This research aims to study an impact of economic crisis towards private hospital sector and their copying mechanism.  Methodologies used were document research, questionnaire survey on throughput to 75 sample hospitals, in-depth interview of medical and non-medical directors and practicing physician in sample hospitals, financial analysts, key member in Private Hospital Association and related key policy makers. The response rate of questionnaire survey on sample hospitals and their financial statements and in-depth interview of private hospitals were 38.6%, 82.6% and 41.3% respectively.  In 2001,diffusion and utilization of private sector was crowed in central region and Bangkok, the capital city of Thailand.  Hospitals having more than 50 beds absorbed a large share of private hospitals at 53.37%.  Private hospital statistic services presented 4,569 of inpatients visit per hospital, 181.94 of outpatients visit per day per hospital and 38.76% of occupancy rate. The number of both inpatient visit and outpatient visit decreased during 1996-2001. In 2000, 72.09% of private hospitals registered as company limited and public company limited.  Source of fund were from local investment. Their operating loss per hospital was at 9.5 million Baht.  However, large hospitals ((200 beds) had operating profit at 20.58 million Baht. About one third of private hospitals, 35.48%, had positive working capital and current ratio.  Thought large hospitals had surplus working capital, their current ratios were better than other hospitals. There were ten hospitals registered in Stock Exchange of Thailand (SET) excluding three hospitals needed debts restructuring because their operating were under requirement of SET.  Income (sale revenue) and cost from providing medical services and operating profit tended to increase continually in hospitals registered in SET.   During economic crisis, however, they started to be difficulty with loss net profits.  They coped with crisis by organization and/or debts restructuring leading to positive net profit in 2001.  Since private hospitals invested more in fix assets than in equities their efficiency ration was > 1.0 and affected their working capital during the crisis. Economic impacts toward private hospitals were decreasing in number of inpatients (76.99% of total private hospitals) and outpatients (69.33%).  Small hospitals were affected more than large hospitals. Decreasing in consumers’ purchasing power and civil service medical benefit scheme affected hospitals having main revenue from out-of-pocket.  They had to lower ward services and be contracted hospital in Social Security Scheme. All private hospitals had interest burden especially in 1998-2001. Interest burden varied with the hospital size.  The larger hospital was the more interest burdened. Private hospitals’ copings to economic crisis were down sizing and permanent shutdown.  One year after crisis, 6 hospitals downed sizing and 43 hospitals shutdown.  Number of medical and non-medical staffs decreased insignificantly but they received lower return.  Most private hospitals increase their revenue by launching delivery package and medical check up.  New competitors were hard to entry to the private hospital industry due to high investment e.g. investment in technologies and medical staffs.  This let purchasers had more purchasing power.  Media, private agencies and government agencies tried to increase purchasing power through legislate regulation and laws e.g. declaration of patients rights. Competitive form among private hospitals were establishing public image through providing medical care by high expert physician.  Expanding market by penetrating service to middle to higher economic group was conducted.  External environment e.g. National Health Act, National Security Health Act, policy on center of regional health provision and Trade liberalization may affect the performance of private hospital sector. We recommend having share resources between public and private sector, defining number and size of hospitals according to health needs are policy recommendations.  There should be quality control of medical care under capitation, establishing organization to suggest investment for new entries and more coordination between public and private sectors in making policy decisions. Quality insurance program should be implement impartially between public and private sector by focusing on ultimate customer protection.


Objectives: To develop and institute a methodology for the study of anesthesia related adverse outcome in 20 hospitals in Thailand: 7 university hospitals, 5 tertiary hospitals, 4 general hospitals and 4 district hospitals.Methods: The Thai Anesthesia Incident Study (TAIS) was prospectively conducted by collecting data of all consecutive anesthetics in preplanned structured data entry form (form 1). The database including patients demographics, anesthetic, surgical factors and anesthesia related adverse anesthetic records and hospital charts and interview attending anesthesia personnel. Data were collected and entered by double entry technique and analysis of outcomes determined for preoperative intraoperative and 24 hours postoperative periods.Results: The 86265 patients were take care by anesthesia personnel. The mean (S.D.)age, weight and height of the patients were 38.5 (21.4) years, 53.2 (18.4) kg. And 146.6 (38.5) cm. In this study 87.5 % of patients were classified as ASA physical status 1 or 2 and 31.2 % were in emergency setting. The six most common choices of anesthesia were general anesthesia (61%), spinal anesthesia (23.3%), total intravenous anesthesia (5.5%), monitor anesthesia care (3.4%), brachial plexus block (2.9%) and epidural anesthesia (1.2%) respectively etc. There were 53 cases (0.1%) of cardiac arrest and 17 cases (0.02%) death within 24 hours due to all etiologies. The common respiratory adverse events were desaturation 123 cases (0.1%), difficult intubation 83 cases (0.1%), reintubation 26 cases (0.03%) and esophageal intubation 19 cases (0.02%). Other important adverse events were coma/CVA/convulsion 9 cases, myocardial ischemia or infarction 8 cases, anaphylactoid or anaphylaxis 9 cases. The systemic events were 10 cases of drug error, 18 cases of equipment malfunction or failure, 5 cases of anesthesia personnel hazard, 6 cases of unplanned hospital admission and 27 cases of unplanned ICU admission.Conclusion: This was first large anesthesia epidemiological data which can be implied to anesthesia practice in Thailand. The rates of cardiac arrest and death within 24 hours due to allKey words: anesthesia, complication, adverse events. Cardiac arrest, death


This report is part of the research project “Monitoring and Evaluating Universal Health Care Coverage in Thailand” The report summarizes major changes and adjustments in the three major schemes in the Fiscal Years 2002-2003, namely, (1) Civil Servant Medical Benefit Scheme (CSMBS), (2) Social Security Scheme (SSS) and Worker Compensation Fund, and (3) 30 Baht Scheme. The study also look into the Car-accident Compensation Scheme, which could be considered a supplemental scheme.	CSMBS provides health care benefits to government officials and their dependent (parents and up to three children) The scheme covers roughly 4 million people and the cost is 26 billion baht for 2003. The payment mechanism is retrospective fee-for-service. During the past 13 years (1988-2001), the program cost has increased six-fold, averaging 15 percent per annum. SSS is primarily a compulsory scheme that covers about 8.3 million private employees in the formal sector. The scheme imposes mandatory social security taxes from the employer, employees, and the government, to the social security fund, and provides health care benefits to the insured as one of its seven benefits. Health care cost for work-related accidents and injuries are paid for by the Worker Compensation Fund, which is also administered by the Social Security Office and collects premiums solely from the employers. Those insured by the SSS can choose a hospital listed as the main-contractor. The payment mechanism of the scheme to the health care providers is mainly prospective per capitation. (The Worker Compensation Fund pay the hospitals on fee-for-service, but with a ceiling per accident or injury). So hospital-based data suggest that the number of outpatient visits increased substantially in 2002 and continued to rise in 2003. The number of admissions and inpatient day also increased in both years. The utilization rate of outpatient for those who eligible for the 30 Baht scheme-except for those who were originally from the HWPLID—is lower than those in SSS and CSMBS (except in the Northern Region where those in the 30 Baht Scheme have the highest utilization rate for outpatients). As for inpatients, those in the 30 Baht Scheme had an admission rate higher than those in SSS, but clearly lower than those in CSMBS who had the highest rate of admission and the highest length of stay. Those in the 30 Baht Scheme had the highest referral rate, but part of their increased visits and referrals could be caused by the regulation that a patient has to seek care from the designated hospital first.	Since the three major health insurance schemes are unlikely to merge in the near future, there have been concerns on equity and overlapping coverage. Part of the overlapping coverage is due to incentive problem : multiple cardholders still benefit from having more than one card as there has been no one dominant scheme under which the benefit package is better than other schemes in every aspect. One plausible measure to solve the incentive problem is to elevate certain benefits under the CSMBS that are still below than those of the SSS and the 30 Baht scheme and also elevate certain benefit of the SSS that are still below that of the 30 Baht scheme. In addition, reform on payment mechanisms is needed to curtail health provider’s incentive in having double/multiple standards in taking care of patients under different schemes.


The reporting system of adverse drug reaction in medicine unit of Sappasittiprasong hospital by multidisplinary approach	The study intended to increase the efficiency of in-patient ADR reporting, that emphasized on moderate and severe cases. Multidisciplinary medical team had been established and run the quasi-experiment in 8 medicine wards. The variables were numbers of ADR case report compared with numbers of ADR case between before and after the experiment. ADR cases were assessed the causality by Naranjo’s Algorithm. The efficiency of ADR reporting was evaluated in 3 period time, followed at before study, 3 months and 8 months after implementation. The results were analyzed in descriptive statistics.Results:  Moderate ADR reports increase in term of efficiency, 0 % (0/12) before study to 75 % (6/8) after 3 month and 100 % (6/6) after 8 month. Severe ADR reports increase from 0 % (0/0) before study to 100 % (1/1) after 3 month but not found any case after 8 month. The number of moderate ADR reports increased 74 reports and severe ADR reports increased 16 reports after implementation of multidisciplinary team. Rare ADR and ADR occurred from new drugs were reported too.  79 patients were notified ADR history in those patient drug profile and advised them  to aware by themselves. In 2000, 149 ADR case reports have been reported compare with only 7 case reports in 1999.Conclusions:   Multidisciplinary team could improve an efficiency of moderate and severe ADR case reports and showed that this developed system trend to run continuously. So multidisciplinary team should be used in full system of Sappasittiprasong Hospital and should be studied in another hospitals in the next time. ADR reporting in the hospital should be run in more proactive manner.


Expenditure and Quality of Life Lost Due to Diseases Caused by Smoking	Objective: To evaluate the expense and quality of life of patients with obstructive pulmonary disease and coronary heart disease, their associated factors, and to estimate the economic and quality of life lost among these patients. 	Methods: Analytic cross-sectional study was conducted in 5 regions all over Thailand, Chiang Mai representing the northern region, Khonkaen the north-eastern, Chonburi the eastern region, Songkhla the southern region, and Bangkok including the outer skirt. The study population included male and female patients with clinical diagnoses of obstructive pulmonary disease or coronary heart disease, who self reportedly had smoked for at least 5 years (in the case of coronary heart disease) or 10 years (in the case of obstructive pulmonary disease), and who attended the hospitals as the out-patients or being admitted as the in-patients during the study period. The comparison group comprised of the general people or persons who accompanied patients to hospitals, who did not have any chronic diseases or disabilities. They were matched with the patients according to gender, age and place of residency. Data were collected between June and December 1998, by using a standard questionnaire and a record form containing questions on personal and sociodemographic characteristics, history of smoking and of the disease, direct and indirect medical costs and indirect costs. The WHOQOL-BREF quality of life assessing instrument was used to measure the subject’s quality of life. Data were presented with descriptive statistics. The patient’s expense and the quality of life lost compared to the compariron group were analysed by chi-squared test, exact probability test, t-test, one-way ANOVA, two-way ANOVA, Mann-Whitney-U test or Kruskall-Wallis test for univariable analysis. The multiple regression was used in the multivariable analysis to adjust for extraneous variables. 	Results: The total expenditure of treatment associated with chronic obstructive pulmonary disease were estimated to be 7,656.72 Baht per year per patient. There were no trends of change according to age, duration of illness, or disease severity. After adjusting for gender, age, education, occupation and income differences, patients with chronic obstructive pulmonary disease were paying 7,520.65 Baht per year more than the comparison subjects, or 431 times as much. The costs were estimated to be 4,114 million Baht per year for the patients all over the country. When added to 8,297 million Baht per year paid by the civil sectors, the total costs were 12,411 million Baht per year, which approximated 0.27% of the gross national product, or 4.40% of the national expenditure on health in 1998. The quality of life among patients with chronic obstructive pulmonary diease scored fair, and was poorer than that of the comparison subjects in every way, except for the environmental domain. The quality of life worsened according to the disease severity, but was unchanged according to age and the duration of illness. Patients who became ill at the age of below 50 years were estimated to loss 11.07 years of quality adjusted life throughout their illness. The total expenditure of treatment associated with coronary heart disease were estimated to be 17,746.44 Baht per year per patient. There were trends of decreasing according to age and the duration of illness, but increasing according to the disease severity, and in patients classified as having a heart failure. After adjusting for gender, age, education, occupation and income differences, patients with chronic obstructive pulmonary disease were paying 14,767.06 Baht per year more than the comparison subjects, or 164 times as much. The costs were estimated to be 840 million Baht per year for the patients all over the country. When added to 14,060 million Baht per year paid by the civil sectors, the total costs were 14,900 million Baht per year, which approximated 0.32% of the gross national product, or 5.28% of the national expenditure on health in 1998. The quality of life among patients with coronary heart disease scored good and fair, and was poorer than that of the comparison subjects in every way, except for the environmental domain, in particular items related to income adequacy, extense of information and health service received, and travel convenience. The quality of life worsened according to the disease severity, but improved according to age, and was unchanged according to the duration of illness. Patients who became ill at the age of below 50 years were estimated to loss 9.19 years of quality adjusted life throughout their illness. 	Discussion: The direct medical costs of treatment were the major component of the total expenditure. Decreasing the cost of medical service should therefore, lessen the economic burden of these patients. Some of the expense were used for travelling in the seek of treatment in distant localities. Increasing the diagnostic and treatment capacity of the local hospitals to meet with the standard and with the patients’ acceptance should reduce this portion of expense, through the decrease in the number of patients seeking health care in hospitals located in large cities, including Bangkok. The direct non medical costs mostly comprised of travelling and food expenditure and the lost of income of persons accompanying the patients. By referring patients back to their local hospitals, these cost should be reducible. The patient’s quality of life worsened according to the disease severity. Rehabilitation programme which has an impact on the patients’ cardiac, pulmonary and vascular function, and which is manageable at domestic level, should be considered in order to decelerate the above mentioned worsening quality of life.


Potential of Women Society for Aids Management	AIDS patients tended to be stigmatised by society resulting their broken families. AIDS crisis reflected inability of public organisations and people’s understanding to cope with AIDS. Social movement for AIDS was an interesting activity to handle such a crisis. A number of AIDS / HIV female patients associated together with objectives to manage AIDS problems for AIDS women in northern region. This study was to explore women ability of doing social movement in two issues. The first issue was grouping and developing its task groups for managing AIDS problems for northern AIDS women. The second issue was developing its potential and ability for AIDS management. 	Qualitative technique was used in this study. 3 studied groups were AIDS / HIV female patients, women society for community development and female members of local administrative organisations. The study found that awareness of problems and their impact was a driving force for women to gather into society and possess civic consciousness. Management potential and ability were largely developed and promoted by NGOS instead of public organisations. However, the infected group’s flexibility to manage their own issues was limited due to little confidence received for their management ability which were perceived by the NGOS while the second group, the community development society was given more flexibility for AIDS management. The second group then became the consultant for the first group. 	A lack of civic consciousness in members of local administrative organisations was a significant inhibitor for AIDS management in local areas. Their concern was more on development of community infrastructure which led to less budget for AIDS management. It is recommended that developing more concrete working partnership in these three groups should be put into practice.


The Cost per Unit of Health Services in Health for All:  a Case Study of Health Service Center (No. 16)To illustrate the cost of services in health promotion and prevention , out patient (OPD) and dental care through a Health Service Center (No.16) Bangkok Metropolitan Administration. The analysis of the cost components could be used as key data for future planning, budgeting and resources preparing for the short and long terms.The cost centers were categorized to be executive, services and supporting unit. The simultaneous  equation  method was employed to allocate all costs from other associated cost centers to the service unit.The unit cost per visit was  372.76  baht, while the unit cost per capitation was  532.83  baht . The unit cost of health promotion and prevention per capitation  was  288.95  baht, whereas the unit cost of OPD per capitation   183.47  baht and the unit cost of dental care per capitation  55.37  baht. The labor cost accounted for 83.67  per cent, capital cost  6.09  per cent and material cost  10.24  per cent of the total cost.  Unit cost of OPD and dental care was lower than the proposed budget while the unit cost  of health promotion and prevention was higher. That could because of some patients seeking the OPD care from the King Chulalongkorn Hospital, while the health promotion and prevention offered was more than other Health Service Centers provided. The labor cost was the main factor to be improved for more efficient and the decrease  of labor cost would be in the short and long term strategies respectively.


A Situation on Environement and Health  in Thailand	The population of Thailand has increased from 26 million to 62 million in the past 40 years. The increase had led to tremendous activities in economic and social development such as the development of land, agriculture and farming, fishery, energy, industries, transportation and tourism. These developments resulted in climatic change and environmental problems including physical chemical biological and social environment. Unplanned industrialization and urbanization, and the influx of rural population into cities had created environmental pollution and social stress in those area. Bangkok, the capital city with an estimated population of 10 million, and provinces in vicinity are facing problems of air, water, land, and noise pollution, hazardous substances and waste, food hygiene, unsafe housing and workplace. These environmental pollutants may enter human body either by eating, breathing, or skin contact. Health impact may vary from annoyance to discomfort, mild symptoms, severe illnesses, injury, disability, or death, depending on several factors such as type and amount of pollutants, exposure time and route of entry. 	Mortality statistics of Thai population during B.E. 2534 – 2541 indicated that hearth disease was the highest cause of death throughout the period, followed by cancers, accidents, poisoning-intoxication, blood hypertension and stroke, injury/suicide/murdered, pneumoconiosis and other lung diseases, liver and pancreas diseases, and kidney disease.	For infectious diseases, the highest illness was diarrhea, followed by pneumonia, hemorrhagic fever, food poisoning, malaria, salmonellosis-shigellosis, influenza, tuberculosis, sexually transmitted diseases, and measles.	Among these leading deaths and illnesses, there are several diseases that could be caused by exposure to either individual or multiple pollutants of physical, chemical, biological form and social factors. However, it is always difficult to pin point the exact causative environmental or social factors. This is due to the incomplete or unknown exposure history and the complexity of dose-response mechanisms of those factors on physiological change and etiologies of diseases, cancer, for example. Nevertheless, the results from animal studies could be cautiously extrapolated to human for the sake of prevention and control of adverse health effects and sustainable socio-economic development.


Process and Outcome Study on Rehabilitation Service for Hemiplegic Patient Causing by Stroke at the Sirindhorn National Medical Rehabilitation Center Stroke or Cerebrovascular disease (CVD) is the main leading cause of health problem among Thai population.  The advance medical technology help the stroke victims to survive longer with another kind of problem, physical impairment and disability.  Rehabilitation is another health care intervention which play a major role in restoring physical function and supporting them to return to their own home.	The study objective is to analyse the process and outcomes of the in-patient stroke rehabilitation of the Sirindhorn national Medical Rehabilitation center.  It was found that stroke with hemiplegia took about 25 percent of the total nuber of admission.  One hundred and thirty-seven stroke victims were admitted 166 times within five years (fiscal year 1995-1999) while 111 admissions (cases) was recruited.	Among 111 cases, the ratio of male:female was 3:2 whereas the mean age was 60.67+11.96 years (95%CI.= 58.42-62.92 yrs.).  Those were left hemiplegia 2-3 times more than right hemiplegia.  Seventy-five percent of those could be determined the type of CVD which showed that infarction is 2 times over than haemorrhage.	The average length of stay (LOS) was 44.22+28.36 days (95%CI. = 38.88-49.55 days) while 7 and 150 days were used as the trimming points.  When the trimming points were substituted with 13 and 84 days, the average LOS became 42.31+19.11 days (95%CI. = 38.18-46.43 days)	According to the outcomes study, 13/48 cases of the year 1999 were recruited.  It was shown that 10/13 cases were partial independent in performing the activities of daily living while 7/13 cases could walk independently.  Moreover, the qualitative data of 4 selected cases pointed that they are still seeking for the treatment and rehabilitation which might cure the disability.  Most of the costs for such a health care process were the family's out of pocket money.	The results of the study revealed the deficiency of the health care system such as; lacking of the standard of stroke rehabilitation service, non-systematic and unreliable medical record, lacking of the outcome measures for monitoring and evaluation etc..  It was suggested that the quality improving process should be implemented especially at the Sirindhorn National Medical Rehabilitation center, the only national medical rehabilitation institute in Thailand.


Core Package for Oral Health Care on Universal Coverage Policy, Thailand The purposes of this study were to review knowledge, concepts and experiences of the core package for oral health care, and to recommend the proper core package for oral health care in Thai context which was applicable and fit with needs of the oral health care. The study was conducted by reviewing literature, evaluating sample province and stakeholders’ opinion discussing.Results of the study, Pathumthani, sample province, had more dental patients since the Universal Coverage policy had started. For example, tooth filling, scaling, and extraction had increased 25.3%, 25.1%, and 16.2% respectively. However, waiting list or queue was also increased for instant, there were 164 dental substitution cases and 136 root canal treatment cases in February 2002. The focus group discussion of providers found that there were some problems of policy implementation such as unclear definition of package, increase in the number of patients, and management. The focus group discussion of consumers, another side, demanded for kinds of services which could alleviate pains and restore ability of chewing. Delphi stakeholders meeting prioritized all of services into three groups: 1) The first priority (4.8-5.0 score): Topical Fluoride, Systemic Fluoride, Periodontitis treatment, Celt lip & palate, Oral cancer, Oral infection, and Amalgam filling.2) The second priority (4.0-4.7 score): Scaling, Sealant, Oral patho, Full denture, Root canal treatment, Impacted tooth, Oral health examination, Consulting, Extraction, Pulp treatment in primary teeth, and Tooth-colored filling. 3) The third priority (less than score 4.0): Partial denture, Crowding teeth, and Fixed denture.There were three alternative concepts of the package establishment: 1) Full Treatment Need, 2) Treatment Need with some conditions, 3) Treatment Need by age groups (for example 0-13 age group: Fluoride, Sealant, Oral Exam, Amalgam filling, Root canal treatment, Extraction, Pulp treatment, Oral patho, etc / 14-59 age group: Fluoride, Oral exam, Scaling, Periodontitis, Amalgam filling, Root canal treatment, Impacted tooth, Extraction, Oral patho, Tooth-colored filling, Acrylic partial denture / 60+ age group: Fluoride, Oral exam, Scaling, Periodontitis, Amalgam filling, Extraction, Oral patho, Tooth-colored filling, Full denture, Acrylic partial denture). These options were subject to budget, manpower and capacity of services.  For policy establishment, there were some suggestions from the research: 1) the third concept was suitable for resource scarcity, 2) co-payment mechanism was a method to control over demand side, 3) condition of treatment care could increase awareness of self care, 4) some treatments with high cost and chair time might not suitable to be in package such as fixed and metal denture, 5) well-organized system of queue, referral system and finance were required. This research may contribute to improve oral health care service. However, it’s needed to have further studies such as, cost of services, public-private mixed service, consumers’ behavior, etc.


Health promotion service is the most important component of the Universal Health Care Coverage Scheme. However, many evidences suggest that its quality could be directly and indirectly impaired, mainly because of capitation payment mechanism. Consequently, quality assurance system is necessary. Most of the national quality assurance systems in Thailand concentrate on curative care instead of health promotion. However, there are a number of quality assurance initiatives in many provinces. In order to set up the efficient system, extensive review of the current situation and ideal solution should be conducted. In this study, literatures regarding quality assurance of health promotion services will be analyzed. Information on existing and expected quality assurance system and factors affecting the quality of health promotion services will be gathered by in-depth and focus-group interview of system experts and medical personnel at the operational level in five provinces—Bangkok, Ayuthaya, Chiang Mai, Nakornratchasima, and Pattani. It can be concluded that quality assurance system of health promotion services is essential. The system should help improve the services by using positive approaches and can merge with some existing quality assurance system. However, there is diverse comprehension among system experts and health care providers regarding the principles and responsibilities of health promotion services. This results in varieties of provincial quality assurance system. Factors that can impact the quality assurance system of health promotion can be categorize into four major aspects—principles and policy, budget, providers, and target population.


Project for potential development of high risk students for drug addiction in a large secondary school of elementary education department	The aim of this project is to develop student potential for avoiding drugs taking  by involving various groups of people in and outside school.  This project is just only first step of all the process.  It is just to get present situation and means to solve the problem from the various groups of people.	The project started with development of researchers of the two institutes;  Khamkaen Nakorn  secondary school  and  DRC in Khon Kaen province.  They were learned and practiced how to use PAR for data collection from the PAR experts in Khon Kaen university.  From this process,  the researchers were changed their  idea and concept for solving the problem.  They are more positive and more understanding the students’ problem and trying to help them.	Data were also collected from parents and community where students live.  This process make teachers and community  cooperate and coordinate in solving the problem.  Previously parents thought that it is not their role and it is  teacher’s duty only.  After focus group discussion, parents and community understand that they have to work with teachers.  They suggested that all should have common activities.	From this study it is found that PAR is very important tool in changing the ways of thinking in all groups but it takes time and money.  However, the process is still needed to get a suitable development.  So the second phase of the project should be developed and launched soon.


School Effects on Children’s DevelopmentIn order to study school effects scientifically, researchers are required to do randomized controlled experimental studies, which is not possible in practice due to ehtical problems. Therefore, schools have to be studied in their natural settings. For instance, one could study the difference in outcomes between term-time and summer break. In addition, one can use sound research methodology with powerful statistical analysis to study the difference between effective and ineffective schools.The  question one should ask in measuring school effects is the outcome of the effects. Research has, by and large, looked at academic achievement like reading  or math abilities as outcomes. However one can also study other outcome variables such as classroom behaviour, attitudes towards learning, self esteem, attendance rate, continuation in education, employment, social functioning, etc.School Effects on Cognitive developmentSchool Effects on general intelligenceStudies have shown that every missed school year is associated with a loss of 0.25-6 IQ points. Cross- cultural studies have shown that there is a difference in IQ between children who attend schools and those who do not. Studies in both developing and developed countries have shown that schooling is associated with gains in cognitive development. Forced closure of schools as a result of war or political problems has been followed by IQ decrements of about 5 points and continued schooling later is associated with an IQ gain of 5-7 points.School effects on academic achievementStudies have shown that children regress in their academic attainment during summer holiday especially for the disadvantaged children. The evidence for school effects  for secondary level is that the differences between the best and the worst schools, after controlling  the intake variables, are in the order of 1 SD in their level of academic attainment.Classroom influences, like teaching and learning processes, quantity and quality of teaching, are more powerful in affecting academic outcomes than non-classroom factors such as school buildings, the number of books in the library, ie learning resources are not as important as teaching and learning processes.Mechanism of school effects on cognitive developmentThe mechanism is likely to be that there is an interaction of experiences and children’s self- concept. This will make children have good attitudes, self-esteem and desire to learn actively. Learning how to learn is as important as the contents of learning. When children have good attitudes, self-esteem, desire to learn, adaptive styles to teachers and parents, these qualities will enhance their level of cognitive development.	Pre-school education brings about chains of changes in that it may open up or close down opportunities. The effects do not result from direct cognitive gain but favorable attitudes; good self-esteem and adaptive leaning styles will increase children’s opportunities, leading to increasing cognitive development.2. School Effects on Self-Esteem 	Schooling experience greatly affects children’s self esteem. Children who start with success will have better self-esteem, which will lead to further success. They would have more inspiration and motivation to learn, more achievement-oriented behaviour. So the ranking of their performance, marks, behaviour, teachers’ expectation- these will affect self-esteem. Vulnerable and disadvantaged children will benefit from good schooling experience. This can improve their self-concept and happiness, which will act as protective factors for their future.3. School Effects on Emotional and Social Development	Schools are a context for children to develop emotionally and socially. In order to understand school effects on emotinal and social development, one has to consider:Individual vulnerabilitiesSchool climateLow achievers are shown to have more emotional and behavioural problems. They may not like the school , leading to association with troublesome company and wrongdoing. Studies have shown that children with hyperactivity or attention deficit are at risk for rejection by peers and teachers, leading to feeling of shame and dislike for the school. When they reach middle childhood, they will have a sense of failure and poor self-concept, eventually leading to withdrawal, avoidance, depression or other emotional problems.School climate has an effect on children’s behaviour such as on-task behaviour in the class, delinquency rate, psychiatric disorders and use of alcohol. Conflicts and disharmony in schools are associated with attention problems, aggression and oppositional behaviour in children.One of the main problems in schools is bullying and victimization. Studies have shown that ex-vitims are associated with low self-esteem and depression. Severe and corporal punishment by teachers is associated with the use of violence in children.


Germany was the first country to institute nationwide insurance-based social and health programs. Three powerful ideas or principles underlie the development of German health insurance and medical care policy, Solidarity, Subsidiarity, and Corporatist organization.   The main roles of government (State and Federal governments) are providing legal framework and regulation while providing of services and insurance are delegated to self-governance agencies, sickness funds, various associations (Association of Sickness Funds, Association of Panel doctor, etc), and health care carriers.The German reform aimed to achieve overall social benefits. Enactment of laws achieved universal access to health care and delegation of public roles to various self-governance bodies enable accountability and transparency of the system. The later reforms intended to control increase of medical care cost to be not exceeding level of income growth and more emphasized on controlling provider and hospital behavior. By conclusion, success of the German health system reform is according to values and principles of the society while economic, political context and increase of health care expenditure determine the need for reform.


This situation analysis of health promotion and oral disease prevention in the contracting unit of primary health care under the health care coveraage insurance  policy is a qualitative study. The sample consisted of 48 contracting unit of primary health care located in 8 purposively selected studied areas which are Chiangmai, Nhan, Khonkhane, Bureerum, Songkla, Phattalung, Prathumthanee, and Bangkok. The depth interview using semi-structured questionnaire and the observation techniques were used in the stage of data collection. The respondents were the executive officers, those who involved in the health care service under the health insurance for all policy at the province level, dentists, dental hygienists, and resident population. The study period is between July, 2002- March 2003. The summary is reported as followed. The result of this study was the dental benefits specified in the insurance are conformed with the existing dental service provided prior to the insurance program. These include the general dental treatment such as filling, extraction, scaling, root canal treatment, and prosthodontic treatment, and also the heath promotion and prevention activities such as screening for the high risk group, oral health education, dental sealant and fluoride therapy. The main target groups for health promotion and prevention program are the pregnant women attending ANC, preschool children in WBC and child care centers, primary school children and the elderly. But the activities were decreased  because of the increasing of the treatment for dental care in the CUP, approximately 15-20%.  Most dentists were lack of understanding in the concept of health promotion and skill in empowerment for the people to take care themselves. The other workload in the hospital, such as , hospital accreditation activities, were the condition for dentists to step down their oral health care promotion and prevention activities.  However, most of them still had a good attitude for the principle of the health care insurance project, but they were not agree with the propaganda on the “ 30 bath for all treatment “.


This cross-sectional study aimed to investigate the effect of management factors the implementation of health promotion and disease prevention in the Universal Coverage Health Insurance Program. The study was conducted in 61 Contracting unit for Primary care (CUP) among 118 CUP of all 7 provinces  of  Regional 6. These provinces are Khon Kaen, Undornthani, Nongkai, Skolnakorn, Loei, Kalasin and Nongbualampoo.  The qualitative methods were applied for data collection.	The results revealed that in The 2002 Fiscal Year, all 7 provinces of regional 6 followed the health for all policy of the Ministry of Public Health closely.  Some  provinces modified organization structure of the division responsible for this task, some province added more unit or additional committee. Each province set up PCU to provide curative, health promotion, disease prevention, rehabilitation and dental public health with proactive work based on family medicine principle. However, there are slightly difference in focus point of this policy which came from different basic thinking of administrator and previous health promotion work. There was adaptation of concept to be based mainly on benefit package. Additional works which clearly showed were family file, house call, and exercise. There was personnel distribution form provincial level to CUP including sending new nursing graduates to work at PCU in some provinces, There were personnel development, budget allocation for health promotion and disease prevention based  on individual card or proportional budget resulting in more budgets for both CUP and PCU and additional supplies for PCU and health center if compared with before project implementation. However, there were still some problems with finance regulation, not much public participation, communication of officers about health promotion. The outcome depended on concepts and supports of chairman of primary health care network which majority of them are still focused on curative rather than health promotion and discase prevention. Budget allocation to PCU had important problem from conflicts between hospital directors and public health district chief. However, there was overall increase in health promotion and disease prevention. Some CUP had project to analyze try to help solving community problems. 	In 2003 budget year, fix cost distribution of budget helped reduce the conflicts between PCU and hospital director and easier implementation, but it reduced incentive to write project to do the work that suit the area. The policy of the Ministry of Public Health to carry out health promotion and disease prevention by separating activities and duration may not suit every area. The reduction of budget allocation to the provinces in the Northeast effected health promotion work especially exercise.


The Project on the Dissemination on and the Campaign for Public Policy in Chiang Mai City is an action research project conducted by the Urban Development Institute Foundation (UDIF) supported by the Health System Research Institute (HSRI). Its objectives are: to disseminate information about public policy to the residents of Chiang Mai; to stimulate Chiang Mai residents to call for public policy that can solve their problems; and to propose their public policy to the candidates who run for the first elected mayor of Chiang Mai to be elected in February.  The study period of this project was from May 2003 to February 2004. This project was divided into 4 phrases.  The First phrase (May-September 2003) was to prepare for the campaigning process, to coordinate with the lecturers from other organizations joined as the campaign network.  They were from the Department of Architectural Technology, The Rajmongkol Technical Institute, Chiang Mai Campus; The Department of Geography, Faculty of Social Sciences, Chiang Mai University; and the Faculty of Nursing, Payup University. The first questionnaire was conducted to get baseline information to be used as one of the indications for the success of the project, to be evaluated at the end of the project.  We wanted to know whether the residents of Chiang Mai have clear understanding about public policy – what it is and who can form public policy of the city.  About 56 % of those who answered had correct understanding about public policy.  Moreover, people proposed several problems should be addressed as the city’s public policies to solve them.	During this phrase, a workshop was organized by volunteers who were students at high school and college levels.  The name of the workshop was “Yiea Ja Dai Jiang Mai tueng ja dee” meaning “How to make Chiang Mai (Jiang Mai) better?” The German “Objective Oriented Planning Process” (ZOPP) was used as brainstorming process.  Participants from various occupations, including academics, housewives, community leaders, non-government organization workers, private sector, media, people’s organization, elderly, etc., were invited.  Many socio-economic and physical problems were addressed at this workshop.  Our campaign process included the poster and essay contests on public policy and the direct election of mayor.  We hoped that information would be passed on from students to parents to raise their awareness. The Second Phrase (November – December 2003) we organized “The 3rd Oo-fuu Ruang Muang Chiang Mai: Oo Gun Bolaew Bohai Gup Nayobai Satarana” meaning public forum to repeatedly discuss about public policy.  This forum was to  collect information about the quality of directly elected mayor in Chiang Mai residents’ mind and the problems that people thought should be solved immediately.  Small group meetings and the campaigning with organized groups and individuals were done on the citywide basis. The Third Phrase (January-Early February 2004) was the time to launch  intense campaign for the first direct election of mayor of Chiang Mai.  Posters, leaflets, radio spots, banners, and handout were produced and disseminated to the public to announce the election day.  Voters were encouraged to exercise their votes and to consider the candidates’ healthy public policies as factors to vote for.  Radio time was bought to turn on the spot. The project hired some radio programs to turn on our radio announcements produced to invite people to vote on 1st February for the first direct election of mayor.  We also pointed out that the voters should consider public policies that each candidate offered whether they are healthy policies or not.  The second questionnaire was conducted during this period.  After the campaign on public policy and direct election of mayor was lunched several months ago, people have had better understanding about both issues and how they were related.  About 75% of the answer sets returned knew the date of the Direct Election of Mayor and had correct understanding about public policy.  About 49% of the answers said they would go to vote and the same percentage had no intention to vote.	Before the election, a public forum on “Direct Election of Mayor – Which Direction is Chiang Mai going?” was organized.  The aims of organizing this forum were to analyze urban problems and their impacts and the strengths and weaknesses of the existing mayor system.   	Formally before the election the “Ruam Duay Chuay Gun” (Let’s Help) radio program planned to invite all candidates to broadcast their public policies so that more general public knew their thoughts.  However, the Election Watch Committee banned this special program.  They were afraid that if the candidates presented their ideas which sounded like they promised to do something, it might be illegal. 	The 4th period (February – March, 2004) post election period.  This study was evaluated, analyzed and lessons were drawn for other cities.  Public policies that would solve critical problems were continuously presented to policy makers so as to implement them.  Final report was finished and submitted to funding agency.  	Extra activities were the co-organization of public forum on “Chiang Mai Muang Ngam and the High Rise Building” (Beautiful Chiang Mai and the Impact of High Rise Building).  The resolution of the meeting was to protest the construction project of the new Municipal Office.  Based on the health impact assessment, conducted last year, revealed that negative impacts high rise buildings caused on social, mental and spiritual impacts to Chiang Mai society.  In addition, we published the special issue of Chiang Mai Journal on the Cable Car Project to Doi Luang Chiang Dao to call for the ban of the project.     	After the election, our project joined the research projects of the Social Research Institute, Chiang Mai University namely the Study of People’s Participation in the Solving of Air Pollution Problem in Chiang Mai Urban Area and the Sustainable Cities Project in meeting with the governor of Chiang Mai.  The purpose of the meeting was to present information of the critical air pollution in Chiang Mai urban area and its health impact and call for strong action from the management.  	This project also organized a meeting on “Public Policy Which way is Chiang Mai heading to” to brainstorm about new public policy in Chiang Mai and the reaction of people’s organizations to these policies.	It is important to notice that statistics showed the decline of number of population and the number of voters due to more out-migration of the middle income families to the suburban area.  In general, Chiang Mai people are submissive and have no courage to argue with others or present their ideas to policy makers. Popular phrase has been “Let the other decide”.   	Those who have good quality but do not have much money dare not run for the election.  Every sector of the society agreed that those who run for any position MUST be using a lot of money.  This is due to the patron-client or superior-subordinate relationship.  Politicians are expected to support the poor voters all the time.  Because the voters were not satisfied with the quality of the new candidates, they did not vote for anyone regardless of the strong campaign calling for voters to exercise their rights to vote.  		The interview and the questionnaires showed that more people had correct understanding about public policy.  They knew that public policy was the policy that could give great impact to the whole society and was widely accepted by the public.  The Central government, local government units and people could all propose public policy.  More people had correct understanding after the campaign of the project than before the campaign was launched.      	Because we could not have exactly the same group of the citizens who answered both sets of questionnaire, the results would not be the only indicators to measure the success of this project.  Particularly when asked about the first directly elected mayor because of the different methods used in each questionnaire.  No matter what method was used, Boonlert Booranupakorn always came first on the list.  Other names on the list changed completely from the first to the second questionnaire.  It is interesting to notice that politician at national and provincial levels appeared on the list when we used open-end method, for example, Dr. Taksin Shinnawatr, Dr. Purachai Piamsomboon, Pakorn Boonranupakorn.  A majority of the answers did not put any name but stated the qualification of the mayor people desired to have.  These answers reflected that most people could not think of a person that they have always thought of or wished to have run for the local election or manage the city.	Five major problems, from both questionnaires and in-depth-interview, that people think should be solved are problems about youth, garbage, drugs and air quality.  It is noticeable that none of the policies announced by all candidates touch upon the youth and drugs problems which were both social aspects.  Most of them were concerned about physical aspects especially the traffic congestion.  Moreover, not very much economic aspect was pointed out.	The following are several reasons why the number of votes reduced from the last election.  First, none of the candidates had an outstanding qualification that touched the heart of the middle class or could attract the voters to vote for.  Even though there was a box that people could check if they did not desire to vote for anyone, most voters still thought it was a waste their Sunday pleasure for local politics.   They thought none of the candidates could improve the city or made a drastic change.  Second, many middle class migrated to the suburban area.  This trend reflected on the reduced number of registered population in the city.  Many of them might have social mind and were interested in politics, but they had no right to vote or run for the mayor of Chiang Mai.	Third, most people thought city management which were in their terms had already paid their ways to the position next term.  This included the regular study tours to other provinces for the community leaders, the all-year free gifts, the free drinking water for the funeral ceremony, etc.  People had tendency to think that their votes could not make a difference, therefore, why would they have to waste their time for the election.  Fourth, besides the Mayor Boonlert Booranupkorn, other candidates were unknown to the public.  This was because other candidates did not perform very much of the public activities.  Some only ran for the election and after they lost, they disappeared and then came back to the lime light again before the next election.  As a result, people never knew their management ability or the willingness to work for the public.	From interviewing the residents and many groups in the city, most people had no interest in the city problems - they only cared for their earn of living.  In addition, Chiang Mai local residents have had the mind set that Seksan Prasertkul called “Contractor mind”, meaning people would not fight for anything for themselves but waited for others to do for them.  In general people would be active only when the problems gave negative impacts directly to them.  Moreover, many people thought politics was a serious matter and had nothing to do to their lives that they did not want to pay attention to or get involved with.  No many people understand the connection of politics, management and public policy.  Some were interested in politics but dared not to criticize it.  They were afraid that their criticism might cause them some trouble.  Those small entrepreneurs along the streets were not very cooperative, partly because they were busy with their business, partly because they would be cheated by strangers.              	From the questionnaires, the most powerful media was the leaflets produced by the project, radio spot, information form others, newspaper, volunteers and the meetings. 	Even though the number of votes decreased from the previous election, it was because of the afore-mentioned reasons.  The number of votes should not be used as the only indicators of the success of this project.  There were more people who had correct understanding about the direct election of mayor, public policy and the importance of it.  The evidence showed by the increase of stakeholders joined in our meetings and activities.  Additionally, more media, academics and citizens have mentioned about public policy repeatedly.  Citizens have had more courage to push for the positive change of the city.     	“Nayobai Satarana” or public policy is a new, unfamiliar word that needs translation.  It is difficult for ordinary people to have clear understanding about the word.  Therefore, it is advisable to find a more simple word to substitute this word.  Simple Thai that is not rooted from Pali or Sansakrit is recommended because every group in the society should be able to understand the word without translation so that people will know that it is related to their well being and they should be concerned and call for healthy public policy. 	One of the problems we faced when conducting this project was the quality of those who applied to be our staffs and volunteers.  Most of them had no knowledge about local government, the old and new election system.  New generation has never paid attention to public policy or urban problems, therefore, they have had limited knowledge on the topic they would have to campaign for.  Therefore, it took time to train the staffs and volunteers.  Apart from the knowledge, the young generation has had no determination to work hard.  They want to get high pay but offer low performance.  Moreover, many of the volunteers were students and when the university opened, they had limited time to work on the projects regardless of the training they got.  Some students never join any student activities and had no experience to work with the community many people lack.  This could be the result of family upbringing, educational system, including the trend of the Thai society.  The young generation now has no patient because they always get something instant and quick.  Many of those who worked for the project had no patient, not torelent or common sense which were one of the major problems of the campaigning process. 	The residents had no sense of strong citizenship, particularly many of those who newly migrated to the city.  The new comers have no sense of belonging to the city.  Very few have good understanding about the city.  Traffic congestion and environmental degradation are something people expected.  They think every city must face all these problems.  They never heard that there are some well managed cities where healthy public policies have been proposed by all sectors of the society.   	There are three comments related to the role and performance of the Health System Research Institute that affects the performance of the project.  First, there were too many changes of responsible persons.  It was confusing who we should contact or seek advice from.  Second, the delay of transferring funding made it difficult to work in each phrase.  UDIF had to allocate some budget to keep the project continued.  Third, in practice there was no other two supporting teams as formerly planned.  Until the end of the projects the other two teams have not signed the contract.  As a result, there was no other team that would comment and give suggestion for the improvement of the campaigning process. 	Lessons for campaigning in other cities are: First, the project leader must spend full time for the project to be able to work continuously and efficiently. Second, the project must have a strong team work.  Third, the success of the campaign depends on the qualification of the candidates who run for the mayor.  Unless there is a charismatic and committed candidate, the silent majority will not go to vote or push healthy public policy through him.


Iron deficiency anemia (IDA) affects human quality of life impaired learning process, working abilities and natural resistance. This impairment is irreversible in some age group although iron status becomes normal. The prevalence data of IDA among young children is rare in most developing countries and different from country to country due to nutrition, child rearing pattern and genetic background. There is a mixtures of hemoglobinopathy genes in Southern Thailand so solving of IDA problem in Southern Thailand suspected to be a complex situation. How big the IDA problem in young children in Southern Thailand is not know and the natural nature of the population due to hemoglobinopathies involve in solving the problem. The special study of the nature and predictors of anemia is needed for proper policy formulation of this public health problem in southern Thailand.                A  community  study was designed to establish the prevalence and predictors of iron deficiency anemia in the pre-school rural children of Krabi province in Southern Thailand. Participants aged 1-4 years were selected by two–stage cluster random sampling , firstly random sampling the villages until get 30 villages and secondly random sampling ten participants from all children of each selected village.Children with history of chronic illness, malaria, prematurity, blood dyscrasias , acute illness and/or cured less than 2 weeks, iron supplement therapy with or without past blood transfusion during last 3 months and second to third degree malnutrition were all excluded. Three hundreds children between ages 1-4 years were identified belonging to this population. All participants should had their consent forms signed by parents to participate in this survey before the study activities started. Venous blood was measured for levels of hemoglobin and serum ferritin. Stool was collected to perform occult blood test for silent GI bleeding identification and Kato’s thick smear for hookworm ova identification. All of them had a full blood count, serum ferritin, hookworm ova and occult blood estimation performed. Data of sociodemographic characteristics (income, religion, parents’ education andoccupation) and child rearing was interviewed. Results: 28% of the sample are anemic (hemoglobin less than 11 gm/dl). The prevalence was highest among 2 years old children. Male among aged 1-3 years is found more anemic than  girl. The anemic prevalence reduced when children grew up. The severity of anemia is moderate. Iron deficiency  (serum ferritin less than 12 microgram/L) was found in 24.3% of this population, 53.6% of anemic children were (IDA), 46.4% were non IDA. Mean hemoglobin of the anemic children is 9.3 ( 1.3 gm./dl. The prevalence of IDA was significantly lower when the children ages increased (p = 0.006 ). There is no significant difference between both sexes. Muslim children had significantly higher IDA than Buddhist children ( p = 0.001 ). Hookworm and silent bleeding were not the IDA causes among this group ( Odds ratio 1.995%  CI = 0.0 - 21.6 ). This study is a new study of IDA prevalence among young children in Southern Thailand. Its finding confirmed that anemia and IDA is a public health problem among pre-school rural children in Southern Thailand. No need to set hookworm prevention program to prevent IDA in this young group because it is rare. There is 46.4% of non IDA anemia which should further study before setting policy formulation of anemia among this population group in Southern Thailand.


In 2001, the Health System Research Institute (HSRI) launched a research programme “Healthy Public Policy and Health Impact Assessment (HPP-HIA)” with an aim to develop an important component of the new health system in the future.   Recognizing that HPP-HIA was a new experience for the Thai society, the HSRI perceived the first three years of the programme (2001-2003) as a research and social experiment to test the relevance and acceptance of HPP-HIA in the Thai society, and as a first step toward capacity and institutional building.  The programme experience will help determine an appropriate approach in developing a HPP-HIA programme in Thailand.    The main purpose of the programme evaluation in 2004 was to facilitate the review of the experience, success, and constraints of the programme, and to consider future options.   The evaluation team’s mission was to conduct and facilitate “empowerment evaluation” to help the management and staff of the HPP-HIA programme reflect on past performance – and consider future options.  This participatory exercise was designed to maximize the opportunities for exchanges among all parties concerned, to plan for better programme performance, and to discuss development alternatives.	In advancing HPP-HIA, the programme has 4 strategies: (1) analytical framework, (2) institutional framework, (3) critical mass, and (4) enabling environment, which are expected to (1) facilitate social learning especially among civil society and community actors., (2) influence policy changes at national and local levels toward a healthy public policy, and (3) support the health reform movement.   	The four strategies were implemented through a system of networking.  The thematic (policy) networks consist of industry and energy policy network, water management network, agricultural and rural development network, urban and transportation network, natural resources and international agreements network.   The regional networks consist of the Northern network, the Northeastern network, and the Southern network.    The programme core team was responsible for overall management.  The programme also included the HPP knowledge development center and the HPP-HIA thesis programme at Chiang Mai University, both of which aimed to create and expand a HPP-HIA “critical mass”.	Findings from the evaluation indicate that:   The HPP-HIA programme’s strength lied in its role in pioneering the development and dissemination of HPP-HIA knowledge and practice in Thailand.   The programme management, staff and networks were highly dedicated individuals who were committed to work as a team.   As a result, the programme, within a span of 3-4 years, produced a large volume of works in various forms, namely research, policy papers, manual, training, workshop, newsletter, etc that covered a wide range of issues and geographical areas. The programme was successful in raising the awareness and the interest concerning HPP-HIA among academics, health personnel, and civil society groups.   HPP-HIA was perceived to have a good potential to drive policy and social changes.  But the programme had some limitations in networking with the public sector especially at the national policy level, and had less success in influencing policy changes at the national level.Although the programme outlined a set of strategies, it expanded at a very fast rate to the extent that it had spread itself too thin, and lacked a strategic focus.   This complicated the coordination within the programme and with other groups.In recent years, the programme encountered a number of problems due to personnel and budget constraints.   The situation called for a medium-term and long-term organization/business strategic plan.The followings were significant “new situations” that emerged during 2003-2004.HSRI scaled down the planned programme budget.  Other “HPP-HIA” programmes were set up, partly as a result of the programme’s success in promoting HPP-HIA.    This represented an opportunity for collaboration, but also called for a serious review of the programme’s positioning, mission, and core competencies, to maximize synergy and minimize overlapping with other programmes.  	The performance review and the situation analysis provided the background and context for the consultations and meetings between the evaluation team and the programme management and staff that took place throughout the evaluation period (January-August 2004).    The followings are results or ideas that play a role in shaping the future of the programme. The programme’s first mission will be HPP-HIA knowledge development and knowledge dissemination; secondary mission will be influencing and shaping HPP, which will be implemented mainly by providing policy advocate groups with the programme’s knowledge and practical experience about HPP-HIA.The programe will develop a medium-term and long-term organization/business strategic plan that includes resource mobilization.  HPP-HIA research and training will be more responsive to the needs of potential clients and the programme will explore the use of social marketing to support its overall operation.The programme will adopt a leaner and flexible structure.   It is possible that the programme will have only 2 work components, namely the regional networks, and the center which features the policy group, the knowledge management group, with administrative support.The programme will outline key strategic results and restructure the programme and work process as well as develop core competencies of various parts of the programme accordingly.The new work process calls for a common strategic focus and synergy among various work groups/network, while allowing adequate room for each group/network to tailor its work in response to local situations.   In the next three years, the regional networks should have the ability to drive the implementation all four strategies at the local level, with support from the center.   The center will focus on strengthening the programme by leveraging on existing outputs and driving the programme’s key strategic results.In medium-term, the programme aims to be an independent institute under the HSRI.


The objectives of this research were to evaluate the roles and problems of Subdistrict Administration Organization (SAO) in environmental health management. Study issues included the roles, capabilities and obstacles in solid waste management, village water supply management and DHF control. Data collection was done using a questionnaire self-completed by the secretary of SAOs of each of the 514 SAOs. 498 responded (96.9%). Site visitation and in-depth interview of executive board members and the secretaries of SAOs were carried out in 20 subdistricts. Data were analyzed using percentage, mean and standard deviation and content analysis. The results from the questionnaire showed a high level of complaints about solid waste (78.1%) than the problems of clean water and DHF control. (63.3% and 34.5%) The site visitations revealed that solid waste was often dumped on the side of the road. Slow elimination and lack of land for treatment were important problems. Some sites were near water sources. Water supply was often insufficient and there was poor public participation and DHF control. Generally SAOs did not have enough manpower, budget and technology for environmental health management. 73.3% did not have an environmental health committee. The actual income of most SAOs was below the criteria set by law. Although there were many problems as those mentioned above, some SAOs were quite successful in reducing the disposal load, promoting the recycling process and producing bio-fertilizer from garbage. It is recommended that personnel competent in environmental health management are needed for most SAOs. The government should produce a manual for these works and train the personnel properly.


The present study aims to reassess and synthesyze the framework of dental personnel development, focusing on dentist and dental nurse, through literature review and qualitative study.The results of the study showed that;  The influential  future streams of changes came from various directions and dimensions.  The main influence induced from the Health System Reform in Thailand  which reshuffled the legitimize structure of all sectors in the broadly defined “health system”, as well as extensively mobilized the current social paradigm and norms, particularly through the concepts of  health-oriented rather than disease-oriented and holistic health.  The health care services was remodeled mainly by financial and administrative measures and expanding the public sector service to include more private involvement.  The reform occurred concurrently with the amendment of the government service system, education system and the decentralization of authority over public enterprises to peripheral units.  In the other side, the expansions of capitalism, comsumerism, free  trade,  globalization, information technology, medical technology were also indicated for their influential  effects.  The change of Thai social structure as well as the current weak points of dental profession including insufficiency of self-dependency dental technology,  the imbalance of institutional knowledge /technology and the appropriate dental knowledge concerning the contexts of Thai society, as well as the limitation of some competence and attitude in graduated dental personnel, should also be taken into account. Apart from these, the reviewed of current dental public health situations and their trends showed that:  Dental caries rate of primary teeth in pre-school children was highly increased, notably in the rural area.  The rate of consuming cariogenic food also deeply increased during the past decade. Dental service utilization of the people was low, especially in elderly and rural people, mostly driven from acute symptom rather than from preventive approach.  The cases of dental profession code of ethics were in the increasing trend.    The future characteristics of dental personnel, apart from the basic professional knowledge and skill, should focus attention on:  the knowledge and skill of health promotion and social mobilization, thinking process, research and long life learning, team work coordination, communication skill, patient relationship and the extensive background of  non-professional knowledge to comprehend the situation and changes of the holistic world.  For the personality aspect, dental personnel should be raised in leadership, emotional literacy, human relationship and the mind of ethical integrity and responsibility to public. The role of dental personnel should be consequently adjusted, notably in the highly overlap role between dentist and dental nurse which partly reflect to the low team work performance affecting the efficiency of dental service outcomes. Dentists, especially in public sector, tended to provide too high proportion of simple services which were the majority of demand, resulting the under provision of the needy complex dental services.  While the interchangable of majority dental services by two types of dental personnel was increasingly be questioned by people under the health insurance system.  In the other hand, dental nurse faced the struggled of career ladder progress.  The direction of the solution, concerning the whole complication of each alternatives, should focus on the improvement of the ‘dental team’ or ‘oral health team’ which had to be systematically defined and organized.  The dentist, the team leader, should mainly responsible in taking care of holistic oral health care, planning and monitoring the overall oral care system, clinical diagnosis and holistic treatment plan, quality control and provide the complex dental services with the sufficiently assisting by dental auxiliaries including dental nurse.  This oral health team approach should be more relevant and flexible for the wide gap situation of dental manpower in the country than the legalized regulation limiting the curative role of dental nurse or to provide the license to dental nurse to work independently.  This approach allowed the oral health team to adjust the borderline roles of dental personnel within the team with the administrative means according to relevant place and time. The supporting training for increasing the oral health team approach should be started from the educational and training period.The recruitment of dental personnel, particularly in the government sector, should involve the community role in the enrollment process of dental student.  The involvement might be in selection process, educational expenditures support, field work training and employment in the local health care unit.The dental education direction have to be balanced between the aim to meet the advancement of dental institutional knowledge and technology and to rightly response to the oral health problems and needs within the belonging social circumstances. The educational process should be developed under the concepts of social or community based, patient-centered, active learning through research and thinking skill enhancement, comprehensive ethical motivation and the extensive evaluation and quality assurance of educational outcomes.This administration of the changing process in dental education should be implemented by adjusting the policy, improving educational manpower as well as providing the appropriate supporting environments such as:  connecting the education institutional dental service with the national or regional health service system, providing the relevant infrastructure and social environment, or developing the curriculum under local community participation.  The distribution of dental personnel in public sector by national monitoring through the compulsory contract of dental students was still considered as necessary. However, the pattern of distribution process tended to be directly indicated by the need or outcome estimation rather than by the current frame of the Civil Servant Office.  The concept of the mentioned  “oral health team” should be taken as the guideline for dental manpower distribution.  The increasing production of dental nurse was clearly indicated as well as the extension of dental public service involving private sector. The distribution management should be run concurrently with the recruitment of dental students and should include the motivational and supporting measures for the remote or the unmet need areas.The capacity building and quality control of manpower should be continuing implemented through the professional standard regulation involving the institutional quality assurance ie. Hospital Accreditation system and individualistic quality control (such as. professional licensing/ relicensing and continuing education).Licensing  by central examination from The dental council was questioned for its difficulty in developing  the complicate and professionally acceptable examination representing the overall achievement of dental education. It was suggested to be implemented only in case of the dental education of Thailand were generated by numerous and  various types of dental schools where the standard control through educational programme monitoring was inconceivable.Even though the relicencing was widely accepted for the necessity, it was scrutinized for the ability of measuring essential competence, as well as its cost-benefit and its concomitance to the quality from the consumer point of view.  It was suggested that relicensing should aim for consumer protection and utilize various evaluative methods rather than rely only on the examination or formal training.The professional control by the public was also the simultaneous measure of quality control. Several approaches were recommended such as the participation of people sectors in the policy board in many levels of the health system, the patient/ people satisfaction evaluation as a part of Hospital Accreditation, the involvement of consumer/people representatives in professional council and the board of dental educational institutions. The progression in professional career in the governmental sector should be separate to the administrative career.  All health professions should be promoted equitably among each other as well as in comparable to the administrators.  The promotion in the public health administrative line should be opened to any competence persons regardless of their professional backgrounds.The planning of the general practitioner and the specialist proportion should be closely supervised to meet the actual need estimation.  The dental specialty branches should be reduced to provide the more comprehensive dental specialists. The recognition and support for general practitioner should be improved such as establishing the system of on-the-job training to enhance the all-round dental skills and knowledge to the general practitioner, leading to the namely the specialist in general practice or family dentistry.  The mechanism of the overall policy making and planning regarding dental manpower should be established as an integrated part of the health manpower system in


Health sector reform: experiences in ten countries	This report aims to synthesize lessons derived from health sector reform experiences in ten countries, namely, Germany, United Kingdom, Australia, New Zealand, Japan, Republic of Korea, Republic of China (Taiwan), Singapore, Malaysia, and the United States. The main source of data for the synthesis comes from reports on health sector reform of these ten countries commissioned by the Health Systems Research Institute. Other sources include journal articles and discussion with academicians from some countries. 	Analysis of the structural aspect of reform addresses 1) overall structure of the health system, 2) benefits and choices available to, and burden borne by the consumers/ patients, 3) provider characteristics and payment mechanisms, 4) insurer/ fund characteristics, sources of fund, number and roles of insurer, and 5) intermediate system outcomes. Policy process model is used as the framework for comparative analysis of reform process. Lessons on the policy processes in each of the following policy stages are compared and contrasted: 1) agenda building, 2) policy formulation, 3) policy adoption, and 4) policy implementation. 	Experiences from these ten countries indicate that countries succeeded in instituting universal coverage of health care all employ compulsory insurance. While systems managed by a single insurer or insurance fund are often found to be less responsive to client needs, those managed by multiple insurers suffer from problems such as cream skimming, distribution of risk among insurers, and system inefficiency. Appropriate rules are needed to ensure overall equity, quality, and efficiency of insurance system(s) in a country. Insurer should be a prudent purchaser, playing active roles in selecting, negotiating with providers, and monitoring quality of care. Payment mechanisms can be designed in such a way that overall costs are controlled, while health promotion and preventive services are promoted. 	Health sector reforms taken place in these countries in the past century had two main objectives: expansion of insurance coverage and cost containment. Reform processes in most countries culminated in the enactment of laws. Experiences in some countries show that simply passing insurance laws does not always lead to the desired outcome. Implementation of policy is no less important than policy formulation and adoption for the accomplishment of reform objectives. Factors affecting the success of reform process include the degree the reform initiatives are in accordant with societal values, whether a comprehensive or a piecemeal approach to reform is employed, economic condition at the time reform movement took place, relative political power among the various stakeholders, political mobilization of the movement, development of technical capability for implementing reform, and the effectiveness of policy communication.


The purpose of this qualitative study was to explore the situation of alternative health systems for promoting the health of middle-aged women in 3 regions of Thailand. The study was undertaken at health services institutions and public places both in urban and rural areas of Chiang Mai (North), Khon Kaen (Northeast), and Songkhla (South), Three hundred and fifty seven women age 40-59 and eighty-two health discussions were used for data collection during March 1999-Februry 2000. Triangulation and content analysis were used for validation and analysis. Seven main themes emerged in describing an existing situation of alternative health promotion in the way of living and holism 2) Factors and conditions within women’s life and social context that lead to health promotion practice 3) Abundant and confusing information on the health promotion for middle-aged women 4) A modern health system which is based on health profession 5) An alternative health system which is independent and community based 6) Alternative health practices which emphasize mostly on nutrition, mind control, exercise, and using chemical agent and 7) Middle-aged women used alternative health systems more than modern medicine but health insurance undermined the health promotion activities. It is suggested that empowering women group in using alternative health systems and expanding their social arena are ways of developing alternative health systems to promote the health of middle-aged women.


Evolution of Thailand's HIV/AIDS  Preventive and Alleviative National ProgrammedObjectives : To study evolution of Thailand's HIV/AIDS  Preventive and Alleviative National Programmed from the advent of HIV/AIDS epidemic until the end of 1997. Subjects and methods : Researchers revised and analyzed the HIV/AIDS related  studies to illustrate Thailand 's missions and activities to prevent and control HIV/AIDS epidemic. To conceptualize AIDS paradigm shift the studies were subcategorized into 6 parts : AIDS  paradigm  development,  evolving  HIV/AIDS  information  system  for  good governance, HIV/AIDS catalytic role for civil society,  AIDS public policy development, as well as evolution of the HIV/AIDS social and health services.  Then the conceptual frame work for Health Promotion from the Ottawa Charter was employed to analyze the emerging Thailand's societal AIDS response.Results : HIV/AIDS public policy have been developed to create up the strategic infrastructure for HIV/AIDS prevention and alleviation. The crucial strategic areas which was the main finding are social environment, personal and community empowerment as well as social and health measure reorientation.   To achieve these societal evolution, the well developed information system to intercommunicate all the strategic alliances have been undertaken and an effective advocacy had been continually worked out so that the government can play their central role to collaborate the participatory function all the sectors. The individual and community empowerment have been turned to be the major tooldeveloped  to  change  the  people's  life  style  so  that   the epidemic of HIV/AIDS is under control and the HIV incidence have declined to a lower rate than last 5 years ago.Conclusions : AIDS crisis is so serious and complex that it can alert Thai society to learn and understand the intertwined health causal determinants which have its roots from social, economic, cultural and political infrastructure. The way its government develop a sounded health promotion strategy is the valuable lesson learnt then apply to other kind of health  problems.


Promoting the Civil Society and Mass Media for Health System ReformThis study is a participatory action research project launched in 4 provinces of 4 pouts of Thailand, including: Nakornratchasima, Trung , Phitsanuloke and Samutprakarn for 18 months  during May 2000 to October 2001.The objectives are to study existing relationships among three local networks:   public health network, mass media network and civil society network ; and to promote learning processes and cooperation model development for creating  health system reform movements at local level.The project  was  delivered by a central team and 4 area teams of researchers. The operation has 4 steps: (1) study the area contexts and mapping local potentialities (2) workshop of the researchers and some key persons from the target networks to identify a definite issue for social movement, target  groups and to design a process of movements (3) take action (4) workshop for lessons learning and synthesizing a body of knowledge about the possible roles of civil society and mass media for promoting the health system reform.The project findings are:	1. In the process of social movements promoting the health system reform to be a consensus local agenda, the issue of “social health” is sound possible and appropriate because local communities have holistic viewpoints for their health.	2. The powerful communications to promote local agenda of health need an integrative model of mass media, traditional media and personal media which request an appropriate designing for a specific area. 	3. A civil society of mass media for local health could be easily organized by setting a angular platform for health issue dialogue. The stakeholders, local intellectuals, academics, professionals, mass media and traditional media are the target groups to participate the forum, which should be started from their common heath problems or same local public issues.	4. The local civil society has potential roles of  “the learning process” and “the movements for social change” which takes part in social a wareness, promoting of  people   participation and local interactive learning through actions as well.


Conceptual framework for reforming the system of diseases prevention and control in Thailand was developed in this study. Issues which were involved, were 1) situation and trend of epidemiology, society changes which had influence to the system 2) strength and weakness of the existing system 3) recommendation for reforming the system. The study results were summarised as following;situations and impact of diseases were considerably changing, globalisation was promoting severity of both communicable and non-communicable diseases,decentralisation was making necessity to reform the system,the existing system had two major problems; lack of coordination in responsible organisations resulting ineffectiveness of handling problems and much emphasis on project based administration in addition to academic development which was useful for coping new and complicated problems,all disease control organisations should be united into single organisation for developing,Health Research Institute should be established to develop body of knowledge similarly to the US National Health,the establishment of the institute and merging all responsible organisations into single organisation should be stated in the National Health System Reform Act,the disease prevention and control system in many countries were studied to be taken as inputs for reforming.


The purpose of research is to study the communication process on health campaign among government, non-government, private and community organizations, by the leader or those who send messages in the organizations, and target groups for the campaign. Sample groups were purposefully selected, with 106 campaigns for quantitative study and 20 campaigns for qualitative study. All of these were campaigns for health promotion projects related to nutrition, exercise emotions. Disease-fee condition, and general good health. Data collection was done by using questionnaire and interview for quantitative data. In-depth interview, group discussion and observation are employed for qualitative data. Results of this study can be summarized as follow.Majority of health campign process were two-way communication, using individual messenger, event specific message, and mass media. Majority of the target group had the awareness but lacking consciousness and sustainability in health practices.In order to have effective health campaign, messenger had to have high level of trustworthiness and public concerns, while the message should be on holistic health. Message was communicated by individual messenger and mixed  media. Receivers should be involved individuals in health campaign.Influential factors in health campaign were leaders, social support, budget, involvement, participatory communication, networking and network communication, holistic health promotion, and community-center campaign.	Recommendations for health campaign are as follow.Empower, promote and support potentials of leadership, and core group to have capabilities in knowledge management, learning process, and skills in having good health and communication.Support networking in health campaign, by organizing activities and having regular network communication.Support for budget and other resources should be collective effort by every members in the alliance, groups, or network. This support should be consistent and completely covered all the necessities.Policy on strategic campaign should emphasize on participation of everyone involved, in every steps of campaign, by government, non-government, private and community organizations.Health campaign should be community-centered campaign, in order for the public to be aware of, interested in, and consciously driven, to have appropriate and sustainable health behaviour changes.


Health systems reform in TaiwanThis documentary study presented the developing process of health system in Taiwan. Strategies, tools, and other experiences those are applied to solve health problems in Taiwan will be learned Taiwan has succeedded in economics and industrial developments as well as impressive gains in the health of the general population. However new health problems accompany with the rapid rising cost of health expenditure and access to care problems are primary factors for formulating policy in health reform in Taiwan.These are:Setting of medical care Network: to balance their medical resources,Applying the National Health Insurance(NHI) Project in 1995Creating Computerized Patients and Health Information Network to improve health service facilities, andDeveloping Family Practice Tranning Programs for their personal. This universal coverage NHI program creates monopsony buying power and promotes administrative efficiency. Fee-for service and co-payment are used as financial strategies.Although the health system reform is able to distribute providers and facilities to remote areas and gives a chance for the poor to access health services, the cost of health expenditure in still rising. Many payment mechanisms such as capitation, case payment, or global budget and other administrative strategies are proposed by experts to solve this problem. Many differencess between Taiwan and Thailand should be concerned when some health reform strategies will be brought to apply in our country. Very contrast to Thailand, the strength of economic sector and government in Taiwan make at least 2 programs, NHI program and medical care network program, possible. Thus, these strategies should be careful if implement in Thai society. Many tools for health system reform from the Western countries, however, many have limitations for solving health problems in oriental developing countries as Thailand.


Pattern of Substance Use in High School Students: A High School Study in Ubonratchathani.The objective of this research is to study pattern of substance use in high school students; including alcohol, cigarette, and amphetamine especially. The factors associate to such behavior, progression of use, consequence, and management of substance use problem from the school were explored. The methodology of the study was a qualitative research. The study site was a high school in Ubonratchathani province, by purposive selection. Key-informants were the students who had experience in substance use or exposed to the user, and the teachers who were advisor of students. Data collection was done from August 1999 to February 2000, by in-depth interview (student 10 cases) and focus group discussion (teachers, 2 groups/18 cases). Then, the data was analyzed by content analysis method.	For the key-informants, the student group, the substance use began from alcohol drinking and then cigarette smoking in a short period of time, between grade 7-9. The use of amphetamine came later, depend on the exposure opportunity to the user and participation with the user group. The pattern of use was similar in each key-informant; initiate from group participation, expose to peer or sibling whom experienced of use, and then ask to try or encouraged by peers. Continue of use was follow because of pleasure and group participation. The significant factor associated with substance use, especially amphetamine use, was their own while the others were influence indirectly; such as social and school environment, family role and status, group participation, and availability of substance. And the factors associated with lowering of use or abstinence were intention of themselves and/or peer group to quit, avoidance from the user group, difficulty in drug seeking, less of money, appearance of the police in school and urinary testing for substance use. These factors influenced frequency of use by the time. However, among high school users, recreational or occasional use with regular use at times were the majority of them.	Among the user, it was no significant impact while taking alcohol and/or cigarette. But in case of amphetamine, there were both behavioral and physical changes when the frequent of use was increase. Behavioral changes might be delinquent or problem behaviors in school, alter school performance, use much more money, and lie their parents. From their viewpoint, physical changes were transient and no significant to worry about it. And no psychiatric sign and symptom or disorder was appearing. In opinion of student group, although alcohol drinking or cigarette smoking seems to be a part of adolescent life, but amphetamine use was only individual behavior.	When the situation about substance use in high school to be asked, the key-informants said that alcohol drinking and cigarette smoking initiated in grade 8, amphetamine use by smoking appeared in grade 9, the user rate increased in all type of substances between grade 10 and 11, and then decreased in grade 12. The favorite substances in boys were alcohol, cigarette, and amphetamine; while in girls were alcohol, amphetamine, and cigarette respectively. And evidence of inhalant or glue was not found in last 1-2 years.	About programs against substance use problem in school such as campaign or education, there were not interested and less participation from the user group and not influence their substance use behavior. In addition, it was no other action plan or relevance program from the school while the policy and strategy were not clear defined.