in the area of doctor fee and medical fee. It is found that welcoming as well as service ranked first and speed ranked second in private haspitals. When compared between government and private hospitals, it is found that there are some slight differences such as doctor's ability is ranked first in government while private ones ranked 6. For services, private ones ranked 1 and government ones ranked  6. Any how it is concluded that service of private hospitals is better than government ones. 3.Expectation. Our population want the government hospitals to provide more high technological equipments.Ranked second is welcoming and services of staff as well as to speed up their services. Those expected from private  hospitals are medical fee (medicine charge, meal charge and room charge). Ranked second is to be less business like. Health services provided by private hospitals is their priority because of good service, attentiveness and up to date equipments. Government hospitals are their second choice because of low price, good service and close to their home. They said that capacity in public hospitals is equal to private ones. They indicated that obstacles are government budgeting and hospital staff. They suggested that public hospitals should improve their service. They should be more cordial and be more responsible so that our public hospitals will be more advanced and be able to provide  satisfactoried service.


Health expenditure model	This report presents the findings of the research "Health Expenditure Model" which consists of a review of related literature and the health expenditure model. 	The review of related research work identifies 3 groups of study on health care expenditures: group A measures and estimates health care expenditures of countries by developing national health accounts (NHA) showing sources of financing for health care. Group B analyzes the difference in health care expenditures among countries at a macro level, utilizing regression analysis of cross section data. The findings from such studies using data of developed countries indicate that national income is the most important factor determining aggregate health care expenditures. Group C studies health expenditures at a micro level, using cross section data from surveys of household income and expenditures in a regression analysis to find the relationship between household health care expenditures and household income and other socio-economic variables. It is found that income is not a very important determinant of household health care expenditures as in the macro study.When comparing the 3 groups of studies, it can be concluded that group A or NHA studies can identify the size of the society's resources used in health activities either in the public or the private sector, in consumption or investment, but it provides a picture at a certain point in time. It does not serve as a tool for forecasting future health expenditures, nor for explaining the changes in health expenditures resulting from external factors and government interventions.	Studies in Group B which construct a model and use a regression analysis can provide an explanation of factors determining health expenditures and of differences in health expenditures among countries, but they cannot say much about health policy directions and health budget determination.	Group C studies on household health care expenditures are studies at a micro level which derive different findings and conclusions from those derived from a micro study.When comparing the 3 groups of studies, it can be concluded that group A or NHA studies can identify the size of the society's resources used in health activities either in the public or the private sector, in consumption or investment, but it provides a picture at a certain point in time. It does not serve as a tool for forecasting future health expenditures, nor for explaining the changes in health expenditures resulting from external factors and government interventions.


Objectives: This research was carried out to illustrate the most likely and most desirable scenarios of drug system in Thailand in the next decade. This included identification and analysis of the prominent agents of change and the suggestion of strategic plans to facilitate desirable events and the elimination of  undesirable events.  	Methodology: It took the form of a qualitative research. Focus Group meetings, Ethnographic Delphi, and Interview In-depth techniques gathered the appropriate information. Nearly one hundred experts from the pharmaceutical sphere, including manufacturers, importers, drug stores, government regulators, non-government organization workers, drug users (professional and layman) and other related fields participated in eight Focus Group meetings in which guided imaginary and cross impact analysis techniques were used to compose the most desirable scenario.  Three key resource persons with high social recognition were interviewed in order to envisage the most desirable scenario.	Results:  Competition, systems of control, drug-use behaviors, knowledge and the mass media were identified as the main structure of drug-use system. The pricing system has a high impact on pharmaceutical manufacturing and marketing systems.  The most desirable scenario was divided into two parts as: change of environment (political system, national policy, knowledge-based society, and trend of healthcare behavior) and change of the existing drug system (perspective I: production, distribution, utilization, controlling; perspective II: product, price, place, promotion, and personnel).  The manufacturing and government controlling systems would be in a stage of decline in the future, while distribution and utilization systems would be transformed in order to create a more effective situation. A group discussion was initiated to reveal the picture of the Thai drug system of the future.	The most desirable scenario was illustrated in the perspectives of drug use behavior and competition of pharmaceutical market.  Equity in drug accessibility, preventative drug use and integrated medicine would offer the most benefit to the entire population.  Evolution of healthcare and the drug system at three levels (system, structure, and process) should be performed at the same time.  Thai demand of drugs should indicate the appropriate level of drug supply in order to effectively balance demand and supply in the Thai pharmaceutical market.


Search for Methods to Develop the Health Service Model at Sirinthorn Hospital : A Case Study of the Community by the Dam.	This study is a qualitative study and uses the Rapid Rural Appraisal (RRA) technique to study a community. The purpose is to find a model for the public health service for the promotion of health in the hospital for the community around the dam, so that is consistent with the operating principles and accepted by the community. Semi-structured interview was used to collect information by interviewing informants in the community and informants at the family level. The data obtained was analyzed collectively for content, and then taken to the community for approval.	The results of the study were that the community around the dam was in a drought area, without rice fields and without their own land for farming for their living. The main occupation of the inhabitants of the area was general labourer. It is a community which is strongly dependent on outside, both for occupation and food which must be found outside the community.	People in the community have 3 forms of treatment seeking behaviour when sick, which can be separated depending on type of illness: emergency illness, chronic illness and general illness. Each type of illness has its own pattern of acceptance and treatment. Villagers still having wrong understanding and acceptance with regard to health promotion behaviour in some aspects, especially some old beliefs such as using anti-biotics for the treatment of all diseases,using condensed milk for rearing babies etc.	When studying ways in which the community and the hospital can collaborate in implementation of health promotion work, it was found that people with an important role were villagers, village leaders, village health volunteers and hospital personnel or public health officers. Villagers realize and see the importance of health promotion and see that they should be educated to create correct behaviour and stress the development of village health volunteers so that they have greater credibility. The setting up of a health network should be stressed in the community, as well as giving information about using medicine, and stressing health education which is consistent with the needs of the community. Also, the hospital should stress the development of an aggressive service system, with an active team working with the community.


Pursuit of rights and equity in health: social and cultural perspectives for health care reform in ThailandThis research is aimed to understand people conceptualization of rights and equity in health from Thai socio-cultural perspective.The research is exploring how people construct meaning of rights and equity in general and how they applied it in issues of health and health care. Numbers of civil organizations are selected based on their local establishment and their concern for local social, health, economics and environmental problems. Members of these organization are selected interview to represent diverse social and economic background of people in the local areas. Focus group interview is applied to bring people opinion,   conceptualization of the terms rights and equity as well as how they see right and equity in health fit their frame of thought.This research try to understand people perception of their current equity in health and their actual needs as well as expectation for better health care. The result of this research is expected to be use in finding direction, patterns or model for health care reform that in concert with human right and equity. Information provided here could be useful for policy implementation and health care reform. This research reveals that civil society/people organization in Thailand has not yet active in raising issues of health as right. When question of right asked people interpret it differently. One set of perspective stress rights of individual. Some groups discussed right of individual provided by law and considered it as to have individual choice. Some groups emphasize the interrelation between individual and community right that "one should have, should be and should receive." Another perspective focuses on rights as social, public, and cultural affairs. However, most people reflex that in the current situation of Thailand, people have not have any right to determined what should be their rights. They have no participation in formulating the right and  do not know what rights they have or granted by the government. They conceived that rights that are provided by the government today are not what common people want. People criticized that government set out rules and regulations without considering social circumstances and cultural tradion of the people. Therefore, many of those rules are not used and sometimes inapplicable. The term equity is too abstract for every groups interviewed in this research. Most people think of it in the same was as equity, particulary when they assess the inequity to health care service.


Health Security Survey 2000The objectives of the surveyTo survey the type of universal coverage of the sample group of Thai populationTo survey an opinion, understanding and expectation of the sample population to the Universal Coverage PolicyTo survey the recommendation of the sample population for the Universal Coverage PolicyThe survey mainly included the experiences of the sample population with and without health security; the opinion, understanding, and expectation of the sample population to the universal coverage policy; as well as the recommendation for the universal coverage policy.  The survey was carried out using an explorative research to determine sample size, collect data, synthesize and analyze the results in order to achieve the objectives.The survey results were divided into 3 parts as follows.General description of the sample groupPattern of illness/behavior and problems associated with health care.The survey showed that 29.3% and 44.8% of the sample group had family members who sought health care services in 1999 and 2000 respectively while 22.0% had no family member who sought health care services.  The ratio of the family members of the sample group to the right for healthcare cover indicated that 31.2% had no right, 30.6% had the right for for only some family members, and 38.2% had the right for for all family members.Opinion to the universal coverage policy.  The survey indicated that the majority or 93.7% agreed that the government should provide universal coverage of healthcare and services to the public, while 4.3% disagreed and 2.0% had no comment.


Cooperation between public organisations and local administrative organisations in Haadyai and Banpru metropolitan before decentralisation	Health care administration by local administrative oragnisations or cooperation with public health organisations were feasible particularly large areas like Muang district. The local administrative organisations received health budgets not correspondent with local health problems while the public facilities under the Ministry of Public Health did. Therefore, the local organisations could then be networked with the hospitals. 	It is recommended that:Initially, public health budget be administered by the Provincial Committee for Health which should have representatives from local administrative organisations, Health budget be given to local administrative body for developing health funds providing opportunity for community involvement,Local administrative organisations be able to provide health care which is not complicated and easily monitored but effective for building health for example vaccination, school health program, condom use promotion, exercise and nutritional campaign.


Sexuality and gender relation within family context : implication and strategies for community-based program for sexually trasmitted diseaese and HIV prevention among rural married womenThis study was a pilot study which employed anthropological methods. The study site was selected through purposive sampling. A village in Chiang Rai province was selected because this is an area where there is a high prevalence of HIV transmission and a large number of male migrant labourers. The  study sample consisted of married women and their partners who were living in the study villge, as well as well as key informants including health workers at the district level and village leaders. The study obiectives were to describe      	1)meanings and forms of conjugal relations among married rural couples, with a focus on idecology and the practice of gender roles and sexuality, 2)the magnitude and forms of womens sexual negotiation power, 3)perceptions of Sexually transmitted diseases and HIV risk among married rural women and men, and      	4)recommendations for community-based Sexually transmitted diseases and HIV prevention program for rural married couples. It was found that married women played major roles in both the domestic and economic spheres. The sexual division of labor was  not rigid. The meanings of sexuality among married couples included love, emotion, feeling, warmth and reproduction. Sexual communication between couples was non-verbal rather than verbal. The extent to which married women could negotiate within their sexual relations with their husbands varied from one woman to another. Factors which determined married womens sexual negotiation power were 1)women's economic status and roles,      	2)number of years in marriage, 3)age difference between husband and wife and 4)women's personalities. The author reveals that women's sexual negotiation relates to their relative position of power in other domains of life. It was also found that the most effective sexual negotiation strategy with the husband involved asking him nicely about extra-marital sexual activity, leading to a confession extra-marital affairs. From this study, the author describes four factors which exacerbate the risk of married women contracting sexually transmitted diseases and HIV. These are 1)women's low perception of the extra-marital sexual activity of their husbands, 2)the perceived social risk (risk to social relationship, personal identity and status) that influences women's actions/inactions associated with the risk of sexually transmitted diseases and HIV transmission,      	3)the lack of knowledge among married women of early symptomsand appropriate treatment-seeking for sexually transmitted diseases, 4)extra-marital unsafe sex among married women, and 5)the lack of familiarity among couples with the use of condoms in the context of marrisage. Strategies for Sexually transmitted diseases and HIV prevention among rural married couples 1)education women about their own bodies and sexuality as well as about reproductive tract infections and HIV, 2)action research to find appropriate starategies to promote women's sexual negotiation power, by using real case stories of women who face the risk of Sexually transmitted diseases and HIV transmission that match the level of negotiation power that women have, and 3)promotion of sexual  and family responsibility in programs targeted at men, i.e. emphasizing fatherhood for married men and using role model, approaches which model responsible male behaviour.


The research project on status and role of non-governmental organizations on health promotion in Thailand conducted by professor Yupa Wongchai and Associates, aims to explore the current finction of NGOs in thailand, and submit recommendation from research finding which analyzed from 513 questionnaires responded by organization authorities, 5 expert-interviews and 15 case studies of selective organization.	It is found that most of NGOs in this study have set up their own agencies for delivering services to their members amd target groups which mainly are the aging. The main activities are giving technical and managerial support and charity work. It is very clear that most of those activities mainly focuses on individual basis not community work. Most of agencies do not obtain support from the outside. Most Of those which gain outside support mainly get from the government side. If considering the amount of budget, the international agencies gave bigger amount the public agencies. It also fond that most of NGO's authorities have sufficent knowledge and clear-cut understanding principle of Ottawa Charter's Health Promotion. They understand that makingbetter environment will make target group's better health. The agencies should advise the target group in order to taking care the target groups health, Health promotion will support self health care, health promotion should be cooperation between government al and non-governmental parts but theyneed more knowledge of commonity resource mobilization. Most of agencies have potentail to involve in health promotion. Most of them have objectice to strengthening community, they can conduct actives following the agencies objectives and rhen follow up their work. They have qualify personnel's which understand their function and roles. However, their weaker points are they still facing uncontrollable health factors. Also, they need more management and administative skills, especially building and working through network. Most of thier activities mainly focus on getting to gather to do community, encouraging people to take good care of their own health. The rare activities are natural and environmental presservation, work plan design, campaigning for changing for target group's health behavioral change.	The NGOs programs in this study focus on individual basis more than community focus. In individual basis, the Y focus on enable people to taking caer their own health., offer health education program. They also conduct activities such as community leaning procees, The weakest point are they do not concentrate on environmemt al reservetion and technical part such as evaluative research, planing and data collecting etc. For their future trend, they aim to give health education health caer, health counseling service, community visit which still focus only on individual basis. The also need to be strainghten their organizational potentiality though resources and technical support. They need to cooperate with health promotion partnership through network and need to gian public recognition.


The impact of paying health pesonnel by fee-for-serviceand non-private-practice allowanceThis research is to evaluate the impact of these  implementations among regional/general/community hospitals. Four research methods were applied to answer different research objectives. Analysis of reported data to the Provincial  Hospital and the Rural Health Divisions was to see the impact on hospital financial liquidity. Postal, self-administered questionnaire survey was carried out in 17 provinces to study  attitude towards non-private-practice allowance including fee-for-service pay. Qualitative research techniques, ie focus group discussions and indepth interviews were carried out in 4 provinces to focus mainly on fee-for-service pay but also included other payment schemes. A before and after case-review was carried out to compare quality of care provided to 3 tracer conditions in 5 hospitals. The overall result suggest that financial liquidity of the hospitals was not affected by the implementation of the payment schemes, although the hospitals had to pay a higher percentage of their revenue for their personnel. In 1991, they paid 7-11 percent of the hospital revenue for their personnel and in 1995, up to 20-30 percent of the revenue. Fee-for-service pay got the highest share (more than 60 percent) of the total payment categories and increased productivity especially the number of extra-office-hour surgcical operations. Non-private-practice allowance increased job satisfaction amongst those who did not work in private sector but caused the feelings of unfair treatment among those who were ineligible. Moral hazard of providers occurred in both schemes but was more frequently observed in the fee-for-service scheme. Management system played a minimal role in safeguarding medical ethics.


This study was aimed to set up public scoping for investigation of possible health impacts from the Wieng Haeng mining project, using the participatory approach from public and other stakeholders. Results from literature review on possible health impacts, and data on the living styles of the affected community were used to identify the possible health impacts. Public and other stakeholders were allowed to join the study and provide suggestions for public scoping. It was found that there were four aspects of possible health impacts: physical, mental, social, and spiritual health. Physical health impacts were: 1) Accidents and injuries from mining and transportation 2) Effects from noise 3) Diseases and effects from air pollution 4) Diseases and effects from water pollution  5) Effects from explosion 6) Labor migration and communicable diseases. Mental health impacts were expected from 7) Stress and anxiety. Social health impacts were likely from: 8) Effects to community life style 9) Effects from community migration and resettlement 10) Effects from depletion of forest and agriculture land. Spiritual health impacts were likely from  11) Effects from aesthetic changes and loss of loyalty to and connection with the locality  and 12) Effects from losing their spiritual haven.


Universal health coverage is one important policy recommendation by the World Health Organisation to governments in both developed and developing countries.  Thailand was ambitious in setting the target to achieve this policy nationwide only a year after the majority vote victory in 2001 by putting up the 30 baht medical care policy.  This research was to document the policy processes at the central and provincial levels during the first year of implementation, and to measure the impact of the policy at household level.  The ultimate aim was to recommend on how to make the policy sustainable.This study employed three research methods in order to complement each other.  The documentary reviews and qualitative methods were used to describe policy processes at the national and provincial levels, and outlined impacts of such implementations on health delivery systems.  The third method employed a full-scale household health interview survey to measure policy impacts at household level.  Four provinces were purposively selected from 21 piloted provinces since April 2001 and June 2001.  In-depth interviews and focus group discussions were the main qualitative methods used with top executives, policy makers, and providers.  Household surveys consisted of about 1,000 households in each province.  It was revealed that the designs of the systems for pilot provinces in April and June 2001 were the day-to-day management style, whereas the decisions for full implementation since October 2001 have been a monthly management.  Unstable policy decisions created turbulence till the end of 2001.  The implementation of the policy at the ministry level faced with the discontinuity of capable responsible officers.  Policy implementations at provincial level were critically at risk under the leaderships of provincial chief medical officers and provincial hospital directors.  It seemed that provinces applying an inclusive outpatient-inpatient capitation budget faced additional risks on substandard quality of care by under referrals with the coincidence of weak leaderships.  Household surveys revealed that the policy was highly supported by both the rich and the poor.  Thai citizens have shifted from their libertarian views to slightly egalitarian views in reducing social policies, that discriminate the rich and the poor.  When compared among three main health benefit schemes (civil servant medical benefit, social security and the 30 baht scheme), the 30 baht still faced with low compliance rates (use of their health benefits when they seek medical care) for both outpatient and inpatient services.  However, the poor families complied at a higher rate than the rich, which means that the policy has at least achieved its main objective.  Comparing equity of financing by out-of-pocket expenditure, the 30 baht scheme was inferior to the social security scheme in protecting the lower income families from financial burden of seeking health care.  To attain sustainable coverage, recommendations on managing supply side are crucial.


Thailand’s Historical Development of TBs Control by DOTs(Directly Observed Therapy, Short-course)The DOTS (Directly Observed Treatment, Short-course is one of the alternatives considered most efficient and supported by most international health organisations including WHO. The DOTs are composed of processes of patient identification, diagnosis, short-course medication, directly observed treatment, management for drug sufficiency, quality control in lab, training and supervision, situation adjustment and public commitment for TB control. DOT is one of these potentially performed by health officials, health volunteers, community leaders and family members. Training for the DOT was started since 1996 in Thailand. In the end of 1998, 299 districts (34.1%) had the DOT program which was problematic in quality due to a number of people performing the program without being trained. The most observers were family members (47.6% - 100%). The supervision by provincial and district tuberculosis coordinators was irregular resulting in poor evaluation which was likely to assess quantity preferable to quality of the program. The patients who were registered between October 1995 and January 1998 were randomly sampled for sputum testing in every 4 months showing negative result in percentage of 79.65, 80.1%, 80.0%, 73.4% and 77.6% respectively. 	Problems of running the DOTs program in Thailand were lack of concern in people at policy administrative level, lack of interests in people who were potential to be effective observers leading to low number of people attending training course, shortage of coordination and supervision at all levels to support the DOTs, and lack of effective information system. This paper recommends establishment of research network to increase positive impact on policy direction and to develop models suitable for particular areas.


Health care reform in Thailand is still in the process of development and planning.  This study emphasized primary health care in Amphur Bangsai, Phra Nakhon Si Ayuthaya.  The participatory action research was utilized and aims to analyze and synthesize the primary health care system in Amphur Bangsai, Phra Nakhon Si Ayuthaya including planning, organizing, staffing, directing, controlling, tools, and what should be the minimum health care service package for people in all age groups. Since the participatory action research was utilized; some traditional research methods were still needed such as documentary review, in-depth interviews, focus group interviews, brain storming, and reflection. The quantitative and qualitative analyses were included within this study as well.  The Bangsai’s situation analysis was done during January 2002 until December 2002.  The action plan was developed and some critical points of primary health care systems including instruction for action, and was implemented during January 2003 until March 2003.The results were as followas:Since health insurance policy for all Thais and the “All For Health and Health For All” policy were utilized, Amphur Bangsai, Phra Nakhon Si Ayuthaya built up the transitional primary health care system by organizing and registering the previous structures into two primary care units (PCU).    PCU 1 includes three northern primary health care centers, and PCU 2 includes three southern primary health care centers.  Bangsai Hospital is the only public hospital (10 bed-admissions) in this area that functions as a contraction unit for primary care (CUP).The study has shown that staffing in Bangsai health care organization still has some positions available especially in the six primary health care centers as stated.  As a result, in both quality and quantity of health care service for these people in this area remains unsatisfactory.Based on the long-term effects of not having enough quantity and qualified workers in each position, causes the services to deteriorate.  Bangsai Hospital (CUP) designed to provide mobile clinics consisting of doctors, nurses, pharmacists from the hospital and the workers from the health care centers.  At the beginning, there was a need to provide services that would emphasize a cure for chronic illnesses.  The health care center workers need to come together with their customer service ability, including teamwork as a whole. Whether they are a secretary, health care worker, nurse, or doctor in the clinic, they need to learn to perform some common procedures to take care of the people.  Even though they may not be a qualified doctor or nurse, they need to be willing to work as a team and get the job done. All workers in the primary health care unit need to be able to get suggestions from other colleagues if their people are sick.  Since the mobile units have been constructed, each care worker in the PCU clinics has improved their ability and has become more efficient in terms of investigation, diagnosis, and treatments.   In this study, we found that most workers lack health promotion and prevention foundation in service quality.  For example, health care workers would provide the person and family preventive service (such as home visit as their schedule posted) when they had enough time, which never was the case.  As a result, the equity and continuous service was not achieved.  We found that in some severe illnesses, there was a need to refer to another hospital but the referral system was not appropriate.  In most cases, it did not serve the quality of care. In terms of community participation, most people in Amphur Bangsai participated to create good health practices such as seeking good nutrition habits, self-care, and building a good environment.  In addition, alternative medicine was also  being used in Bangsai, which has proven not to be risky in medical science point of view, and in some cases, it saved money and improved the quality of health.  However, some villages still have little awareness to solve their own health problems.  The community institute in Amphur Bangsai has a lack of concern in health care if we compare to other communities due to the budget being arranged for visible stuff instead of health promotion and prevention.  	In terms of directing, the executive team in Amphur Bangsai had the most experience, since they had worked and solved many community problems in the past.  Some good strategies have been used which emphasized making a serious situation into a positive learning atmosphere. Some things were ignored from the executive team if they felt they could not change the situation at this time.  The Bangsai’s workers preferred not to point fingers at each other, instead wanting us to move on in a positive attitude.  This attitude made Amphur Bangsai progressed in a positive way by having good teamwork with good intention to develop Bangsai community. In terms of using tools in primary health care system in Amphur Bangsai, the Komart’s 7-tool was modified based on the concepts of anthropology being used.  The workers stated that the tool was effective to study the community.  The tool also helped to understand the people at Amphur Bangsai.  They continue to use this tool to work with the community.Within the short term of this study, the minimum health care service package for people in all age groups resulted in showing most people lack the knowledge to know what they need for health care services.  They trust health care workers as their representative to direct their health care.  However, the minimum health care service package for people in all age groups including promotion, prevention, curing and rehabilitation still need to be researched in each health care problem, especially dealing with chronic illnesses such as diabetes or hypertension. In Bangsai’s view, most people in Amphur Bangsai were not satisfied in the transitional primary health care system because of the following reasons: Not enough health care workers in both quantity and quality.No trust from the people since the health care center has no technology in both technical service and instruments.No effective referral system for severe cases.Since the Bangsai’ situation analysis has been completed, the solution of the action plan was, “We want to develop the referral system to the one which is effective so we can earn trust and credibility from the people in Amphur Bangsai.”  The action plan had been done during January 2003 to March 2003.  The team decided to increase the potential of writing the health project to develop the community in Amphur Bangsai.  Therefore, those health care workers can learn to write the project to develop their community.  Two research proposals were as follows:1.   Hypertension and Diabetes screening and health education in people with the age 40 or higher in Amphur Bangsai.2.  Health promotion of exercise related to need of the people in Amphur Bangsai.After the implementation of the referral system in Amphur Bangsai, all objectives have been met in both quality and quantity.  We received instruction for the referral system so that they could refer patients between the health care centers in Amphur Bangsai, Phra Nakhon Si Ayuthaya with more effective and high quality.  During the implementation, we met the most important challenge, which was to increase the potential of the health care workers in Amphur Bangsai.  All health care workers in the projects said that their ability improved in terms of working as a team, learning how to turn problems into challenges. Every worker had a chance to take turns in the leadership role within each team.  We all learned how to complete the process of monitoring and evaluating with positive thoughts.  We learned how to utilize resources in the most effective way.  We all agree that it is useful for further development of primary health care reform research to meet the health community and governments goal “All For Health and Health For All.”	There are some suggestions in terms of plan and policy to make it better next time and they are as follows:                  1.  Continuing development of health care workers in terms of role and       functional fit in their positions with the highest potential. Utilize especially in terms of       transitional primary care unit system.   We need to make job descriptions for each        position.2.  Retrospective study of man-power and job from both ministries (Publichealth Ministry and Interior Ministry, and “All For Health and Health For All” policy), man- power is all right for all requirements.  Workload needs to be done for the PCU.Encourage health care workers to further their studies by supporting community’s scholarships and having them utilize their existing potential. Sign contract in joint programs with academic institutes such as Ramathibodi School of  Nursing to produce graduate nursing students to work in the community.  For the open positions, they need to recruit people for the position that are vacant such as a dentist. Executive team should continue strategies to encourage health care workers to have unconditional love for their community and be proud to work with their community to make them meet the over all goal “All For Health and Health For All”Due to earning very little money working with the government, we should support health care workers whenever we can by rewards or presents to create more happiness.Planning and management should be continuous such as workload or budgets.Personnel training in specific courses have to be appropriate in timing frequency, so that they would be able to utilize what they have learned in their community. Emphasize work quality more than quantity including service and educatingpeople in the community.Coordinating planning and development between Ministry of public healthand Ministry of the interior in terms of underlying what kind of jobs need to be done by health care workers in the community.In terms of development in researchers, we discovered and applied improved primary health care mechanisms and strategies into Bangsai Primary health care system research.  We mobilized actions and initiated collaboration to continue, articulate and promote new health care teams to promote a future vision for all in Bangsai community.  We had a chance to take a positive role in policy development.  Finally, we maintain that the researchers’ team and Bangsai have developed a healthy relationship with strong communication that leads to future projects working together.


Problems Rhinosinusitis (RS) is a common disease in Thailand and still has problems in the diagnosis and treatment. It is one of the most expensive diseases since a lot of investigations and antibiotics have been prescribed to treat this disease. It has also been shown to impair patients’ quality of life and, if not treated properly, may lead to orbital and/ or intracranial complication or development of chronic sinusitis. The data of this disease is quite limited in Thailand since it has not been studied systematically before. Objectives To investigate the natural history, clinical manifestations, practice variation of use of various instrument in the diagnosis, precipitating factors, the expense of investigation and treatment especially antibiotic, and complication of RS in Thailand. Methodology During April 2003 to May 2004, we performed a prospective study on 735 patients with acute (n=569) and subacute RS (n=43), recurrent acute RS (n=73), and acute exacerbation of chronic RS (n=47) recruited from Ear, Nose, and Throat (ENT) Department of 7 medical schools in Thailand. Results Seven hundred and thirty-five patients with RS were recruited in this study with the mean age of 34.1 years. The majority of patients’ age ranged from 20 to 50 years. There were 275 male (37.4%) and 460 female (62.6%). The average follow-up visits were 3 times. The most common clinical manifestations of RS are rhinorrhea (42.1%), followed by nasal congestion (38.6%), postnasal drip (32.3%), and facial pain (32.2%). ENT physicians used nasal speculum (91%), nasopharyngeal mirror (88%), otoscope (25%), and nasal endoscopy (11%) in the diagnosis of RS. Plain film paranasal sinus (PNS) and CT PNS were ordered in 17% and 1.6% of cases, respectively. Pus and/ or sinus tissues were sent for microbiological culture and sensitivity test in 30% of cases. The most common precipitating factors of RS is acute viral upper respiratory tract infection (62%). The majority of patients (98.6%) received medical treatment. Four percents of cases required surgical intervention. Complication was found in 11% of cases. Amoxicillin plus clavulanic acid is the most common antibiotic prescribed (31.5%), followed by amoxicillin (21.6%). Ninety-five percent of patients had favorable outcomes. Antibiotics account for the majority of the expense (74%) in the treatment of RS. Conclusion and recommendation Sinusitis is a costly disease, which needs more attention to reduce the cost of diagnosis and treatment. The Clinical Practice Guidelines (CPG) of diagnosis and treatment of RS have been developed recently. This CPG aimed to optimize the use of expensive and unnecessary investigation and to help physician in prescribing the proper treatment, either medical or surgical. The cost effectiveness of the practice according to these guidelines should be thoroughly studied before being implemented for nationwide use.


The Suffering of Thai People Within the Health SystemThe Suffering of Thai People Within the Health System is a study that utilizes a qualitative and case study research study design. The data for this study were collected from in-depth interviews of eight marginalized groups including elderly, disabled people, people with kidney problem, chronic patients, people with HIV/AIDS, migrant workers, homeless children, women who are violence victims, and patients who are victims of medical malpractice.	The study specifically focused on: 1) suffering of Thai people from different perspectives, namely social, economic, political, cultural and medical aspects; 2) the coping processes for their suffering caused by different problems, within the context of the existing health and social system of individuals; 3) the social support and social service mechanisms that exist, and the result from these systems. The study of marginalized groups will reflect the nature of their coping with suffering and the context of the existing social structure and services in which they exist. The study found that the nature of suffering includes: 1) physical suffering that includes illnesses that happen which are more severe than those usually experienced by middle class people; 2) psychological suffering resulting from abandonment from family members, feeling of being their family’s burden; 3) social suffering from being in an unjust social and cultural system were exploitation, gender inequality, social stigmatization, and dehumanization exist to varying degrees. These are all factors that exacerbate the victims’ physical and psychological suffering.	 How to Cope with Suffering 	The studied population coped with their own suffering alone. They lack social capital and family support. Most of them are faced with abandonment from the community and society, and they lack knowledge and skills in self-care practices. They were poor and disadvantaged and they must struggle to survive day by day. These life conditions deliberately or non-deliberately cause them to get more and more sickness. The study found patterns of coping strategies including utilizing existing medical and social health services from government and non-government sectors, self-care practices, alternative medicine such as traditional Thai and Chinese herbal medicine, witchcraft, and monk healers. Some victims cope with their suffering by listening to the Thamma, becoming a monk, or interpreting their own suffering as their own karma and accepting it.Medical and Social Services		Support from medical and social services from both government and non-government organizations for the marginalized groups does exist to some degree. The existing problems with these services include:  lack of collaboration in working together; lack of provision of information related to patient’s rights and welfare needed for the patients; lack of sensitivity to the patient’s needs and problems; having discriminatory attitudes toward patients; lack of responsibility in following health professional ethics and principles; and using economic criteria to judge patient’s rights to receive services.RecommendationsForm the study, it should be pointed out that the suffering of the Thai people is not only caused from the medical system but also from the social and cultural systems of the country. Health system reform alone is not enough to solve the problem of suffering of the Thai people. The solution of this problem is also social and educational reform for the existing unjust society.For the government sector, the state must have mechanisms to decrease the gap between the poor and the rich, and reforming the health services and information provided to the patients to make it accessible and equitable. The state should strengthen the capacity of the people to utilize self-care practices. The critical solution is the reform of the existing policy-related structures that are obstacles for the marginalized groups to achieve well-being. Reforming health policy should be similar to the reformation of social policy including providing information and fundamental human rights to the public. Advocacy procedures should be understandable and practical. Partnership between government and non-government sectors should be emphasized. Civil society, especially family, should play a major role in supporting the patients. The community members should create support mechanisms among themselves to take care of their own health, economic and social problems; so that the need to depend on government can be decreased.


Civil Society Proceeding for Public Hospitals Reform at District Level	This study was conducted in collaboration  in the search of excellence community hospital for the whole community, strategic partnership was apppraached through all media channels and also direct marketing by sending 7,771 letters to all sectors at all levels for help proposing a delighted community hospital.  Voluntary basis of the hospitals was concerned.	Self-assessment report by executives (60 applied-hospital: 503 non applied) and core personnel (725: 1185), and external evaluation by district health officers (652:1078) and community leaders (225:334) were used in combination including  double teams sites at the end.  Eighty four out of 714 hospitals were proposed a champion, 60 hospitals joined, and 23 were defined as highly effective, 5 entered the third round, and were distinct performance.	The study results revealed that, community hospitals took care of 41 millon people and covered 90.26 percent of all districts with doctor per population 1:19,038; and 32.89% morbidity rate was found with average 2.67 visits per patient.  Increasing trend of inpatient admission and bed used were indentified.  Financial stability was assumed through revenue and expense ratio and current ratio. Most of critical success factors(CSFs) and key performance indicators(KPIs), showed higher mean scored rating by applied group than those non applied with statistical significant differences.  However, community problem-solving and involvement activities had low mean scores for both groups.  Effective coordination and good image were recognized by district health officers and community leaders except rating for participation in health service organization as low.  Those applied hospital were received higher mean scores than non applied significantly.	In conclusion, responses of civil society were fair as the existing circumstance, and high active response from health sector at all levels particularly community hospitals.  At least 23 hospitals showed strong leadership for pursuing development and act as role models.  Stage for sharing their visions, experiences, and success result should be available for continuous learning and deployment.  Community or comprehensive health care accreditation should also be institutional at national level.


This research project has three main objectives. The first objective is to analyze and assess the health insurance problems, resulting from a lack of national health insurance policy. The second objective is to propose a model for health insurance policy coordination and management system in order to achieve universal coverage. The last objective is to provide the appropriate measures, including policies, law, organizations, as well as plans,  to implement a model of health insurance policy coordination and management system. The measures should have sufficient details for the policymakers so that they can make an effective decision.	This  is a policy research that searches for information necessary to set up alternatives of health insurance policy for policymakers. In addition, this research is an action research. That is, it focuses on pragmatic results.	The study employs both  qualitative and quantitative approaches. The research sample consists of four groups : policymakers, top executives, managers of health service providers, and rural community leaders. Two types of sampling techniques are used in combination:   purposive sampling and snowball sampling. 	Various  kinds of data collection are used such as reviewing literature, indepth-interviewing, focus group, brain-storming, public workshop, and self-administered questionaires.  Data compiled is analyzed by both qualitative and quantitative methods.	Research findings are as follow:	First, there are three main problems to the current health insurance system.There is limited stakeholders awareness regarding the policy formulation of universal health Insurance.   	2.) The  coverage   of   health   insurance  in  Thailand  is  to  only  about  eighty percent of Thai     	     citizens,   whereas  about  twenty  percent  of  them  are  not  covered  by  any kind of health   	     insurance  schemes. Besides, there are overlapping   target population  among  the  various 	     kinds  of  health  insurance  schemes. Therefore,  in  reality,  the  figure  of  health  insurance   	     coverage is less than eighty percent.   	3.) Problems  of  equity  and  justice  of  health  care services directly affect the quality of health    care services.	Second, the study proposes a model for health insurance policy coordination and management system in order to achieve universal coverage (Fig. 4.2, page 82). The model recommends the establishment of the Office of the Board of National Health Insurance and the Provincial Health Insurance Offices. The Office of the Board of National Health Insurance is an agency under the administration of central government.


A Study of Collective Opinions Regarding someAspects of Childcare Center  Management in ThailandThe objectives of this study were to find  collective opinions about childcare centers services regarding the following: 1) purposes of childcare centers and goals of child development, 2) the main organization responsible for coordinating childcare centers, 3) roles of community, private organization, and government  in childcare centers services, and 4) activities for quality control and evaluation of  childcare centers services.Sample consisted of  four groups of  people. The first group consisted of academics, politicians,  chief executives of  private  and governmental organizations  providing childcare services.  The  second group consisted of officials coordinating between central  government  and local organizations providing the services in Chiengmai, Khonkan, Songhkla, Chonburi, and Bangkok.  The third group consisted of  workers  at  childcare centers from top level such as heads of schools to bottom level such as care providers.  The last group consisted of  parents of children at the childcare centers.  The total subjects were 1,663.	There was a  collective agreement on the purposes of the childcare centers.  They  were  to promote the correct practices of child development ,and to provide basic social habit training for children.  The results showed also the collective agreement  on goals of  child development for the 0-3, and 3-6 years children.  These  were  good physical health, balance  of psychological, emotional, and social development, and happiness. Moreover  creative thinking  was selected as child development goal for the 3-6 years old children.  As a result, we recommended that the government should  take  actions in  collecting ideas from experts and practitioners on standard of practices for childcare centers in order to achieve the above purposes and goals.  At the same time childcare centers,  related organizations, the general public, and other stakeholders should  be informed.  Their roles and functions should also be identified.


The “Forum on a New learning Paradigm to Healthiness” project emerged from the impression that the current health-care system emphasized solely on the aspect of  medical treatment after people falling ill. The learning process on health care is strictly in a vertical line, that is from “the learned ” to “the unlearned” and the general belief is that whenever one falls sick, one must go see a doctor. Hence one’s life and health focuses around one’s body, illness, and dependence on doctor, with regardless of other aspects of life and how they may affect one’s health. It currently comes to light that a number of diseases cannot be cured by modern medicine alone. Thoroughly regarding other aspects of health and life is likely to be the answer. The existing learning process, however, barred any other thinking frameworks. Nevertheless, when health problems increase, new learning outside the mainstream system occurred to cope with such problems in broader aspects of health, education, medicine, and lifestyle. The new learning process is acquired by both individuals and groups through various means such as using media, namely radio, book, and internet as well as taking action and practicing by oneself.	It is interesting to study how these people have changed their views in taking care of their health and lifestyle. How they can cross over the old thinking framework. How they learn to view all things as a related whole. And how they come up with a new way in health-care based on self-reliance through various means and not clinging to any single approach.	This research is divided into two parts. Part one is comprised of a framework of concept and an analytical observation. The framework includes the definitions of “paradigm”, “health”, “learning” and how they are related to one another. Also included here are what the old and new paradigms in health care and the working process of the research team. As for the analytical observation, it is the conclusion drawn from the case studies, that is learning process is quite unique and fit for each person’s way of life. There is no clear-cut pattern of learning. Part two consists of eleven letters written to a friend telling the detailed stories of each case study. They are as follows:	Letter No. 1 explains the project’s background, objectives, and studying methods.	Letter No. 2 tells the story of the case studies Kaew’s diary and Ae. Both are inflicted with HIV, but with different medical indications. They come from different family backgrounds, yet they lead a rather happy life. Kaew develops her learning process through the cyber world, while Ae learnt from a real life of suffering experiences.	Letter No. 3 tells the story of a group of parents who use unconventional learning systems to solve their kid’s educational problems. Through this process they change their ways of life and gain a new idea about health.	Letter No. 4 tells the story of special-need people and their families as well as doctors and therapist who work with them. The problems of this group are very complicated involving the aspects of medical, educational, and social status.	Letter No. 5 is the story of two doctors, one suffered lethal disease, changes her way of thinking in health care in order to live peacefully with the serious illness. The other frustated with her working life, strengthens her mind to overcome the suffering by learning Enneagram.	Letter No. 6 the learning process of a people who highly regards and inner life and practices dharma as a mean to change the way of thinking at Sathien dharmasatham and Chewakasem.	Letter No. 7 is the story of a middle-class person who also focuses on an inner life, yet using yoga and, dharmayatra, a spiritual walk through the nature, to educate oneself.	Letter No. 8 tells the lives of two folk scholars living in the countryside and with no conventional education. They use their wisdom to change a life crisis into an opportunity to learn new things and share their learning experience with others.	Letter No. 9 is the story of a community-based social worker cum teacher, Kru Surin; and another story of a middle-class city woman who has the courage to lead a totally different life of a farmer.	Letter No. 10 tells the story of two people with nothing in common. One is a “sick” person who seems to lack everything; another is a well-to-do middle class who dedicated his life to heal other people’s sufferings by MOA.(Mokighi Okada Association)	Letter No. 11 is a unique life of a person who was born in primitive surroundings yet becomes a learnt man by studying with many scholars in various skills and become to be a holistic healer.	In all, what presented here in form a conversation between two friends is and idea compiled from all the case studies. The research team can eventually says that the changing of each person’s thinking paradigm on good health care occurred in accordance with certain factors in each person’s way of life. Moreover, they need some practice to attain and insight to understand things as they really are. And this helps elevate them to a new paradigm of thinking.


Adverse events can cause huge damages to both patients and hospitals financially and socially. Countries are seeking ways to resolve the problems. To do so, the first step of any institutional actions should be the development of procedures and tools to efficiently detect and monitor adverse events.ObjectivesTo study the reliability and validity of the methods for screening and detecting 	adverse events used by the Harvard Medical Practice Study when applied in ThailandTo estimate incidence, and distributions of adverse events among hospitalized patients in Thailand MethodsThis was a descriptive study. 400 cases were randomly selected from computerized medical records kept in CD-ROM of the Office of Social SecurityA three - step medical record (chart) review by 4 trained nurses and 3 physicians was employed. The procedures were adapted from the methods used by the Harvard Medical Practice Study.ResultsThe agreement of screening process among the nurses and a physician was low  (Kappa = 0.34, 95% C.I. of Kappa = 0.24  to 0.43,  Sensitivity  =  70.23 %,   Specificity  =  66.27 %, Positive predictive value  =  51.69  %, Negative predictive value  =   81.25 %).The agreement of the 2 physicians in detecting the occurrence of adverse events was also low (Kappa = 0.393, 95% C.I. of Kappa = 0.25 - 0.53). The incidence of adverse events was 9.1 per cent (95 % C.I. = 6.19  ถึง  11.94 ). 71.4 % of adverse events occurred were considered preventableConclusions	The reliability of the procedures to screen and detect adverse events in hospitalized patients applied in the study was low. Therefore, studies to improve the reliability of the procedure are needed.