The objectives of this study are to study a conceptual framework for a theory concerning good governance of health system management in local areas, to create good governance indicators regarding provincial public health office management, which can then be implemented as a tool to evaluate and further develop the organization’s effective governance and also evaluate the level of good governance management of the provincial public health offices in the four pilot provinces: Chiang Mai, Krabi, Cholburi, and Nakhon Pathom. Analysis is done by secondary data, such as annual reports, and related documents, and primary data which were obtained from a questionnaire using three sets: the first set was evaluated by internal officials within the agencies and consisted of 50 indicators, the second set was evaluated by officials with specific functions and contained 11 indicators; and the third set was evaluated by related agencies and consisted of 37 indicators for evaluating good governance management. The evaluation was divided into two parts: the first part was evaluated from the first and the second set of questionnaires by 86 internal officials and the second part was evaluated from the third set of questionnaires by 184 related agency officials. Purposive sampling was used to collect the primary data. Descriptive statistics were used to analyze the data and t-test used to compare the average scores.
The findings based on the evaluations concerning management of the four provincial public health offices, as evaluated by the internal officials, revealed high levels of good governance management. There was an especially remarkable score shown in the Principle of Information Technology and Communication, the Principle of Value for Money, and the Principle of Rule of Law. The evaluation results for good governance management of the provincial public health offices by the agencies related to the provincial public health office of Chiang Mai, Cholburi, and Nakhon Pathom revealed that good governance management was moderate. For the Krabi provincial public health office, good governance management was rated as high. For all four provincial public health offices, the Principle of Transparency was found to have the most significant rating.
In considering the evaluation by the internal officials and related agencies, the results showed that development was still required regarding the Principle of Management, the Principle of Human Resources Development, and the Principle of Participation. Thus, it would be appropriate for each provincial public health office to consider improving its work standards in line with a systematic evaluation of administrators’ work performance. Training programs should be established along with an incentive system for personnel participation and successful official development. Finally, listening to feedback from the outside agencies concerned could help to improve work performance.


Background: Essential drugs in Subclass 4 are high-cost drugs (HCDs). Their use was an important factor in influencing pharmaceutical expenditure. Exploring drug items, extent of their use, and the difference in their use among health insurance schemes would provide in-depth understanding of the efficiency and equity of their use. The objectives of this study were to identify items of HCDs, to assess their impact on pharmaceutical expenditure, and to explore HCD users classified by age and type of health insurance schemes.
Methods: Retrospective data on overall drug expenditure including the top 10 HCDs in Subclass 4 of the Essential Drug List in three fiscal year (2003-2005) were obtained from the Hospital Inventory Database. Drug use data of the to 10 HCDs in 2005 were obtained from the Dispensing Database. The rates of the top 10 HCD use per 1,000 patients were classified by age and health insurance scheme, including the Universal Coverage Scheme (UC), Civil Servants Medical Benefit Scheme (CSMBS), and Social Security Scheme (SSS), and compared.
Results: In the three consecutive years, the six HCDs most highly used were human erythropoietin 4000 u. inj., atorvastatin 10 mg tab., meropenem 1g inj, imipenem/cilastatin 500 mg/vial IV, cefoperazone/salbactam 1g inj and clopidogrel 75 mg tab. The top 10 HCDs used in the hospital consumed 45.6 million, 50.5 million, and 68.8 million baht in 2003, 2004 and 2005 respectively. Expenditures on erythropoetin 4000 u., atorvastatin 10 mg., clopidogrel 75 mg and meropenem inj. 1g increased every year. In 2005, 63.8 percent or 46.8 million baht of the expenditure of the top 10 HCDs was on CSMBS. These items were the drugs used for chronic diseases: erythropoietin, atorvastatin, clopidogrel. and mycophenolate. HCD spending in UC was 32.3 percent or 23.6 million baht, but it was only 1 percent in SSS. In UC, the drug
items mainly used were anti-infectious drugs, including meropenem, imipenem/cilastatin and cefoperazone/salbactam. The rate of use of atorvastatin and clopidogrel per 1,000 patients in the aging group in CSMBS were 20.08 and 6.47 respectively. In UC, they were only 0.05 and 1.45 respectively. The rate of use of meropenem per 1,000 patients in every age group in UC was greater than in CSMBS.
Discussion: The impact of HCD use on pharmaceutical expenditure is quite high since only 10 HCDs account for 18-20 percent of overall pharmaceutical expenditure. There is a difference in HCD use based on the insurance schemes. Further studies should be focused on the evaluation of HCD use, effective measures to control HCD use, and methods to balance equity of HCD access among health insurance
schemes.


This study explored health status, risk factors, and health promotion via occupational health nursing practice concepts, and explored knowledge about noise-induced hearing loss and silicosis, and the practice of using personal protective equipment. This part was a quasi-experiment, with pre- and postparticipatory group process. This study was conducted between March and August 2008. Study subjects
were 47 workers in a granite-processing factory in Muang District, Rayong Province. Data were collected by a walk-through survey form, area air sampling to measure silica dust, sound level meter type I, a health and health behavior interview form, measurement of weight and height, pulmonary function test, audiometer, chest X-ray, questionnaire on knowledge, observation form for health protection behavior, occupational health nursing practice, and participatory group process. Data were analyzed descriptively by number and percentage and inferentially by t-test.
The results revealed major health risks: silica dust above the standard in the gang-saw section (%SiO2 = 7.648) and polishing section (%SiO2 = 6.622); and noise above standard of 90 dB(A) in 4 out of 15 points in the gearing and trimming section (2 points: 97.4 and 102.3 dB(A)) and polishing section (2 points: 91.1 and 99 dB(A)). The results on health status showed that most (78.7%) had abnormal audiograms – reduced high tone hearing (37/47), threshold shift 8.5 percent (4 /47); restrictive lung 6.7 percent (3/47); abnormal chest X-ray requiring surveillance 10.6 percent (5/47), physician observation 2.13 percent (1/47); but none were compatible with silicosis. Regarding health protection behavior, 83.0 percent of workers used ear plugs (39/47), with mean duration being 6.3 hours per day; and nasal masks 55.3 percent (26/47), with mean duration of 6.26 hours per day. Health promotion and counseling were done via participatory group process, demonstration, health education on noise-induced hearing loss, silicosis, and prevention. Before the group process, only 15.38 percent of the workers wore ear plugs correctly (6/39); this increased to 100 percent (39/39) after the group process. Before the group process, workers had knowledge score of 6.52 (SD = 2.12) which increased to 9.81 (SD = 2.60), and the difference was significant (p <0.01).
Silica dust was above standard, but no case of silicosis was detected yet. Audiograms revealed those with abnormality, i.e. 87.23 percent of the total and some areas had noise above the safety threshold. The factory should therefore establish a surveillance program on health and environment and continuing education, especially for new workers. Group process should be deployed to enhance employers’ and employees’ participation.


This cross-sectional descriptive study was aimed at determining the efficiency and cost-effectiveness of four serum lipid screening methods: Method 1 proposed by the Thai Royal Medical Association (TRMA), Method 2 of the National Cholesterol Education Program (NCEP), Method 3 of the British Hyperlipidemia Association (BHA), and Method 4 invented by the first author. Study subjects included 2,000 workers aged 35 years and older who underwent an annual health examination provided at King Chulalongkorn Memorial Hospital during the period July-September 2008. All subjects answered the questionnaires of four screening methods and took blood tests for TC, TG, and HDL. LDL was calculated by Friedewald’s formula. The performance of each screening method was then analyzed, using lipid blood test as the gold standard. Overall sensitivity and specificity of the screening methods were 30 to 99 and 0.5 to 74 percent respectively, with the AUC of 0.506 to 0.671. Method 4 had the highest sensitivity and the lowest specificity at 99.4 percent and 34.3 per cent, respectively. Method 3 and Method 1 had higher AUC of 0.671 and 0.621 respectively. Method 2 had high specificity and low sensitivity (74% and 45.2%). In conclusion, the performance of the four serum lipid screening methods used in Thai adults was modest and therefore the methods need further improvement.


Objectives: This study was a literature review assessing the clinical efficacy of statins available in Thailand (i.e., atorvastatin, fluvastatin, pravastatin, rosuvastatin and simvastatin) for use in reducing acute coronary syndrome (ACS) and stroke events.
Methods: A systematic review and a meta-analysis of randomized controlled trials (RCTs) of statins were studied. The clinical trials on an electronic Medline database were searched. Efficacy studies of statin monotherapy were compared with placebo or other statins on the occurrence of fatal and non-fatal ACS and stroke. Odds ratios (OR) and 95 percent confidence interval (CI) were used to determine the summary efficacy of statins. Indirect comparison of the random effect meta-analysis, using the Bayesian approach and WinBUGS14 software program, were applied.
Result: Twenty-nine RCTs in 26 studies enabled comparing statins with a placebo; one study compared statins with no treatment, another compared statins with usual care, and yet another compared atorvastatin with pravastatin. For ACS events, the relative risk reduction (RRR) of simvastatin was 42 percent (OR=0.58, 95%CI=0.51-0.65), the RRR of atorvastatin was 41 percent (OR=0.59, 95%CI=0.51-0.70) and the RRR of pravastatin was 26 percent (OR=0.74, 95%CI=0.66-0.83). For stroke events, the RRR of simvastatin was 26 percent (OR=0.74, 95%CI=0.66-0.83), the RRR of atorvastatin was 19 percent (OR=0.81, 95%CI=0.72-0.93) and the RRR of pravastatin was 14 percent (OR=0.86, 95%CI=0.75-0.97). However, fluvastatin did not significantly reduce ACS (OR=0.37, 95%CI=0.11-1.05) and stroke events (OR=0.85,
95%CI=0.46-1.55). No efficacy study of rosuvastatin on decreasing ACS and stroke events is yet available. Conclusion: The available evidence indicate that simvastatin, atorvastatin and pravastatin significantly reduced ACS and stroke events.


This study was aimed at exploring satisfaction with health education about health promotion among 324 patients attending the outpatient department, King Chulalongkorn Memorial Hospital in the period from January to April 2006. The majority of them (63.6%) were women, whose education levels were lower than diploma in 50.3 percent; 6.0 percent had qualifications higher than bachelor’s degree. Their occupations were housewives and laborers in 33.9 and 26.8 percent, respectively. The reasons for the visit were annual check-up in 67.5 percent and follow-up appointment in 17.3 percent. The reasons for choice in attending this hospital were knowledge of its good service and the expertise of physicians and nurses (82.1%) and of its up-to-date medical equipment (48.4%). The study disclosed that television was the most influential medium (77.8%) and newspapers (48.5%).
Regarding satisfaction with the health education given, patients were most impressively satisfied with the health educators’ suggestions (79.4%), simple terms used in communication (73%) and patients’ self study of the documents and leaflets provided (30%). Another indication of satisfaction was that most patients were willing to recommend acquaintances to visit this hospital (93.8%). There were no associations of satisfaction for health education as such between health promotion and personal factors (sex, age, educational level, and occupation).


This proceeding summarizes discussion points and implementation proposals from a consultative workshop on “Research Framework on Pharmaceutical Systems and Access to Medicines”, hosted by Health Systems Research Institute (HSRI) during 26-27 August 2009 at Siam City Hotel, Bangkok.  An opening remark by Professor Dr. Vijarn Panich, the HSRI Board shed light on an urgent need for quality research framework on pharmaceutical systems that are relevant to the national policies.  The framework may cover around 5-6 project  packages that address research strategies in-depth through the holistic picture of Thai society.

A panel discussion on “Current Situation of Pharmaceutical Systems in Thailand: Catching up with the Global Trends” began with an elaboration on impacts of the global drug patent systems on the domestic generic drug industries. Health service behavior related to drug utilization like over-prescribing of the single-source, non-essential, and expensive drugs under Civil Servant Medical Benefit Scheme (CSMBS) is an obvious contention between the responsiveness and efficiency goals of the health systems.  Other systems issues included drug pricing that does not reflect the true cost structure.  The discussion ended with description of influencing factors to pharmaceutical systems and knowledge management tasks related to pharmaceutical systems research.

The current situation of pharmaceutical systems research presented was based on a rapid review of peer-review  publications during the past 5 years by the HSRI and a summary from the ThaiHealth’s Plan on Mechanism for Monitoring and Development of Pharmaceutical Systems (Kor Por Yor)’s databases.  The conclusion was scarcity of the research at the national level and the research weakness due to the use of non-systematic approaches and under-utilization of the study results.

Two sessions of small group discussion proposed some better approaches to pharmaceutical  systems research management.  These include (1) a precondition of the clear research direction, (2) a facilitating channel for access to research funding agencies, (3) a platform of consultation with stakeholders or policy makers for upgrading and translational research, (4) building research teamwork within and between academic institutes, central organizations and service organizations, to learn from senior mentors, and establishing knowledge sharing networks, (5) developing pharmaceutical systems research network, and (6) setting up an information center of  pharmaceutical systems by HSRI coordination to facilitate researchers access to national databases.

The concluding discussion resulted in a proposal of establishing a coordinating body between available networks of pharmaceutical systems research for knowledge generation and management, which includes capacity building missions based on the UNDP’s Individual-Node-Network-Environment model for translating knowledge to changes.

The pretest and post test feedback by the participants revealed the research priority in the following areas: (1) formulation and implementation of drug distribution and utilization policies; (2) study of rational drug use behavior; (3) drug reimbursement and payment under health insurance systems; (4) monitoring of drug expenditures; (5) evaluation of clinical outcomes of drug use.  The HSRI as the host for the meeting should lay out a clear research framework related to the above mentioned areas to prevent fragmentation and duplication.  This can be fulfilled by orientating the pharmaceutical systems research towards the health systems strengthening framework and arranging the mentorship platform for junior and senior researchers.


The objective of this study was to review and analyze the problems and obstacles of health surveillance system for haze in Chiang Mai including to propose policy recommendations for the development of health surveillance system for haze. The study methods were literature reviews of health surveillance systems in overseas countries, in Ministries of Public Health and Natural Resources and Environment, and in Chiang Mai province. For domestic reviews, the related governmental officials were in-depth interviewed. In addition, the experts in the field had been convened for brainstorming.
The results showed that the surveillance system that might be suitable to Thailand is the World Health Organization’s STEPwise approach to Surveillance or STEPS, by using model so-called DPSEEA Model developed by the World Health Organization to construct the health indicators. In regard to data dissemination derived from surveillance system, the Internet-based Health & Air Pollution Surveillance System (iHAPSS) developed by the John Hopkins University is recommended. The recommendations for the policy makers are that the Ministry of Public Health should play a major role in setting the health surveillance system including database system, health indicators and steps of surveillance in full details. Furthermore, it should develop a manual of health surveillance system for haze for the health personnel to use as a guildline. There should be also training courses for the health personnel to upgrade their capacity in diagnosing haze-related health problems and in statictical analysis to link the health problems and air pollutants. For Chiang Mai province level, the role model of health surveillance system for haze should be developed by focusing on reporting system, frequency of reports, linkage analysis of air pollutants and health problems, including on the utilization of data analyses to seriously warn or manage the haze problems. Additionally, the health surveillance system for haze in general population version should be promoted.


The study looks into six cases of health and environmental damage compensation in Thailand. The study aims to provide an economic foundation for determining the economic value of health and environmental damages to be compensated to the victims. These economic values will reflect the true opportunity cost of natural resource and environmental damage forgone hence will enable the court system to arrive at a more accurate value of compensation. Accuracy in court compensation will be achieved under three conditions, they are, accuracy in terms of the economic value of the damages, a complete coverage of items to be compensated and a complete list of both the liable parties involved and the concern beneficiaries to whom compensation is to be made. From the six cases the study found that 1) health and environmental litigation frequently lacks evidence that will provide linkages between the source of pollution and the health or environmental outcome, 2) legal processes are time consuming and involve substantial legal expenses that can become a burden to the low income families, 3) legal procedures rely heavily on concrete scientific evidence that can be difficult to obtain, 4) the Thai court system does not provide compensation when lack of concrete evidence, and 5) the amount of compensation often vary depending on court judgment.
From reviewing the five cases the study makes the following recommendations that will enhance health and environmental damage compensation of the Thai court system.  First, the causes, both scientific and administrative, of environmental damages need to be carefully assessed. Second, the rights of the parties concerned have to be clearly specified. Third, court compensation should be based on sound economic valuation fundamentals. Forth, compensation scheme ought not involve double counting error. Fifth, compensation procedures ought to involve all the liable parties and all the rightful victims. Not only an increase in the accuracy of damage compensation will provide fairness to all the parties concern it will also play a role as incentives and disincentives mechanism and hence help promote sustainable development in Thailand.


The objective of this documentary research is to review knowledge related to legislative measures in connection with addicts.  Results of this research indicated that each addictive substance is harmful and has medical necessity differently.  According to the Addictive Substances Law, 2522 B.E. categorized addictive substances into 5 separate classes.
1.	Most potent addictive substances
2.	General addictive substances
3.	Addictive substances which are derivatives of medicinal effect and has some category 2 addictive substances
4.	Addictive substances which are chemicals used in producing category 1 and 2 addictive substances
5.	Any addictive substances which are not included in the previous four categories
Basic concept and philosophy related to punishment measures for addicts is for retributive reasons, in order to control and paying for punitive damages.  At present, measures for punishment are of many varieties, to be suitable for those who committed wrongful deeds, and nature of crime.  There is less imprisonment measures and emphasize on community penalties as priority, by categorize punishment levels according to severity of the crimes committed.
The Law on Rehabilitations of Addicts, 2545 B.E., brought in the principle of drug user as patient, not criminal.  This law considers drug addicts as patients who need curative or rehabilitative care.  The law delays the use of court of justice, in order to replace criminal justice system for a better diversion.  Curative and rehabilitative processes are effective in separating addicts for a complete patient care, both by voluntarily and enforcement.  The complete patient care system provides follow-up system, support system, and encouragement for those who have gone through the curative and rehabilitative process, in order for them to be able to return to family, community and living normally.
There are preventive measures for drug traders, who pretend to be addicts, before or after being arrested, to use this law in order to avoid criminal justice system.  These drug traders do not have the rights for rehabilitative process according to this law.  The sub-committee on rehabilitative process for addicts should inform authority or prosecutor, to pursue criminal justice process.
By reviewing literature during 2547-2548 B.E., researches which study legal measures related to drug addicts, indicated that the Law on Rehabilitations of Addicts, 2545 B.E., emphasizes forced rehabilitative process for addicts.  Therefore, having institutions for rehabilitative process for addicts is of vital importance, but some areas do not have such institutions, or limited space for addicts in such institutions.  Moreover, there are some limitations for keeping up-to-date statistics of those who have gone through the process of proven for curative and rehabilitative process.


The objective of this research study is to review knowledge on policy and strategy of illicit drugs’ prevention and suppression between 1997-2007.  This is a documentary research which compiled knowledge and case studies related to policy and strategy of illicit drugs prevention and suppression.
	Results of this study indicated that the framework on looking at the problem of illicit drugs had at least 4 related factors, which were necessary for strategic planning.  The related factors are, estimation and categorization of individuals in general population who are involved with illicit drugs, individuals who are at risk with illicit drugs, individuals who are selling illicit drugs, those who consume / use and those who are addicts etc., including those who are involved with solving illicit drugs problems both directly and indirectly.  Factors involved with areas are, at the level of village/community, sub-district, district, province, regional and national level, which area related to illicit drugs problems related to production, import/export, storage, distribution etc., including societal unit area such as school or educational area, workplace or factory area etc.  Factors related to illicit drugs itself, such as, opium, heroin, marijuana, amphetamine, etc.  Factors related to environment are such as economic factor, political, international relations, and social factors, etc., which has positive or negative impact on illicit drugs problems.
The important content of government policy according to prime minister order number 119/2544 and 120/2544, and the 9th National Plan for Economic and Social Development related to the prevention and suppression on illicit drugs, are as follow.
	1.  Problem of illicit drugs is a national priority, with strict enforcement through the principle of “prevention before suppression; addicts shall receive therapy sessions; seller/distributors shall receive severe punishment”.
	2.  Winning over the illicit drugs problem by intervening 3 circles: controlling illicit drugs, separating addicts from drugs trafficking through therapy and rehabilitation process, and prevention of illicit drugs use through empowering and raising public awareness by focusing on target communities.
	Important illicit drugs are as follow:
	a. Amphetamine is an important illicit drugs which remains a major problem nationally for the past 10 years.  Myanmar is an important producer for distribution to neighbouring countries and then smuggled into Thailand, through various borders from northern to central part, and Bangkok.
	b. Marijuana is cultivated mainly in Lao and some part in Thailand.  Major area of this illicit drug are northeastern, southern parts of Thailand and Bangkok.  Some of the drugs are smuggled out to other countries.
	c. Various vaporizing addictive substances are popular among young people under 18 years old.  Principle areas are northeastern part of Thailand and Bangkok.
	d. Kratom (Thai herb) and cough medicine are increasing in popularity for the past few years.  Principle areas are southern part of Thailand, certain areas in Bangkok and neighboring provinces.
	e. Club drugs or illicit drugs in bars, nightclubs or various entertainment places at night.  These are Ice, Ecstasy, cocaine, and Ketamine which is imported.  Areas of heavy consumption of these drugs are tourist spots such as Bangkok, some provinces in southern, northern and central area.  These drugs are limited to certain population groups.
	f. Opium, other variations of opium / heroin.  There are certain areas of opium cultivation in Thailand, which needs to be reduced continuously.  Majority of heroin in Thailand are smuggled from various borders.  Southern, some northern areas and Bangkok are major areas of heroin consumption.
	Various groups of individuals who have major roles in distribution and trafficking at present are the same group of people in the past several years.  They are,
1. Foreign labor force such as Myanmar, Lao and Cambodia are increasing in number for selling and distribution of illicit drugs.
2. Foreign nationals who sell illicit drugs such as Africans, Asians etc.
3. Group which sell illicit drugs along borders and networks with those selling in the country, such as northern and central part.
4. Foreign labor force who sells drugs such as Myanmar, Lao and Cambodia.
5. Those who sell drugs in inner areas of the country.
According to Prime Minister Office order number 29/2546 and 30/2546 related to winning the war over illicit drugs and establishing National Center of Illicit Drugs Prevention and Suppression, and number 31/2546 related to establishing regional center for illicit drugs prevention and suppression, are for the objective of getting rid of illicit drugs.
	Between 2003-2004 Thai government declared war on illicit drugs with the result of 2,500 homicides in order to cut short the real connection of drug lord or mastermind, who may be high ranking government officials or politicians.  Even though the war on illicit drugs reduces national consumption drastically, but problem of drugs along the borders is increasing with smuggling and importation.  The route for trafficking drugs is from the northern part but store for shipment in eastern part of Thailand.  This makes it look like there was a change for different route from eastern area.  Another favorite route is from Lao, in the golden triangle area to Luang Prabang province.  From there, drugs will be transported to Viengtiene, with one route going through Loei province.  Special route to be considered is the one from Myanmar and going through Andaman Sea.
	From estimation, there are over 100 groups of drug cartels all over Thailand.  The problem of drug distribution has reduced drastically between 2006-2007.  Number of arrested drug cases has reduced.  Policy and strategy in prevention and suppression during the past 10 years was dynamic, since this is complicated and increasing in violence both domestically and internationally.  From the strategy of “People and Government Fight Illicit Drugs Together” to “Power of the Land to Win Over Illicit Drugs” in order to get rid of drugs, the strategic planning is national agenda, with priority not less than economic problem or other social problem.
	The conclusion of this documentary research reflects the development and taking it seriously as the national agenda.  The result indicates legal measures and budgeting process to facilitate this national strategy, including performance-based results from various important plans for prevention and suppression of illicit drugs.


Mae Moh Power Plant is the biggest coal-fired power plant in Thailand. Each year the power plant utilizes over 17 million tons of lignite coal from Mae Moh mine, an open-case mining located in the same area. Both the power plant and coal mine produce pollutants that can affect the environment and human health. However, at present, there is no surveillance system to monitor health effects, especially long-term effects, of people living nearby the power plant. This study aimed to review health impacts among people living nearby Mae Moh power plant, current surveillance system, and to suggest an appropriated health surveillance system. Information was gathered from a literature review, interviewing, and meeting with experts, related persons, and representatives from people living nearby Mae Moh power plant. Data were analyzed by content analysis.
From literature review, it was found that health impacts of  coal mining and  power plant were  1) increase prevalence of respiratory system diseases, especially chronic obstructive pulmonary disease, asthma 2) reduce pulmonary function 3) hearing loss 4) dermatitis, urticaria, and itchy rash  5) increase risk to get an accident 6) effect to child development 7) annoy due to odor and vibration. The result also found that there was no surveillance system for monitoring  health effects  of people living nearby Mae-Mao power plant.  The current surveillance system  was Ministry of Public Health’ surveillance system which showed size of problem and distribution of diseases. It could not provide details on risk exposure and cause of diseases.
It was found that the health indicators that should be monitored were: 1) emergency room visits, 2) hospital visit and service requested, 3) mortality monitoring, 4) pulmonary function of school children,   5) lung function of adults with respiratory problems, 6) chronic obstructive pulmonary disease cases, 7) pneumoconiosis among coal worker, and  8) stress and annoy due to environmental problems.
To implement this program, environmental law should be revised and the requirements for conducting health risk assessment added, in addition a health monitoring system should be set up. The regulatory system should also include grant and operation team  to support the surveillance system. The system should be operated by a committee consisted of all involved stakeholders, including Electricity Generating Authority of Thailand (EGAT)(Mae Moh), representatives from people living nearby Mae Moh power plant, staff from the government office and non-governmental organization, and specialists from an education institutions.


Laparoscopic surgery is a modern surgical technique in which operations in the abdomen are performed through small incisions for treatment and diagnosis.  As compared to larger incisions needed in traditional surgical procedures, the patients with laparoscopic surgery had smaller incisions and less blood loss which leads to better quality of life.  However, laparoscopic surgery is more expensive.  Currently, the reimbursement method and rate are different among health insurance schemes.  Therefore, this study aims to evaluate the utilization of laparoscopic surgery  between  patients under Civil Servant Medical Benefit scheme (CSMBS) and those under Universal Coverage scheme (UC) as well as the cost-effectiveness and budget impact of laparoscopic surgery in health insurance system in Thailand.
The data of inpatients undergoing laparoscopic surgery obtained from the Central office for Healthcare Information (CHI) from 1 January 2005 to 31 December 2007 based on procedure code (ICD-9-CM) and principal diagnosis code of laparoscopic (ICD-10) were used to determine the access to laparoscopic surgery between the patients under CSMBS and those under UC. It was found that diseases of gallbladder and cholecystitis, diseases of gynaecology and acute appendicitis were the most dieases performing laparoscopic surgery. Patients’ health insurance is the facor associated with the access to laparoscopic surgery the most. The patients under  CSMBS had significantly higher access to laparoscopic surgery compared to those under UC because the reimbursement method and rate are different among these two insurance systems. Moreover, large hospitals were more likely than small hospitals to perform the laparoscopic procedure since surgeons with expertise in laparoscopic surgery and and expensive equipments are usually in large hospitals.
           The cost-effectiveness analysis of laparoscopic surgery was obtained from the study in 2005 i.e., the cost-utility of laparoscopic surgery versus conventional open cholecystectomy. It was found that the incremental cost per QALY was 144,692 Baht under government perspective and 86,464 Baht under a societal perspective. Laparoscopic surgery would be considered as a cost-effective strategy regarding to a threshold of one to three times of gross domestic product per capita recommended by the subcommittee of the development of benefit package and service system, the National Health Security Office (NHSO).

	Based on the results, it was concluded that although laparoscopic surgery in cholecystectomy would be cost-effective, the patients under UC still could not appropriately access to laparoscopic surgery when compared to patients under CSMBS for the reason that the NHSO does not provide higher reimbursement rate in case of laparoscopic surgery compared to traditional surgery procedures. This reimbursement system of NHSO does not support hospitals to perform laparoscopic surgery which had higher cost but same reimbursement rate compared to traditional surgery.  In order to increase the access to laparoscopic surgery, the NHSO should provide the interventions such as an increase in reimbursement rate of laparoscopic surgery compared to open surgery to hospitals by assigning the higher relative weight score or allowing patients under any Thai health insurance schemes pay the co-payment when receiving laparoscopic surgery.  In addition, the Ministry of Public Health should provide financial support for the training on laparoscopic surgery to increase the number of surgeons in this field.


An inappropriate use of antimicrobial is not only a major cause of antimicrobial resistance but also a huge wasted expenditure in many countries including Thailand especially in teaching hospital. Many appropriate antimicrobial prescribing interventions can improve rational antimicrobial use. Therefore, the objective of this study was to select the most appropriate rational antimicrobial prescribing interventions for Thai health care system. The focus group technique was used to select the rational antimicrobial prescribing interventions. The members of focus group included the experts who have had experienced in rational antimicrobial prescribing interventions and stakeholders who would have an impact if the selected interventions were implemented.
Based on all international and national literatures related to interventions, many rational antimicrobial prescribing interventions were available. Due to a diversity of setting and methodology used in each study, the efficacy of interventions was not concluded in a harmonious direction and a comparison between interventions were needed to compare by indirect method. Multifaceted interventions were more effective than single intervention. Moreover, the effective interventions such as education, antimicrobial order form, infectious disease specialist approval and clinical pharmacist acting as a reviewer and decision supporter were proposed to a focus group as a preliminary data. Then discussion and judgment of the intervention selection was made among members.
The consensus of focus group suggested that the above interventions were not appropriate for Thai health care system because there were many limitations.  For example, there were not enough infectious disease specialists and clinical pharmacists, the role of clinical pharmacists were not so accepted as compared to developed countries and physicians still had the highest power in prescribing. However, the intervention called drug use evaluation (DUE), a process to monitor and promote the rational use of drugs might be used as a tool for solving this problem. In addition, pharmacists who have had experienced with antimicrobial DUE in hospitals suggested that the explicit policy related to DUE from the central was very necessary and should be restricted. It may be a feasible measure to promote rational antimicrobial use in Thai healthcare system in the future.


This study aimed to evaluate the access to cataract surgery as well as the factors associated with cataract surgery between patients under Civil Servant Medical Benefit scheme (CSMBS) and those under Universal Coverage scheme (UC) using the data containing (1) the CSMBS and UC inpatient data during January 1, 2003 and December 31, 2007 obtained from the Central office for Healthcare Information (CHI) and (2) data of patients participating in the cataract surgery project, the National Health Security Office (NHSO).  Moreover, this study also assessed the cost-effectiveness analysis of cataract surgery using a foldable compared to a rigid intraocular lens in Thailand using decion tree model based on healthcare provider’s perspective.
Based on the results regarding the access to cataract surgery, it was shown that patients with cataract in Thailand especially those under UC increasingly received cataract surgery every year.  In addition, most UC patients (96.9%) performed cataract surgery in the provinces where they had UC eligibility and the rest had cataract surgery in other provinces. Large provinces had higher cataract surgery rate and the provinces where there were one more ophthalmalogist would have cataract surgery rate 52 times higher. Furthermore, based on the factors associated with cataract surgery, patients under CSMBS were 22 times more likely to be performed cataract surgery using foldable intraocular lens compared to those under UC.  The patients with rigid intraocular lens had significantly more complications than those with foldable intraocular lens. In addition, patients being performed cataract surgery at teaching hospitals or private hospitals had significantly higher complications than general hospitals.

The cost-effectiveness results of cataract surgery using a foldable intraocular lens compared with a rigid intraocular lens showed that if third party payers had willingness to pay (WTP) less than 200,000 Baht per quality adjusted life year (QALY), using foldable intraocular lens would not be cost-effective.  When comparing to the previous decisions made by the subcommittee of the development of benefit package and service system, NHSO, they tended to not invest on the health technology which incremental cost-effectiveness ratio greater than 200,000 Baht. The result of this study is in accordance with the NHSO policy and practice guideline which has supported the cataract surgery using a rigid intraocular lens.  However, if WTP per QALY is changed or increased in the future, there will be a little probability that cataract surgery using a foldable intraocular lens is more cost-effective compared to a rigid intraocular lens.

In addition, our research team also surveyed the prices of foldable and rigid intraocular lens in order to calculate how much saving would be based on assumed scenarios. If the reimbursement amount for foldable and rigid intraocular lens equal to the surveyed prices, the government would have cost-saving of 55 million Baht.  Moreover, If the reimbursement amount equal to the surveyed price of rigid intraocular lens, both CSMBS and UC schemes would have cost-saving of 144 million Baht. Therefore, if the organizations responsible for reimbursement amount could determine the appropriate reimbursement amount of intraocular lens, it would help saving a huge budget which could be allocated to other necessary healthcare services.
Based on all study results, policy recommendations are summarized as follows.  First, the government should allocate the budget for special training on ophthalmology especially in the provinces where lack ophthalmologists. Second, our results indicated that using rigid intraocular lens was more cost-effective, so that the reimbursement amount equal to the price of rigid lens would be appropriate.  Third, patients should be correctly educated on using rigid and foldable intraocular lens, since they might be persuaded by healthcare providers to pay more.  Lastly, the price of intraocular lens based on the survey was much more inexpensive than that of NHSO and the Comptroller General’s Department. The price of rigid intraocular lens could be decreased by four times, and that of foldable lens could be reduced by 50%.  Therefore, the reimbursement amount on the prices of both rigid and foldable intraocular lens should be reviewed and revised in the future.


An attempt to include “spiritual health” into WHO definition of health has been made since 1980. It was proposed by member states of WHO in Eastern Mediterranean Region. There were both proponents and opponents of the proposal. Finally the Executive Board of WHO has concluded to propose amendment of the definition of health from that “the state of complete physical, mental and social well-being and not merely the absence of the disease or infirmity” to “the dynamic state of complete physical, mental, spiritual and social well-being and not merely the absence of disease or infirmity.” However, the proposal did not become the resolution at the World Health Assembly. Thus the definition of health remains the same as stated in the preamble of the Constitution of WHO. In Thailand there was a movement to include the “spiritual health” into the definition of health during the campaign on health system reform in the last decade. Such movement brought about strong controversy rooted from some leading Buddhist organizations which rejected the “spiritual dimension” as a concept influenced by theist paradigm which is opposite to Buddhism. Finally, the consensus has been reached to accept the term “intellectual well-being” as the fourth dimension of health. The Health Act B.E. 2007 has then defined health as “the state of human being which is perfect in physical, mental, spiritual and social aspects all of which are holistic in balance.” There are still some problems in the new definition of health concerning the exact meaning of mental and spiritual well-being especially when translates into English. This paper proposed not to try to reach consensus in this issue which is very complicate, since the four dimensions have covered all aspects of health. It also proposed Buddhist way of development of the four dimensions of health as an example. The people in different faith can freely develop or extend their means on the basis of their own faith


Globalization and climate change are important phenomena in a changing world. Among them global
warming has been marked by a series of events that affect natural resources and the health of human
beings. The magnitude of global warming will depend on future emissions of greenhouse gases and climate
sensitivity. To date, global warming and globalization have the potential to influence the emergence
and re-emergence of infectious diseases. The effect of globalization on infectious diseases from vectorborne
to respiratory infection has been well established. The influence of global warming has also been
scientifically recognized; however, there is still no conclusive evidence of the effect of global warming on
the pattern of infectious disease distribution.


This mixed methodology research study was conducted to assess health equity within a human
rights framework, comparing situations among three groups in Thailand in order to close the gap between
these groups. The sample included 789 subjects (ethnic Thais, and hill tribe and stateless hill tribe
people) from 10 provinces in northern Thailand; they were studied from December 2006 to August 2007.
The tool for comparison was the benchmark of fairness for assessing health care reform. Data analysis was by ANOVA, Z-score and fulfilled qualitative data. Based on the research results 17 experts suggested
policy options.
The results revealed significant differences among the three population groups on seven out of the
nine benchmarks (all at p < 0.001). The non-significantly different benchmarks were efficiency and quality
of care (p = 0.170) and administrative efficiency (p = 0.227). With regard to to Z-score analysis, Thai
nationals (group 1) had the highest score (Z = 0.3293), the hill tribes with Thai citizenship (group 2) had a
mid-level score (Z = 0.1275) and the stateless hill tribes (group 3) had the lowest score (Z = –0.3885).
Recommendations from experts to bridge the gap included the need for budget allocations to fit with
population, health care standards, legal reforms and the decentralization of health services to the local
governments.
In conclusion, this research suggested that the Thai government should close the inequity gap by
adopting a policy mix that would affect every population group in Thailand. The establishment of equity
with regard to basic health care will promote human rights concerns within Thailand and will serve as an
example for the promotion of humanitarian efforts elsewhere.


This health status and quality of life study was a cross-sectional descriptive one. It was aimed at
exploring the health status and quality of life and their related factors in the study population: 943 people
living near one of the petrochemical plants in Rayong Province. Data were collected during July and
October 2008, using an interview questionnaire and WHOQOL-BREF-THAI. Data were analyzed by
descriptive statistics (frequency, percent, mean) and inferential statistics (chi-square).
Results revealed that the majority of the study population were females (76.8%) with a mean age of
46 years, and having had a primary school education (57.8%). Of the total, 27.9 percent were traders, 16.5
percent consumed alcohol, 8.7 percent smoked, and 48.9 percent did exercise. The distance between their
house and the petrochemical plant was less than 5 kilometers (59.4%). In the past three months, 6.8
percent of them got ill and sought care at hospitals. In the past month, 61.8 percent of them had respiratory
symptoms, 57.2 percent had neurological symptoms, and 53.7 percent had dermatological symptoms.
Regarding their family members, 26.9 percent were allergic to dust or had hay fever. In the past
month, 59.8 percent of them experienced chemical odors: 52.3 percent a gas-like odor, 21.5 percent a
pungent odor, and 15.6 percent an odor similar to a ripe guava. A third of them experienced these odors
in the evening (33.3%); 23.2 percent smelled the odor during the day and 17.2 percent did so at dawn.
The majority of them (68.6%) had a moderate level of quality of life, 31.3 percent had a good level of
quality of life, and 0.1 percent had a poor level of quality of life. Factors related to quality of life were
personal factors (gender, education, job, exercise), health status (getting ill and family illness), and distance
from the petrochemical plant. In addition, respiratory, neurological, and dermatological symptoms
in the previous year and the previous month were significantly related to experiencing the chemical
odors.
This study emphasizes the concern that experiencing chemical odors in ambient air relates to health
and may affect people’s quality of life. Health authorities should develop and enhance measures, especially
short-term and long-term surveillance, and monitor the health status and quality of life of the
people living around industrial zones.


This research study concerns the situation, potential and readiness of local government organizations,
communities and networks of health service units at the primary health care level which work in partnership
for local health. It is aimed at bring about improvements in the direction of and the role played by networking
of the tripartite members of the community health system. The study emphasizes the process of both the quantity
and quality approaches. The selection of the study area was made using the purposive method, with the
distribution being two provinces each in four regions of Thailand. They were included in both the primary area
with regard to their experience with the transfer of the mission of primary health care units to local government
organizations and with the cooperative efforts of 12 sub-districts. The method of this qualitative study involved
the use of a questionnaire with guidelines for interviews and focus group discussions, all of which had been
passed and tested by professionals. With regard to the study of the potential and readiness of local government
organizations, a scale was set up concerning the criteria and use of descriptive analysis.
The study resulted in significant information on the situation, capacity, and readiness of the network of
health services relating to policy dimensions and the system of support for health service providers, which still
has an incomplete structure, especially at the provincial level. However, at the district and sub-district levels,
the clearing structure has worked more effectively in some of the study areas with regard to the principles or policies governing the transfer of the health service mission to local government organizations in a different
manner. The number of health service providers, their capacity regarding knowledge, and their experience,
including duration of work, all have had a positive impact on their work as partners because, while individual
relationships are important, the supporting system still lacks capacity for the development of more effective
health officers working in communities and local areas. However, most health personnel possess understanding
regarding the management and use of information; they can report on the level of the working unit more
effectively than use the information for planning to solve problems at the area level. The capacity and the
readiness of individual communities were found to depend on the variety, role, and strengths of the community
leaders and the development groups within those communities. This observation includes the level of acceptance
of health service units and the local government organization in the area concerned, as well as the focus on
management, and bringing about good governance. Concrete negotiations on health from the community level
are still limited, particularly with regard to funding. The capacity and the readiness of the local government
organizations regarding the structure of the health system in most of the study areas varied by specific unit of
management capacity. The entire study unit was accepted by the communities with regard to the local politics.
However, the ability to obtain local revenues and generate income differs according to the size of each organization.
For expenses on health development in those areas, each obtains a little over 6.6 percent of the total
expenses from the study area. It was found that participation in the universal health insurance coverage scheme
in these areas was still limited, with regard both to policy setting in the area in order to extend the coverage to
all people in the areas concerned, involvement in providing and purchasing health services, including service
monitoring and practice management.
Important suggestions arising from the study as it concerned the health service network and communities
comprised the following: (1) support is needed for learning more about the local mechanisms for working
cooperatively for health; (2) improvement in capacity-building should be promoted in each sector clearly and
continuously according to their capacity and ability; (3) a mechanism and support system should be developed
such as a management system, and information system for planning, and implementing, and for monitoring
and evaluation.
Other suggestions called for (1) modifying the development goal regarding the transfer of the responsibility
for providing health services to the local government organizations in order to promote the concept and
process of partnership development among those in the health sector, local government organizations, and
community; (2) advocating policy mechanisms and organizational management at the district and provincial
levels for developing public policy on health, as it relates to social marketing and public communication on
health; (3) supporting clear and continuous capacity-strengthening measures for local governments, such as
databases developed to cover interesting case studies, and organizing appropriate activities for improving the
learning process on networking issues in all sectors.


The purpose of this action research study was to solve clinical risks in patient care by professional
health care teams. Researchers and participants were heath personnel in Sung Noen Community Hospi-tal, including the hospital director, physicians, pharmacists, registered nurses, laboratory technicians, radio-
logy technicians, physical therapists, psychologists and ayurvedic doctors. The study was divided
into three steps: (1) situation analysis: by analyzing clinical risk incident reports and former preventive
measures, (2) implementation: by setting up integrated case conferences, i.e. integrated patient care by
professional health care teams, with physicians serving as leaders (the physicians set up case conferences
once a month), (3) monitoring and evaluation: by participating in conference meetings, using questionnaires
created by a quality development center, evaluating new preventive measures and clinical practice
guidelines (CPG) released and enabled to practice. The study was conducted from October 2007 to December
2008, a total of 18 months. It was found that the clinical risk incident report in 2007 was higher in
coverage, especially patient care topics, but repeated incidents were still periodically reported; also there
was a lack of root cause analysis (RCA) of clinical risk in time and discontinuity of preventive measure
practices. An integrated case conference on high-level clinical risk topics, with physicians as leaders, was
set up to analyze the root cause analysis (RCA) of the patient care process. The results were new preventive
measures and new clinical practice guidelines that were more practical for promoting quality in patient
care teams. This study showed that integrated case conferences could be effectively conducted in
community hospitals


This descriptive study was aimed at comparing the cost of herbal medicine to replace conventional
medicine for the treatment of five health conditions in a five-year period (2002 - 2006). The study was
performed between May 2007 and August 2008. The study samples comprised 65 health care workers
and 260 clients in regional hospitals and 12 community hospitals in Lampang Province. The research
instruments used consisted of (1) a record of the cost of herbal medicine and conventional medicine treatment
of five health conditions: irritable bowel syndrome, sore throat (non-infectious) constipation,
herpes, and musculoskeletal/joint diseases, (2) a questionaire for herbal medical orders, and (3) a satisfaction
form to record the use of herbal medicine. The data were analyzed by descriptive statistics; the cost of
herbal medicine replacing conventional medicine was compared by t-test and clients satisfaction analyzed
by chi-square.
The results indicated that the cost of most herbal medicine compared with conventional medicine
for five health-condition treatments in Lampang Province increased during the period studied. The cost
of Turmeric increased from 85,717 baht in 2002 to 551,272 baht in 2006; Andrographis increased from 28,152
baht to 138,681 baht, Senna alata leaves increased from 2,797 baht to 27,104 baht, and Clinacantus nutans
leaves increased from 3,490 baht to 18,101 baht and Zingiber montanum increased from 14,243 baht to
298,446 baht. The comparative cost of herbal medicine during the period 2002-2006 significantly increased
(p < 0.05), except for Zingiber montanum (p = 0.074).
Concerning the health care workers’ perceptions about herbal medicine, we found that the sample
population experienced increases of 75.4 percent in ordering Turmeric, 63.1 percent for Andrographis, 40
percent for Senna alata leaves, 41.5 percent for Clinacantus nutans leaves and 58.5 percent for zingiber
montanum. The main reasons for the decision to order was a perceived drug indication. For the clients’
satisfaction in using herbal medicine as a replacement for conventional medicine, we found that the
clients had experience in using Turmeric (68.5 percent), Andrographis paniculata (70 percent), Candelabra
bush (15.4 percent), Clinacantus nutans (29.6 percent) and Zingiber montanum (69.2 percent). Satisfaction
was highly significant (p < 0.001); the reasons for satisfaction were knowing the indications and having
experience in using the herbals.
Based on our study results, the herbal medicines used were Turmeric, Andrographis, Senna alata
leaves, Clinacantus nutans leaves and Zingiber montanum for increasingly replacing conventional medicine
in the regional hospital and 12 community hospitals in Lampang Province from 2002 to 2006. The
increasing rate resulted from the supportive policy of promoting herbal medicines in the health delivery
system, organizing herbal medicine symposiums, and reminding healthcare workers by displaying
posters on how to use herbal medicines at dispensing units.


Rapid social changes and the structural reform of health systems in Thailand in the past two decades
have posed new challenges relating to how the governance of the national health system operates. Following
the establishment of the Health Systems Research Institute (HSRI) in 1992, a number of new national
health organizations were created. The emergence of these new national bodies within the old structural framework and institutional practices of the Ministry of Public Health has created ambiguity of
roles and difficulties in national health system governance.
This study was aimed at formulating a conceptual framework for National Health System Governance
(NHSG) and using this framework to analyze the system and synthesize a proposal for its improvement.
The study was conducted using document analysis, in-depth interview and participatory observation,
all of which were carried out during the period from August 2008 to July 2009.
The study found the following crucial roles for NHSG: policy guidance, intelligence and oversight;
collaboration and coalition-building; regulation; system design; and accountability. It also found that a
multi-dimensional approach was useful for making more unambiguous analysis of NHSG in contemporary
society.
The study argues for a new system to create a more effective NHSG in the Thai context. In so doing,
the Cabinet has a vital role to play in improving the structural framework and institutional practice of
government actors in NHSG, and in considering the three dimensions of governance: (1) build a strong
“governance network“; (2) develop ”good governance” for each actor, the main obstacles to which are the
crony system and bureaucratic culture; and (3) develop processes and mechanisms which engage stakeholders
from all sectors in system governance, by using a “reflexive governance“ framework.


Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related death in the world; it
causes 600,000 deaths globally per year. Most cases of HCC occur in Asia and developing countries. The
major risk factors for the development of HCC are viral infection (chronic hepatitis B and hepatitis C),
cirrhosis from consumption of alcohol, and the intake of aflatoxin as well as iron overload, obesity and
diabetes mellitus type II. Prevention of infection with hepatitis B and C viruses and avoidance of risk
factors are the key strategy for reducing the incidence of HCC. This communication describes a summary
of interrogatory questions frequently compiled for potential research study.


Obstructive sleep disordered breathing (OSDB) is a collective term that encompasses a spectrum of
disorders which can range from primary snoring and upper airway resistance syndrome (UARS) to
varying levels of severity of obstructive sleep apnea syndrome (OSAS). Snoring is a common problem
encountered in Thailand and indicates upper airway obstruction. It is very annoying to patients’ bed
partners since it could deprive them of proper and restful sleep, which is essential to good health. If the
degree of such an obstruction is severe, it can lead to OSAS, which is a life-threatening condition. Recognition
of OSAS is important since it causes daytime somnolence, neurocognitive defects, chronic fatigue,
and depression. In addition, it can increase the risk of having traffic accidents, hypertension, cardiovascular
disease, stroke, pulmonary hypertension, and cardiac arrhythmia. The treatment options for OSDB
include weight loss, positional therapy, oral devices, continuous positive airway pressure (CPAP), and
surgery.


Thailand has used silica and asbestos for years, but there have been few reported cases of silicosis
and asbestos-related diseases such as mesothelioma. There are several reasons for this. Registration of risk
groups exposed to silica and asbestos will serve as the key initial step in surveillance for silicosis and
asbestos-related diseases. This article describes the system in the United States as an example. It also
suggests three approaches to the registration system: industries using silica and asbestos, workers/occupations
exposed to silica and asbestos, and materials/products containing silica and asbestos.


The disease management program of open heart surgery in Northeast of Thailand was the co-operation of National Health Security Office, Ministry of Public Health and Khon Kaen University. The program was aimed to promote the equality of accessibility for patients under the Universal Coverage Health Scheme who waited for an open heart surgery treatment. Four hospitals providing open heart surgery in this program were Queen Sirikit Heart Center of the Northeast, Khon Kaen, Sringarind Hospital, Khon Kaen, Sappasitthiprasong Hospital, Ubonratchathani, and Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima. The quality of care is an important factor that would result in the lower rate of mortality and complications, and the higher quality of life. This study was conducted to evaluate clinical outcomes, quality of life, and cost-effectiveness of the disease management program. This report was divided into three chapters: chapter I, clinical outcomes; chapter II, quality of life; and chapter III, cost-effectiveness of the disease management program.
The mortality rate of 302 patients who undergone the open heart surgery was 6%. The mortality rates differed by types of surgery that the rates of CABG, valve, congenital heart disease, and more than one types of surgery were 3.6%, 6.9%, 1.7%, and 14.3%, respectively. The 28-day hospital re-admission rate in this study was 8.5%. The complication rate was 34%, and the common complications were arrhythmia (12.6%) and wound infection (12.3%). The significant factor associated with the overall mortality of open heart surgery was fever condition (> 39°C) when patients were in ICU/CCU (Hazard Ratio = 5.2, 95% CI 1.4 – 20.1).
The study assessed quality of life of 225 patients in terms of physical activity using DASI, physical health and mental health using 9-THAI, cognitive function using RAND, chest pain after coronary artery bypass graft using SAQ, depression using CES-D, and overall quality of life using EQ-5D VAS. Patients were assessed their quality of life at baseline, 3 and 5 months after the operation. The patients under the disease management program had a significant improvement in physical activities, physical health and mental health, depression, cognitive function, chest pain for CABG patients and overall HRQoL at 3 and 5 months after open heart surgery.
The cost effectiveness for open heart surgery in disease management program was compared with usual care. This study analyzed the cost effectiveness for two types of surgery including coronary bypass grafting (CABG) in the 60 years old patient and surgery for patients with valvular heart disease in 40 years old patients. Decision Analysis Model was used to calculate life expectancy, quality-adjusted- life- expectancy (QALY), lifetime cost and incremental cost-effectiveness ratio (ICER). Compared to usual care, CABG under the disease management program improved life expectancy and QALY, and was more costly. Life expectancy were 9.83 and 9.36 years which were equivalent to 6.29 and 5.82 QALYs for disease management program and usual care, respectively. An ICER of the disease management program as compared with that of the usual care was 17,276 Baht per QALY. For surgery in VHD, compared with the usual care, the disease management program also improved life expectancy and QALY, and was more costly. Life expectancy were 13.17 and 11.54 years which were equivalent to 11.54 and 7.35 QALYs for the disease management program and usual care, respectively. An ICER of the disease management program as compared with that of the usual care was 5,904 Baht per QALY. A cost effectiveness acceptability curve, based on Monte Carlo simulation suggests that at a willingness to pay threshold of more than 15,000 Baht per QALY, more than 50% of CABG in the disease management program will be cost effective. For the surgery for VHD, at a willingness to pay threshold of more than 10,000 Baht per QALY, more than 50% of surgery for VHD under the disease management program will be cost effective. Based on the WHO cost-effectiveness threshold, open heart surgery under the disease management program is considered the cost-effectiveness management when compared to the usual care.


The purpose of this study was to explore the implementation of the Local Administrative Organizations
(LAOs) according to a Resolution of the National Health Assembly 2008. Data were collected by using
questionnaires in September 2009. The subjects were 195 staff of LAOs. The study also involved a focus
group discussion with 20 staff members from the Provincial Administration Organization (PAO), League of
Municipalities, and Tambon Administration Organization (TAO). Descriptive statistics were used to analyze
the quantitative data and the qualitative data were analyzed by content analysis.
The results revealed that the majority of the subjects did not get information about the Resolution of
the National Health Assembly 2008, especially on item number 1.7 “Roles of Local Administrative Organizations
in Managing Health, Natural Resources and Environment”. However, they functioned in these roles
by their own plans, which conform with the resolution, because they had been funded by the National
Health Security Office.
The major problems of policy implementation were (1) lack of knowledge in assessing health impacts;
and (2) the Association of PAOs, the League of Municipalities and the Association of TAOs having taken
very little action on pushing the resolution.
The recommendations from this research are as follows: (1) The National Health Commission Office
(NHCO) and related organization should build the capacity of the local authorities, especially in health
impact assessment and using health assembly tools; (2) the Association of PAOs, the League of Municipalities
and the Association of TAOs should be core mechanisms to communicate the resolution of the National
Health Assembly, which is involved with the role of the local authorities and to analyze the rules and regulations
which constitute obstacles for managing good health within a suitable environment.


While there is an increasing need for institutional long-term care, however, there is still lack of neither good practice guideline nor registration bodies to regulate institutional long-term care. This study aims to explore the caring practice and to recommend model of institutional long –term care in Thailand.  Qualitative research method, such as focus group discussion and in-dept interviews were carried out for seeking opinion and practice experience from the academic expertise, care providers, care receivers and policy maker of 60 participants.
	It was revolved that there were 2 models of Institutional long-term care; 1) low care model for older person who need social care and assisted living with minimal health care such as, residential home and assisted living. The staff included social worker, nurse, care assistant, physiotherapist and occupational therapist and 2) high care model for older person who need continuing care, nursing care and somewhat medical care, due to being frail or chronically ill, thus the staff included nurses, care assistant and medical doctors.  This type of institution were nursing home, long-term care hospital and hospice care unit.  The caring would focus on holistic care, comfort and spiritual care.  In each model need to include philosophy of care and minimum care standard.
 	Policy recommendation are: to divide institutional long-term care into two levels, low care and high care; assigning low care institution to register with Ministry of Social Development and Human Security and the high care facility to register with Ministry of Public Health; to develop a minimum care standard at national level; to establish nursing home by local authority and encourage the private sector to particulate in providing care; and encourage community hospital to provide intermediate care. For practice recommendation, to have a clearer criteria for nursing home setting, to develop a dependent assessment tools, to provide sufficient information related to national policy on private setting, encourage volunteer in caring for older person, and media communication in a positive way.


As a part of developing the research management system in Health Systems Research Institute (HSRI) and its alliances, the project of developing good governance index as a tool for research administration in health system is initiated to promote various research projects to be managed transparently, efficiently, and accountability.   The operation of this project will be an empowerment tool which provides good governance practices to reform organizational management system, leading to sustainability and future breakthrough.
Objectives of this project are 1) to define the framework of monitoring and evaluating the project administration in accordance with good governance practices 2) to develop good governance index 3) to study the appropriateness of the developed index, issues, and barriers for index perceived 4) to set a guideline to gather essential data for project performance evaluation which is based on good governance principle of research management team in health system.
The process of this project begins with 1) reviewing theories, concepts, and research reports related to good governance practices and its index both domestically and internationally 2) interviewing experts from related disciplines, and research managements 3) developing and testing questionnaire and then analyzing data 4) using the drafted good governance index to conduct internal pilot test with HSRI  5) reviewing index and modifying it to be more suitably.
According to study, Good Governance means “the good and fair process which diverse organizations including private and public sector, government, and civil society apply to set their own direction. It is regarded as a process to change collective moral intentions to effective and accountable institutional actions”
The result of this study has indicated that two crucial conceptual frameworks of index development has emerged and they are comprised of 1) conforming to six good governance practices including Rule of Law, Transparency, Worthiness, Participation, Quality, Accountability and 2) applying six good governance practices to five steps of the research management process including the process of defining a policy, planning of research management, gathering and allocating resources, operating research, and utilizing research.   Shown in this study are total thirty indices which are collapsed into six composite indices to evaluate holistic picture of good governance practices in research management process.
The outcome of evaluating Health Systems Research Institute (HSRI)’s good governance practices has been depicted that overall in the organizational level HSRI has high good governance practices. When considered in the perspective of five research management process, the process of gathering and allocating resources gains the highest level of engaging good governance practices and is followed by the process of planning the research management as a second.  Other research management processes are evaluated that their involvement in good governance practices are in the middle level.


Health care system in Thailand has developed rapidly during a few decades ago. Thai citizen have enjoyed universal coverage for health care since 2002. Ministry of Pubic Health as a government body is responsible to oversee health service for people in Thailand. This ministry also has responsibility to enact many health laws.

At the same time, health care expenditure has continuously increases, and will increase rapidly in the future from maturation of ageing society, changing disease pattern to chronic diseases and the most significant one, fragmentation of health care system. For instance, patients from car accidents were victims of the game between social health protection schemes and private insurance companies. Anecdotage evident showed problems of adverse selection and moral hazard both from beneficiaries and health care facilities. These problems came from different payment mechanism and different payment rate in the same treatment from different social health protection schemes. It can be said that Thailand does not have system government on health care financing. Ministry of Public Health has loosed power to governance the system from time to time, Many financing agencies e.g. Social Security Scheme, Local governments and private health insurance companies, were established under authority of other Ministries.. Promotion of health export (Medical hub policy) is another example of conflict and no system governance of Thai health policy.

Objectives of this study aim to document and synthesis the current structure and function of institutes which play system governance role of health care financing in Thailand and developed countries which have already had universal coverage for health care. And assess how well the existing structures for system governance in Thailand measure up to the need. Finally, appropriate system governance structures for health care financing in Thailand are proposed. Analysis of this study used a framework of health system of the World Health Organisation, which health care financing is one of four missions of health system to provide universal financial risk protection, equity in finance, equity of access and use, transparency, effectiveness, and appropriate incentive for good quality providers.

The results of study founded, a common feature of the design of system governance of the 4 selected countries; England, Canada, Germany and japan, is a governance body which locates in administration structure of central government. This governance body is responsible to decide policy direction and to prepare amendment of related laws or new bills to shape the health care financing system of the country. These countries have different in revenue collection method, pooling, purchasing and payment. Therefore structures for system governance are also different. However, there are common features among these countries. Regarding revenue collection, contribution rates are regulated in counties which sickness funds or local governments are allowed to collect contribution by themselves. Equalisation fund or resource allocation formula has been implemented


The project “Management Experiences of the Provincial Public Health Offices” has four main objectives: 1) to enhance the understanding related to the Public Sector Management Quality Award (PMQA); 2) to increase the opportunity to exchange knowledge and experiences among the Provincial Public Health Offices (PHOs); 3) to obtain lessons learned from the PHOs relevant to the PMQA; 4) to publicize PMQA knowledge and experiences learned from the Provincial Public Health Offices.
The methodology used in this project consists of qualitative methods using focus groups, seminar meeting, document reviews, work-visits, and in-depth interviews.  Content analysis is used for analyzing the data.  There are seven PHOs participating in this project, namely Nakhon Ratchasima, Lop Buri, Ang Thong, Sukhothai, Nakhon Pathom, Ubon Ratchathani, and Krabi.
The results of the study found that the participants from the PHOs are very enthusiastic in joining this project.  Most of them have good attitude towards PMQA in terms of helping them to do more systematic works and to develop the potential of their staffs and organizations.  However, they also think that PMQA is a new management tool which is quite complicated and difficult to implement in some areas.   Below are the results of the experiences learned from the PHO regarding the seven categories of PMQA implementation.
The first category is related to organizational leadership and social responsibility.  It is found that many PHOs have systematic planning, communication, implementation, and review processes.  However, the problematic issues include the translation of value to the policy implementation, inefficient linkage between decentralization and innovation caused by unclear guidelines, inadequate feedback process, and unclear prioritization criteria. The flowchart of this category is suggested to link all steps for the convenience of practice. The key success factors include top management support, understanding of staff, commitment with the shared values, good attitude of top management and staff toward PMQA, and PMQA evaluation.
The result of the second category is related with strategic planning.  It is found that the problems of this category are limited understanding of the concept and the criteria of this category, inadequate involvement of participants, and inefficient deployment process. The process for this category is also suggested.  The key success factors of this category are the alignment among factors in the planning process, the knowledge and understanding of personnel, the learning mechanisms, information technology in supporting the planning process, and top management support.
The third category is related to the stakeholders of the PHOs. The problems are related to the techniques to classify the stakeholders, and the unclear definition of customer and stakeholder.  The key success factors are the concept and techniques to classify the stakeholders, satisfaction and dissatisfaction measurement, and the readiness of databases.
The fourth category is relevant with the measurement, information systems, and knowledge management.  From this study, it is found that the PHOs have systematic processes in selecting, collecting, and improving data. They can communicate these data through different channels. Lessons learned from this category include knowledge selection to manage first, the criteria for checking knowledge validity, and knowledge management evaluation.  The key success factors are top management support, supporting culture, the knowledge and understanding of staff, supporting infrastructure, and continuous evaluation.
The fifth category focuses on human resource systems, learning and motivation, and personnel happiness and satisfaction.  Many PHOs have both formal and informal systems for human resource planning. However, how to bring culture and the thoughts of personnel and community into the systems is still problematic for most PHOs.  The communication systems in PHOs are very well established by using both formal and informal channels. The personnel evaluation systems followed the government regulations. The reward and motivation systems are for creating the awareness among people. Key success factors include top-management commitment, personnel participation, experience exchange, continuous improvement, and the fairness treatments for both at organization and personnel levels.
	The sixth category emphasizes on process management, including value processes  (most important processes relating to agency mission or creating values or benefits to stakeholders) and supporting processes. Lessons learned from this category are the differences in interpreting the roles and functions of PHOs, unclear criteria to define the important processes, no standards for selecting value processes, and ambiguous definition of customers and stakeholders. The suggestions are that the organizations should simultaneously implement this category in conjunction with other categories, i.e. organization profile, the second category (strategic planning) and the third category (customers and stakeholders).  Guidelines for process management include 4 stages, i.e. process planning, designing, controlling, and improvement.  Key success factors are management commitment, experience sharing, stakeholder participation, process standardization, good evaluation, and other category integration.
	The seventh category	 is relevant with the results of performance by using four dimensions: effectiveness, service quality, efficiency, and organization development.  Since there are much data involved with this category, PHOs need a good computer program to deal with these data. In addition, to reduce the workload in data collection, the common data sets used by many sources should be organized. Key success factors include indentifying the clear indicators, accessible data base, simultaneously implementation with other categories. Finally, policy and practical recommendations are provided, together with the future research suggestions.


Objective: To identify the factors, including knowledge, attitudes, beliefs, values, fears, and perceptions,
which influence breast cancer screening behavior among different groups of people.
Methods: A structured literature search was undertaken, using the United States National Library
of Medicine’s PubMed database. Thirty-one breast cancer-related studies were selected; these were summarized
by applying the Health Belief Model and Knowledge, Attitudes, and Behaviors Model to the
framework.
Results: Most of the studies had been conducted in North America, and the designs used were
mostly cross-sectional studies. The percentages of women who underwent mammography ranged from
5.3 to 82. Women who had performed BSE (breast self-examination) ranged from 6.4 to 83 percent, and
women who had undergone CBE (clinical breast examination) ranged from 26 to 61 percent. The review
found that not only did knowledge of breast cancer play an important role in people’s behavior regarding
breast cancer screening, but also regarding beliefs, attitudes, cultures, values, and perceptions.
Conclusion: This literature review addresses issues regarding the importance of knowledge, attitudes,
beliefs, values and cultural awareness when implementing prevention programs. Further research
needs to explore the threshold level of breast cancer knowledge in order to achieve a higher rate of the
breast cancer screening.


The Bureau of Drugs and Narcotics, Department of Medical Sciences, conducted a five-year longitudinal
study that monitored the physical deterioration of drug products in 829 hospitals nationwide,
supervized or owned by the Ministry of Public Health, as well as some other hospitals in Bangkok,
between 2003 and 2008. The study encouraged healthcare professionals to voluntarily observe and report
defects or physical deterioration problems found in marketed drug products, available in government
hospitals. A total of 2,407 reports were gradually received. The results revealed the major problems: 37.1
percent of the total reports were related to container and packaging defects, 14.5 percent of which were
chipped, cracked, or splitting tablets, followed by discoloration or abnormal odor (11.5 percent) and suspected
product contamination and/or labeling concerns (6.2 percent). In terms of dosage forms, 47.4
percent were tablets, whose major issue was incomplete/missing amounts in original packages. The
percentages for other forms, including injections, solutions, capsules and inhalers, were also included.
Finally, the information regarding the physical deterioration of drug products obtained from this study is
helpful for healthcare providers in making decisions on product selections and for the quality assurance
of drug schemes, as well as for use in identifying standards in pharmaceutical development.


When adverse events occur in the hospital the patients or their relatives often bring cases to court or
submit claims for compensation from the National Health Security Office (NHSO). A descriptive study
was carried out to determine the trend relating to claims for compensation in order to obtain information
for designing a new and better system.A survey employing questionnaires was used to obtain information at 230 hospitals in the country;
the response rate was 70 percent, among which 21 percent had experienced in 2008 claims for compensation
owing to adverse events occurring in the hospitals. The findings showed that community hospitals
were subjected to such claims more often than regional general hospitals, e.g., 23.4 vs. 15.7 percent. As
many as 43.1 percent of the studied cases were related to pregnancy and delivery. The median of the
compensation amounts was Baht 200,000; the highest claim was for Baht 15 million. The median amount
of money allowed was Baht 100,000. The main source of compensation was from NHSO (49.0%). Among
the claims, 13.3 percent of the cases were brought to court. Community hospitals had a higher chance for
claims brought to court than general/regional hospitals (14.3% vs. 10.0%).
The study concluded that 21 percent of the hospitals surveyed experienced claims for compensation.
Most cases were related to pregnancy and delivery. The money received was smaller than the claims
submitted. Therefore, some claimants brought their cases to court in lawsuits.


Objectives: To evaluate and review the tuberculosis situation in various populations at high risk of
contracting tuberculosis, at various periods of time and general tuberculosis control outcomes in northern
Thailand.
Methods: Data on various high-risk populations were analyzed from the DOTS database and special
project paper-based record systems for various high-risk populations in areas of northern Thailand in
various periods of time.
Results: The 2003 and 2004 reports showed 30 and 60 percent of multidrug-resistant tuberculosis
respectively with cure rates of less than 60 percent of the registered cases. The 2004 report revealed that
tuberculosis was the most common opportunistic infection (38.9%) among the HIV-seropositive/AIDS
cases. Reports of isoniazid therapy for tuberculosis prevention among HIV-seropositive/AIDS populations
showed that 78 percent of them had not developed tuberculosis at the end of the 24th month since
starting therapy. The 2005 report demonstrated that only 3.2 and 37.1 percent of the suspected childhood
tuberculosis cases were diagnosed as tuberculosis and latent infection cases, respectively.
There were no statistically significant correlations between the types of the patient observers and the
cure rates among the general tuberculosis population analyzed from the 2003 report (Pearson correlation
coefficients > 0.01, 2-tailed). There also were no statistically significant changes or improvement in the
treatment outcomes (sputum conversion rates, default rates, death rates, and treatment success rates),
when comparing the 2003 and 2004 reports (p > 0.01).
Conclusions: These findings indicate the DOTS program implementation was not well-developed
for various populations at high risk of tuberculosis in these areas. Recording and reporting systems for
childhood tuberculosis cases in this area still were not well-developed and this contributed to
underreporting of this section of the high-risk population.


The concept and perspectives of administrators can reflect the direction of development. This research
was aimed at studying the concept and perspectives of administrators regarding the issue of attempting to
extend community pharmacy services under the National Health Security Scheme (NHS). The study was
conducted using in-depth interviews of the administrators responsible for the status of pharmacies with regard to the possibility of providing pharmacy services under NHS, the direction of development for pharmacies,
the value of pharmacies in NHS, stakeholders and factors for success in extending pharmacy services
under the system. Data were gathered and analyzed by content analysis. The results showed that the
administrators agreed with the idea of incorporating community pharmacy services within NHS, but the
standard of practice and the quality of service first had to fulfill NHS criteria. Community pharmacy had to
have a clear status and position in the system. Reimbursement of the services would have to be specified.
The administrators saw the value of extending private pharmacy services as it would increase the accessibility
of the patients to another dimension of health care. Accredited pharmacy services may be an option for
increasing patients’ accessibility to health. To be successful, the administrators said that every stakeholder
would have to take part in his or her own roles according to the context. However, every partner would
have to aim for benefiting the patient, as the system is patient-centered.


Influenza is one of the most important respiratory infections of humans; it is responsible for an
estimated half million deaths worldwide each year. Recently, the influenza pandemic caused by a new
strain of influenza A (H1N1) 2009 virus was declared by the World Health Organization, whereby the
pandemic level has been raised from phase 5 to phase 6, as defined by a widespread human-to-human
transmission and sustained community level outbreaks in more than one region of the world. The guidelines
for prevention include routine recommendations on basic personal hygiene and annual vaccination,
which by far is considered the best possible method of prevention especially for high-risk populations.
Influenza vaccines, mostly trivalent, are indicated for the active immunization of individuals against seasonal
influenza caused by influenza viruses subtypes A and type B contained in the vaccine. However,
the protection is transient and yearly immunization is thus necessary. In addition, the antigenic changes,
i.e., antigenic drift and antigenic shift, in influenza viruses necessitate yearly surveillance for emergent
strains and incorporation of such strains into the current year’s vaccines. At present, two types of vaccines
are available, namely, inactivated (killed) vaccines administered by injection and cold adapted, liveattenuated
vaccine administered by nasal inhalation. This mini-review provides a brief description of
influenza vaccines with respect to their types, composition, method of manufacture, indication and usage;
a list of USFDA-approved commercial vaccines is also included.


Health care reform movements in Thailand have occurred during three main overlapping periods.
The first wave of health care reform focused on increasing the geographical coverage of the health care
infrastructure, while the second wave focused on reforming health care financing mechanisms. The third
wave shifted its focus to strengthening primary care. This paper is aimed at exploring the third wave of
health care reform in Thailand using literature and document review. It was found that, among five areas
of reform initiatives to strengthen primary care, there was an imbalance of investment in the primary care
infrastructure and capacity building of health staff. An insufficient number of health centre staff, along
with their limited capacity, is a major constraint affecting the ability to improve health centre performance.
The development of a referral system has been neglected and could reduce confidence of the
people in primary care. Although health care financing reform has improved financial status of the health
centres, it still needs continuous development in order to promote the responsibility and productivity of
health centre staff toward its registered population. Finally, there is a need to develop and adapt the
concept and practice of family medicine to fit with the country-specific context and to promote it to be
well recognized by the general public as well as by physicians. New challenges for the development of
primary care in Thailand include its governance system, in the context of health care devolution, and the
provision of health services for chronically ill patients and the elderly.


This research is a matched case-control study, the objective of which was to determine the association
between couples’ alcohol consumption and the violence of husbands against their wives, in Khon
Kaen Province. A structured interview questionnaire was used to elicit data from 47 women attending the
One- Stop Crisis Center of Khon Kaen Hospital, who experienced violence at the hand of their drinking
husbands. Ninety-four married women living in the same neighborhood and in the same age group
served as controls. The results revealed that non-drinking wives whose husbands drank alcohol and
drinking wives and husbands were of risk of spousal violence (4.27 times (adjusted OR=4.27, 95%CI=1.10-
16.62) and 8.55 times (adjusted OR=8.55, 95%CI=1.75-41.90) respectively), compared with non-drinking
couples. Drinking more than five glasses (adjusted OR=4.17, 95%CI=1.14-15.28) and substance abuse
(adjusted OR=3.97, 95%CI=1.04-15.07) were also significantly associated with spousal violence.
In conclusion, alcohol consumption is an important activating factor in spousal violence.


The global temperature has increased by 0.74 ± 0.18 °C (1.33 ± 0.32 °F ) during the past century. The
same period has seen an increase in natural disasters and disease outbreaks. Reviews of the evidence of
links between climate change and human health suggest that a warmer climate could result in increases in
mosquito-borne diseases like malaria due to increased reporting of malaria cases in temperate climates
and malaria epidemics in upland areas. Within the range of survivable temperatures, warmer temperatures
reduce the duration of the extrinsic cycle of malaria parasites in mosquito vectors. Therefore, higher
temperatures should result in higher rates of malaria transmission. Mathematical-model estimations suggest
that more deaths will be attributable from malaria. However, during the past decade, the number of
malaria cases has not changed markedly, with 300-500 million cases per annum and > 1-3 million deaths.The complex natural history of malaria transmission involves interactions between humans, anopheline
vectors, and malaria parasites. Many different factors influence these three primary components, including
climatic, ecological, environmental, socio-economic and human behavioral factors. Thus, malaria transmission
may not simply be affected only by global warming; the relative importance of all the factors
involved should be considered jointly. Measures to control malaria–developing new preventive methods,
improving diagnosis, more effective treatment should all be encouraged and supported. An analysis of
the impact of global warming on malaria has implications for the effects of global warming on other
disease outbreaks, i.e., that they may not occur, or if they do, they may not be as serious as some predict.
However, disease surveillance systems must be closely monitored by epidemiologists if global warming
persists. There is an urgent need for ongoing public debate regarding what, if any, action should be taken
to reduce future global warming, and the development of more holistic information about the epidemiology
of disease in this context.