Valuing Health and Economic Costs

of Water Pollution in Thailand

By

Siripen Supakankunti
Pirus Pradithavanij
Tanawat Likitkererat

The Centre for Health Economics

Faculty of Economics, Chulalongkorn University
Bangkok, Thailand

July 2001

Table of Contents
Page
1. Introduction

2. Natural History of Selected Water-borne Diseases

2.1 Diarrhea
2.2 Dysentery
2.3 Cholera
2.4 Typhoid

2
3
4
5
5

3. Method of Valuing Health Impact and Economic Costs

3.1 Health Impacts in term of Burden of Water-borne Diseases
3.2 Economic Cost of Water-borne Diseases:

6
6
6

4. Study Results
4.1 Calculation of Disability Adjusted Life Years (DALYs)
4.2 Direct and Indirect Cost

7
7
12

5. Summary
5.1 Diarrhea
5.2 Dysentery
5.3 Typhoid

14
14
14
15

Annex
Reference

16
26

List of Tables

Table 1
Table 2
Table 3
Table 4
Table 5
Table 6

Causes of acute diarrhea

Life Table
Years of Life Lost
Years Lived with Disability
Disability Adjusted Life Years
DALYs, YLLs, and YLDs of the 3 Specific Diseases Classified by
Selected Provinces Based on Classification of Water Quality in

Table

Source of Drinking Water

Table

Cost of Out -Patient Care by

Table

Page
3
7
8
8
8

Specific Disease

Sensitivity Analysis of Out-Patient Cost

Table
Hospitalization cost of In-Patient Care classified by specific diseases
Table 11 Length of Stay and Wage Lost due to Hospitalization of Thai People
Aged More Than 14 years old
Table 12 Income Forgone from Premature Death Caused byWater-borne diseases
Table 13 Direct and Indirect Cost classified by 3 specific diseases
Table 14 Quality Standard of Water in the Ground Reservoir
Classification of ground water reservoir
Table 15 Income forgone from premature death caused by Diarrhea & Food
Poisoning
Table 16 Income forgone from premature death caused by Dysentery
Table 17 Income forgone from premature death caused by Enteric Fever

13
13
13
14
16

18
20
23

Valuing Health and Economic Costs of Water Pollution in Thailand

Siripen Supakankunti1 , Ph.D.
Pirus Pradithavanij2 , M.D., M.P.H.
Tanawat Likitkererat3 , M.Sc.
1. Introduction
Thailand is a tropical country. River and water reservoirs are essential for living and
considered life of Thai people. Water quality is one of the serious environmental problems
facing Thailand. The purpose of this paper is to make rough estimates of the health and
economic costs associated with water pollution in Thailand, excluding the estimate of
production impacts. Earlier studies conducted by the World Bank indicated that the health
benefits of providing universal access to clean water and sanitation to the Thai people
would be significant (World Bank, 1997). The results of this study are intended to raise
awareness of policy makers about the importance of water quality issues, to contribute to
the setting of priorities for action, and to improve the quality and management of water
resources in the country. However, this analysis is only limited to the estimation of public
health impacts of water pollution and measured in terms of the burden of water-borne
diseases, including diarrhea, dysentery, cholera and typhoid on the population. In valuing
the economic costs of these four diseases, two types of costs are considered: (i) direct costs;
and (ii) indirect costs.
2. Natural History of Selected Water-borne Diseases4, 5
Water borne diseases refer to illnesses caused by contaminated water. Very often
contaminated water is mixed with food, so the characteristics of a food borne diseases are
rather similar to those water borne diseases. Contamination may be both by biological
agents and chemical agents. This study, nonetheless, emphasizes only on biological agents.
Diseases or abnormal conditions usually present themselves with gastrointestinal
symptoms, because pathogens contact directly and firstly with gastrointestinal tract.
In pathogenesis, there needs to have an imbalance in three main factors, host, agent,
and environment. All the factors are interdependent. The host is vulnerable when exposed
to environment contaminated with virulent agents, by drinking or eating unclean water or
food. An immuno-compromised person is more susceptible to disease. A minimum quantity
of agents is also required to cause the disease. Many pathogens can survive in natural water
after passing from patients or asymptomatic carriers to environment via secretion such as
stool. A coliform bacterium is therefore a standard indicator to demonstrate whether
suspected water is unpurified with feces or not. There may be vectors such as flies or other
insects, which carry pathogens from one place to another place. In an area where sanitation
and public water is poor or does not exist, pathogens such as cholera can spread very
quickly and widely.
1

Director, the Centre for Health Economics, Faculty of Economics, Chulalongkorn University.
Assistant Director, Bangkok Pattaya Hospital, Chonburi.
3
Academic Staff, The College of Public Health, Chulalongkorn University.
4
Grendell JH, McQuaid HR, and Friedman SL. Current Diagnosis & Treatment in Gastroenterology. International
edition. LANGE medical book. 1996.
5
Jaroonvej N. Tropical Diseases. 2nd edition.
2

Besides, socio-economic status and education are important host factors. High
socio-economic status will generally prevent host from exposure to hazardous environment.
Sufficiently educated people will know how to protect themselves and how to take care
primarily of themselves, if afflicted, better than uneducated people. For these reasons, the
prognosis and outcome of treatment, if any, are predictably good in more educated patients.
2.1 Diarrhea
Diarrhea is a common condition with severity varying from acute to chronic and
from self-limited symptom to severe life threatening condition. The causes of diarrhea are
numerous for both acute and chronic. It is helpful in clinical practice to differentiate acute
from chronic diarrhea as to which the proper management of such cases can be
administered. Acute diarrhea is basically infectious diseases, whereas chronic diarrhea is
fundamentally patho-physiological abnormalities. This study will, therefore, focus on acute
diarrhea as a contagious disease associated with water.
Exposure to unpurified water and contaminated food is one of the common causes
of acute diarrhea that may lead to ingestion of either infectious agents or their toxins that
are summarized in Table 1.
Table 1. Causes of acute diarrhea4
Noninflammatory Diarrhea
Viral

Inflammatory Diarrhea
Viral

Norwalk virus
Rotavirus

Cytomegalovirus
Bacterial

Protozoa
Giardia lamblia
Crytosporidium
Bacterial
1. Preformed enterotoxin
Staphylococcus aureus
Bacillus cereus
Clostridium perfringens
2. Intra-intestinal enterotoxin
production
E coli (Enterotoxigenic)
Vibrio cholerae

1. Cytotoxin production
E coli O157:H7 (Enterohemorrhagic)
Vibrio parahaemolyticus
Clostridium difficile
2. Mucosal invasion
Shigella
Salmonella sp.
Enteroinvasive E coli
Aeromonal
Yersinia enterocolytica
Plesimonal
3. Bacterial proctitis
Chlamydia
N gonorrhoeae

New medications
Fecal impaction

Protozoal
Entamoeba histolytica
Intestinal ischemia
Inflammatory bowel disease
Radiation colitis

Thanks to the breakthrough in molecular biochemistry, advance laboratory

investigation in acute diarrhea can reveal pathogenic microorganisms up to 60-80% of the
cases. It is, however, costly and unnecessary, particularly in mild cases. Such investigation
5

will therefore be useful in epidemiological studies and biomedical research rather than the
routine management of disease or daily medical practices. More useful investigation in
clinical practice is a microscopic examination of the stool.
This method can help
distinguish noninflammatory (enterotoxigenic) and inflammatory (enteroinvasive) diarrhea
as their therapies are quite dissimilar.
Most prevalent diarrhea is acute in onset and usually persists for less than 3 weeks.
More than 90% of acute diarrhea is mild and self-limited and responds within 5 days to
simple rehydration therapy or symptomatic antidiarrheal agents.
The goal of initial
intervention is to distinguish these patients from those with more serious conditions.
Food poisoning is another clinical form of acute diarrhea.
Gastrointestinal
symptoms usually include both upper and lower tracts. Nausea, vomiting, abdominal pain,
and diarrhea with or without low-grade fever are commonly present in most cases within a
short period of exposure. One of the major causes of food poisoning is bacteria and their
toxins listed in Table 1.
2.2 Dysentery
Dysentery has two main types, bacillary dysentery (Shigellosis) and amoebic
dysentery.
Bacillary dysentery is caused by a gram negative bacilli, namely Shigella. It can be
divided into 4 subgroups according to their biochemical properties, Sh. dysenteriae, Sh.
flexneri, Sh. boydei, and Sh. sonnei. In tropical areas, Sh. flexneri is responsible for the
majority of cases up to 78%, whereas in subtropical areas, Sh. sonnei is responsible for up
to 85%. Shigella bacilli are passed within stool and can contaminate food and water by
hand of infected persons or fly. Incubation period is approximately 1-7 days, but usually
less than 3 days. Classical case will present with severe bloody diarrhea, crampy
abdominal pain, and fever. In early stage, watery diarrhea without gross blood can be
found and bloody stool will follow 3-5 days later.
Severe case usually occurs in children, elderly, and unhealthy people and is caused
by Sh. dysenterias the most. In such cases, gangrene of large bowel, circulatory collapse,
and death can occur. Chronic shigellosis and chronic carrier may be developed in some
cases. Extraintestinal complications may involve remote systems like respiratory system,
neuromuscular system, and hematological system.
Epidemiologically, it can be found all around the world, where public utility and
sanitation are not well established, where people live together in crowded places, and where
personal hygiene is poor, especially in tropical areas. The incidence is approximately 1015% of acute diarrhea cases in adult. This number is higher in children, particularly in the
age under 8 years. The incidence may rise up to 15-25% and reach its peak in the age of 918 months.
Like bacillary dysentery, amoebic dysentery or amebiasis is an inflammatory
diarrhea. However, it is caused by protozoa, namely E. histolytica. Clinical symptoms can
vary from asymptomatic infected person or carrier to a full-blown dysentery with hepatic
abscess. The patients can also be presented with both acute and chronic illness.

Incubation period is approximately 8-10 days. Patients may suffer from lower
abdominal pain, intermittent bloody mucoid stools, and fever. No or improper treatment
may result in;
Asymptomatic amoebiasis or carrier
Chronic amoebiasis
Amoebic granuloma or amoeboma
Serious complication such as intestinal perforation, widespread of disease with
abscess formation (hepatic abscess)
The prevalence has been estimated at 10% and up to 80% of population in endemic
areas. Man and women are equally at risk in all age group especially after 20. The
reservoir of protozoa is a person who could be either a carrier or a patient. An infective
stage is a 4-nucleated cyst passing with stool. It can contaminate food and drinking water if
the sanitation and personal hygiene is poor.
2.3 Cholera
Vibrio cholerae is a gram-negative, comma-shaped rod that can produce the most
severe form of acute watery diarrhea (cholera gravis). The clinical spectrum is, however,
ranging from nothing in immune person or asymptomatic carrier to profound volume and
electrolyte depletion and death soon after first 2-3 hours of onset, although severe cases are
less frequently found. The organism produces toxin, named cholera toxin. This toxin leads
to sudden and severe fluid and electrolyte imbalance by promoting secretion and inhibiting
absorption in small bowel.
Early onset may manifest with vomiting and abdominal distension followed by
rapidly repeated passing of watery stool probably with incontinence. The characteristic of
stool is large in volume and looks like a rice water with minimal content. Low grade
fever may be presented. Serious complications may include pulmonary edema, acute renal
failure, and severe electrolyte imbalance.
The organism has capability to spread very quickly, either sporadically or
epidemically. It infests only in human beings. The prevalence is notably high in illegal
immigrants near the border and some major industrial cities. Consequently, sporadic
outbreak can be found in some specific areas where there are illegal immigrants. In
endemic areas, adult is usually immune to the disease, whereas children are at great risk.
One of major risk factors is sanitation and access to pure water, since water is major route
of transmission.
2.4 Typhoid
The causative agent is Salmonella sp.. Salmonella can actually produce 2 major
clinical syndromes, typhoid fever and gastroenteritis. Typhoid is a systemic illness that has
few primary symptoms relating to gastrointestinal tract. Typhoid fever or enteric fever or
paratyphoid fever are caused by S. typhi, S. paratyphi A, B, or C. It is characterized by a
prolonged fever with other systemic manifestations. In classical case, incubation period is
ranging from 7 to 21 days and symptoms involve a 4 week period.
The first week is characterized by fever with or without chill, headache, poor
appetite, and weakness. The second week is characterized by high and sustains fever,
7

dehydration, and drowsiness. Organomegaly can also be found. Patients usually come to
see physician during this week.
Pulse and temperature dissociation will support a
diagnosis. Many patients still have normal bowel habits. The third week is characterized
by intermittent fever, intestinal involvement, and systemic involvement.
Intestinal
hemorrhage and perforation, and acute cholecystitis are potential complications that might
need surgery during this period. Other complications that need medical treatment include
pneumonia, jaundice, anemia, dissiminated intravascular clotting (DIC), psychosis, and
renal involvement. Clinical symptoms will be subsided in the fourth week even no
antibiotics is treated. Recurrent case and chronic carrier can also be found, particularly in
gallstone patients.
Incidence of typhoid is higher in children than in adult and highest in the age below
6 months. Salmonella can be found in animals such as birds, livestock, reptiles and
household animals. It is estimated that the infected quantities are 102 -106 . The spread of
disease can occur sporadically or epidemically from contaminated food and water. Chronic
carrier can pass the pathogen into the stool for more than one year if left untreated.
Vaccination is available in both oral and injected forms.
Again all diseases mentioned above are closely related with food and drinking
water. In fact, the balance between immunity and infectivity is theoretically important to
prevent the diseases individually and collectively. The improvement in public sanitation
and personal hygiene, and access to clean water are however still main stays to protect a
large scale of population from the diseases.
3. Method of Valuing Health Impact and Economic Costs
3.1 Health Impacts in term of Burden of Water-borne Diseases
This analysis is limited to the estimation of public health impacts of water pollution
and measured in terms of the burden of water-borne diseases, including diarrhea, dysentery,
cholera and typhoid on the Thai population. Health impact valuation includes the estimation
of DALYs, Disability-Adjusted Life Years, which includes year of life disability (YLDs)
and years of life lost (YLLs). DALY was developed as the measurement unit for the Global
Burden of Disease Study (Murray 1994), which was an attempt to quantify the burden of
disease and injury on human populations. This quantification also requires a unit of timebased measures of health status that incorporate non-fatal health outcomes.
3.2 Economic Cost of Water-borne Diseases:
Economic cost can be estimated in term of direct and indirect economic cost. In this
study, the direct economic cost includes the cost directly incurred by the patient such as
cost of medical expenses as an outpatient or inpatient. Indirect economic cost refers to the
cost that is indirectly incurred by the patient such as wage lost. Lost wages in fact should
include both lost wages from disability and death. In this study, lost wage includes those
that are the results of hospitalization as an inpatient and income forgone due to premature
death.
Income forgone due to premature death of Thai population caused by water borne
diseases and quality of water can be classified into two categories. One is for productivity
lost due to illness but can continue working and the other is due to premature death or

productivity becomes zero. This approach is one among three approaches of estimations of
human capital. Income forgone here is calculated based on premature death only but does
not account for income loss due to illness (reduced productivity) because of insufficient
data.

Income Forgone Loss =

n = 60 - d

n= 0

GNP per capita * (1 + g) n

(1 + r) n

Where
n = number of productive years lost due to premature death
d = age of death
r = discount rate (8.00%)
g = increasing growth rate of income per capita per year (5.00%)
Assumption: Working age is 14 to 60 years old.

4. Study Results
4.1 Calculation of Disability Adjusted Life Years (DALYs)
In calculating DALYs for the 3 selected diseases, 3 steps of calculation were
performed which are 1) Life table calculation, 2) Year of Life Lost (YLL) calculation and
3) Years Lived with Disability (YLD) calculation.
To calculate life table, mid-year population and number of deaths from the birthdeath registration system of the Ministry of Interior of the year 1998 has been used. Taken
into account that registered population and death of infant and aging people is distorted.
The distribution of the population must be adjusted. The calculated life table is as shown in
table 2.
Table 2: Life Table
Age Group
<1
-

Life Expectancy
Male
Female
70

For YLL and YLD calculation, as being communicable disease specific mortality
and morbidity data from 1998 Annual Epidemiology Surveillance Report have been used.
According to the nature of the 3 selected diseases, once the disease occurred, there are 2
possible ways, which are normal health, or death. There is no disability after patients have

been treated. Thus, the data from DRGs payment system that composed of more than one
million cases together with mid-year population have been used to figure out remission
rate, incident rate and case fatality rate.
The results of YLL and YLD calculation are shown in tables 3-6. The numbers in
the bracket are parameters input to the calculation. The first parameter is discount rate and
the second is age-weighting modulation factors. For discount rate, 0 means that there is no
discount rate used in the calculation and the figure 3 demonstrates that the discount rate of
3% has been used. For the second parameter, the value could be 0 and 1, which indicates
that age-weighting modulation factor is used in the calculation, or not. The discount rate
was applied in this study because the result of the DALYs calculation must reflect lost in
the future and must be calculated at present value. But for the age-weighting, we decided to
apply uniform age-weighing on the assumption that lost of ability to work for various age
groups is equal.
Table 3: Years of Life Lost
Diseases
Diarrhea
Dysentery
Typhoid
Total

Male
7,399.90
242.88
,

YLLs (0,0)
Female
Total
6,890.28
14,290.18
240.79
,
,

Male
3,758.00

YLLs (3,0)
Female
3,468.04

Total
7,226.04

We reported only 3 diseases since there is no report on Cholera cases found. It is

likely that Cholera cases were already reported as severe diarrhea. For all 3 types of
diseases, there is no great difference between males and female. Diarrhea cases are found to
be the greatest in numbers, compared to the other 2 diseases. This evidence showed that
Thailand is faced with more serious case of Diarrhea than the other two types of water
borne diseases.
Table 4: Years Lived with Disability
Diseases
Diarrhea
Dysentery
Typhoid
Total

Male
,
,
,

YLDs (0,0)
Female
,
,
,

Total
,
,
,

Male
,
,
,

YLDs ,
Female
,
,
,

Total
,
,
,

From calculated YLL and YLD, as a result of summation of those parameters

DALYs of the specific diseases are illustrated in table 5.
Table 5: Disability Adjusted Life Years
Diseases
Diarrhea
Dysentery
Typhoid
Total

DALYs (0,0)
Male
Female
Total
62,749.36 64,079.20 126,828.57
2,
,
,
,

Male
58,303.78
,
,

DALYs (3,0)
Female
Total
59,831.76 118,135.54
,
,
,

10

The health value or outcomes of calculation above are DALYs of the diseases for
the whole country in the year
For this study, DALYs of the diseases by selected
provinces were calculated Provinces were selected by their quality of natural water across
the country. The data were surveyed and reported annually by Bureau of Environmental
Health, Department of Health , the Ministry of Public Health.
Unfortunately, the Annual Epidemiology Surveillance Report of the Epidemiology
Division, Office of the Permanent Secretary for Public Health, does not provide data
segregated by age group and province at the same time. From the report, data separated by
age group do not reflect provincial perspective. And data segregated by province were not
segregated by age group. To solve the problem, we assume that distribution of cases over
age group is the same in every province. Calculation of YLL/death and YLD/case have
been performed. The YLL of the selected provinces caused by the 3 diseases by multiply
number of death of the province by YLL/death were also computed. The YLD can be
calculated by multiplying number of case by YLD/case. Finally, DALYs caused by the 3
diseases of the selected provinces can be done by summation of the YLL and YLD. The
final results are as displayed in table 5.
Table 6. DALYs, YLLs, and YLDs of the 3 Specific Diseases Classified by
Selected Provinces Based on Classification of Water Quality in 1999
Diarrhea
Province

No. of
Case

Incidence
rate (/1000)

No. of
Death

CFR
(/

YLLs

YLLs death

YLDs

YLDs case

DALYs

Class
Nan

Roi-et

Class
Chai Nat

Nakorn Sawan

Ang Thong

Ayutthaya

Sakol Nakorn

Nakorn
Rajsrima
Nonburi

Class

Nationwide

Dysentery
Province

No of
Case

Incidence
rate

No of
Death

CFR

YLLs

YLLs death

YLDs

YLDs case

Class

11

DALYs

Nan

Chai Nat

Nakorn Sawan

Ang Thong

Ayutthaya

Roi-et

Class

Class
Sakol Nakorn
Nakorn
Rajsrima
Nonburi

Nationwide

Typhoid
Province

No of
Case

Incidence
rate

No of
Death

CFR

YLLs

YLLs death

YLDs

YLDs case

Class
Nan

Roi-et

Chai Nat

Nakorn Sawan

Ang Thong

Ayutthaya

Sakol Nakorn

Nakorn
Rajsrima
Nonburi

Class

Class

Nationwide
Note

CFR case fatality rate

Classification of water quality is illustrated in an annex. Basically class 2 is better than class 3 and 4
and class 3 is better than class 4.

Table 6 shows that the quantity or the number of cases is greatest in diarrhea,
dysentery, and typhoid respectively. After adjusting for population in each province, the
incidence rate remains highest in diarrhea, dysentery, and typhoid respectively. There is no

12

DALYs

relationship or association between either the number of cases or the incidence rate and
water quality, as class of water quality increases from class 2 to class 4 for all 3 selected
diseases.
The quality of the severity of the cases may be estimated from CFR, YLL/death,
and YLD/case. Unfortunately YLL/death, and YLD/case cannot be directly estimated for
each specific province due to the limit of the existing data as already mentioned.
YLL/death, and YLD/case of the nation are used instead to find the YLL and YLD for each
specific province. YLD/case of all three diseases seem to be almost the same, varying
between 0.08-0.10. YLL/death is particularly low in diarrhea (22.37), whereas those of the
other two diseases are differentially high (25.53-26.79). CFR, however, is highest in
diarrhea (0.279) and quite the same for the rest (0.134-0.135). All severity indicators of all
diseases are again not related to water quality, as class of water quality increases.
The greatest burden or DALY can be found in diarrhea (118,135.54), since the total
number of cases is greatest, up to 1.16 million cases. The second and the third burden are
from dysentery and typhoid respectively.
The relationship between burden of these
selected diseases and the water quality cannot be quantified.
The data on sources of drinking water from the Report of National Statistical Office
shows that only 0.8% of households in Thailand consume water from River, Canal, Stream,
Water Fall (Figure 1). Rather, most households drink water from safe sources. This helps
explain why the outcomes of diseases, as mentioned above, do not relate to the quality of
drinking water.
Figure 1 Percentage of Sources of Drinking Water

Table 7 Source of Drinking Water

0.2
15.7

18.7

Tap Water Inside

Tap Water Outside

0.8
Public Well
2.3
Private Well
6.0

Rain Water
River, Canel, Stream,
Water Fall
Bottle Drinking Water
Others

37.7

18.6

Unknown

13

Source of Drinking Water

Tap Water Inside
Tap Water Outside
Public Well
Private Well
Rain Water
River, Canal, Stream, Water Fall
Bottle Drinking Water
Others
Unknown

Household
2,806,011
,
,
, ,
, ,
,
, ,
,
,

Percentage
18.7

Direct and Indirect Cost

For economic evaluation, direct economic costs were estimated from the cost of
medical services as an outpatient or inpatient case in Tables 8-10. Cost of medical
expenses in OPD clinic was estimated to be 170 baht/visit using data from the pilot study
for Health Insurance Project, Ministry of Public Health (S. Supakankunti and W. S.
Janjaroen, 2000). There is no doubt that the cost is highest in diarrhea, because it causes
the highest number of OPD visits. Once again dysentery is the second most and typhoid is
the last. Sensitivity analysis shows not the ranking of the diseases by the OPD visit cost,
but the possible range of number of OPD visit, as the cost per visit can vary in different
settings and areas.

Table 8. Cost of Out-Patient Care by 3 Specific Diseases

(Bahts)
Disease
Diarrhea
Dysentery
Typhoid
Total

No. of case
1,157,629
59,064
7,165

Cost
196,796,930
10,040,880
1,218,050
208,056,030

Table 9. Sensitivity Analysis of Out-Patient Cost

Disease
Diarrhea
Dysentery
Typhoid
Total
Assumption

No.of case
,

Cost at cost case

,
,
,

,
,
,

,
,
,
,

,
,
,
,

,
,
,
,

,
,
,
,

,
,
,
,

Utilization rate of community and provincial hospital is the same

Number of OPD cases also includes IPD cases The reason is that, for IPD case,
the patient has to visit OPD first then admit as an in-patient. So that we count IPD
case as an OPD case as well.

For IPD cases, the hospitalization cost was estimated based on the data of DRGs
from the Health Insurance Office, Ministry of Public Health in Table 10. The cost per case
for each particular disease is different. Diarrhea has the lowest cost per case, while

14

dysentery and typhoid are almost the same, which are higher in cost. This characteristic is
similar to YLL/death in Table 7.
Table 10. Hospitalization cost of In-Patient Care classified by 3 specific diseases
(Bahts)
Disease
Diarrhea
Dysentery
Typhoid
Total

No.of case
94,199
,
,

Cost/case
1,019.59
,
,

Hospitalization Cost
96,044,424.35
, ,
, ,
,
,

Indirect economic cost firstly refers to wage lost due to absence from work as a
result of hospitalization. The age of 14 was set to be the youngest age of the working
group. The cost depends on the length of stay and the wage of patient or minimum
wage/day. Wage lost from diarrhea is the highest, but the second highest is typhoid
followed by dysentery. This is simply because the length of stay of typhoid is 2 times
longer than that of dysentery (Table 11).
Table 11. Length of Stay and Wage Lost due to Hospitalization of Thai People
Aged More Than 14 years old
(Bahts)
Disease

No. of case

Diarrhea
Dysentery
Typhoid
Total

,
,
,

Length of Stay
Total
Average
,
,
,
,

Wage Lost
,
,
,

,
,
,

Another indirect economic cost was calculated from income forgone due to
premature death as shown in Table
Diarrhea can lead to life lost in all age groups of
population Although diarrhea seems to be an uncomplicated disease and needs no special
therapy, CFR is high as shown in Table 7. Its CFR is higher than those of the other two
diseases. This is especially true in very young and very old persons. Accordingly, income
forgone from premature death is highest in diarrhea. Income forgone is highest in the
youngest age group (116 million DALYs), followed by dysentery and typhoid respectively.
Table 12. Income forgone from premature death caused by water-borne diseases
(Bahts)
Disease
Diarrhea
Dysentery
Enteric Fever
Total

0-4
,
,
,

,
,
,

5-1
,
,
,
,
,

,
,

,
,

,
,

,
,

,
,

Total
,
,
,
,
,
,
,
,

15

Table

Direct and Indirect Cost classified by

specific diseases
bath

Cost
Disease
Diarrhea
Dysentery
Typhoid
Total

Direct

Indirect

Total

292,841,354.35

303,947,614.87

596,788,969.22

19,280,057.64

11,212,773.57

30,492,831.21

6,965,617.55

3,839,864.17

10,805,481.72

319,087,029.54

319,000,252.61

638,087,282.15

5. Summary
Water borne diseases refer to illnesses caused by contaminated water. Very often
contaminated water is mixed with food, so the characteristics of a food borne diseases are
rather similar to the water borne disease. Contamination may be both by biological agents
and chemical agents. This study, nonetheless, emphasizes only on biological agents.
Diseases or abnormal conditions usually present themselves with gastrointestinal
symptoms, because pathogens contact directly and firstly with gastrointestinal tract.
5.1 Diarrhea
From natural history of selected water-borne diseases the exposure to unpurified
water and contaminated food may lead to ingestion of either infectious agents or their
toxins that are already summarized in Table 1. Most prevalent diarrhea is acute in onset
and usually persists for less than 3 weeks. More than 90% of acute diarrhea is mild and
self-limited and responds within 5 days to simple rehydration therapy or symptomatic
antidiarrheal agents. Food poisoning is another popular clinical form of acute diarrhea.
Nonetheless, the exposure history is sometimes not obvious or mixed with other causes of
acute diarrhea. The existing records may therefore include food poisoning with other acute
diarrhea.
Diarrhea leads to wage lost the most among 3 selected diseases. This is not
surprising, since it produces the highest number of IPD cases. However, this does not mean
that diarrhea produces more severe clinical cases than the other two diseases. It is simply
because the incident cases of diarrhea are much higher than those of typhoid and dysentery.
This number is probably underestimated.
5.2 Dysentery
Epidemiologically, it can be found all around the world, where public utility and
sanitation are not well established, where people live together in crowded places, and where
personal hygiene is poor, especially in tropical areas. The incidence is approximately 1015% of acute diarrhea cases ni adult. This number is higher in children, particularly in the
age under 8 years. The incidence may rise up to 15-25% and reach its peak in the age of 918 months.
16

5.3 Typhoid
Incidence of typhoid is higher in children than in adult and highest in the age below
6 months. The spread of disease can occur sporadically or epidemically from contaminated
food and water. Chronic carrier can pass the pathogen into the stool for more than one year
if left untreated. Vaccination is available in both oral and injected forms.
In summary, the results from Table 3-11 showed that Diarrhea cases are found to be
the greatest in numbers compared to the other 2 diseases. This evidence showed that
Thailand is faced with more serious case of Diarrhea than the other two types of water
borne diseases. In term of YLL and YLD, YLD/case of all three diseases seem to be almost
the same, varying between 0.08-0.10. YLL/death is particularly low in diarrhea (22.37),
whereas those of the other two diseases are differentially high (25.53-26.79). CFR,
however, is highest in diarrhea (0.279) and quite the same for the rest (0.134-0.135). All
severity indicators of all diseases are again not related to water quality, as class of water
quality increases.
The greatest burden or DALY can be found in diarrhea (118,135.54), since the total
number of cases is greatest, up to 1.16 million cases. The second and the third burden are
from dysentery and typhoid respectively.
The relationship between burden of these
selected diseases and the water quality cannot be quantified.
For economic evaluation, direct economic costs were estimated from the cost of
medical services as an outpatient or inpatient case in Tables 8-10. There is no doubt that the
cost is highest in diarrhea, because it causes the highest number of OPD visits. Once again
dysentery is the second most and typhoid is the last. For IPD cases, the hospitalization cost
was estimated in Table 10. The cost per case for each particular disease is different.
Diarrhea has the lowest cost per case, while dysentery and typhoid are almost the same,
which are higher in cost. This characteristic is similar to YLL/death in Table 7.
For indirect economic cost, firstly refers to wage lost due to absence from work as a
result of hospitalization. The age of 14 was set to be the youngest age of the working
group. The cost depends on the length of stay and the wage of patient or minimum
wage/day. Wage lost from diarrhea is the highest, but the second highest is typhoid
followed by dysentery. This is simply because the length of stay of typhoid is 2 times
longer than that of dysentery. Another form of indirect economic cost comes from income
forgone due to premature death. The results showed that Diarrhea could lead to life lost in
all age groups of population. Although diarrhea seems to be an uncomplicated disease and
needs no special therapy, still its CFR is higher than those of the other two diseases. This is
especially true in very young and very old persons. Accordingly, income forgone from
premature death is highest in diarrhea. Income forgone is highest in the youngest age group
(116 million DALYs), followed by dysentery and typhoid respectively.
Again all diseases mentioned
water. In fact, the balance between
prevent the diseases individually and
and personal hygiene, and access to
people from afflicting the diseases.

above are closely related with food and drinking

immunity and infectivity is theoretically important to
collectively. The improvement in public sanitation
clean water are however still main stays to protect

17

Annex
Table 14 Quality Standard of Water in the Ground Reservoir
Item
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21

22

23
24
25
26
27

28

Quality
Colour, odour and
taste
Temperature
PH
DO
BOD
Total coliform
bacteria
Fecal coliform
bacteria
NO3
NH3
Phenols
Cu
Ni
Mn
Zn
Cd
Cr Hexavalent
Pb
Total Hg
As
Cyanide
Radioactivity
Alpha
Beta
Total
organochlorine
pesticides
DDT
Alpha-BHC
Dieldrin
Aldrin
Heptachlor &
Heptachlor
epoxide
Endrin

Statistics

Unit
c

P20
P80
P80
P80

mg/l

MPN/
dl

Class 1
N

Water Quality by Utility

Class 2
Class 3
Class 4
N
N
N
N
5-9
>2
<4

Class 5
-

N
N
N
N
N

N
5-9
>6
<1.5
<5,000

N
5-9
>4
<2
<20,000

<1,000

<4,000

mg/l

N
N
N
N
N
N
N
N

N
N
N
N
N

<5
<0.5
<0.005
<0.1
<0.1
<1
<1
<0.005*
<0.05**
<0.05
<0.05
<0.002
<0.01
<0.005

b/l

mg/l

N
N
N

<0.1
<1
<0.05

g/l

N
N
N
N
N

<1
<0.02
<0.1
<0.1
<0.2

Not
found

Note: Announcement of National Environmental Committee, volume 8, 1994

N
natural condition
N
water temperature does not higher 3 degree celcius than normal temperature in nature
*
CaCo3 < 100 mg/l
**
CaCo3 > 100 mg/l
>
equal to or more than
<
equal to or less than
P20
percentile 20
P80
percentile 80
mg/l
milligram/liter
dl
deciliter
b/l
becerel/liter

18

g
MPN

microliter
most probable number

Classification of ground water reservoir

Quality standard values will be set for only reservoir class 2-4. Values of reservoir class 1
represent a natural water condition while those of reservoir class 5 will not be determined
Class 1: reservoir where quality of water is in natural condition without any wasted water
from any activities. Water can be used for;
- consumption by passing a normal disinfecting process
- natural reproduction of basic life unit
- conservation
Class 2: reservoir where wasted water is drained from some activities. Water can be used
for;
- consumption by passing a normal disinfecting process and general quality
improvement process
- conservation of water animals
- fishery
- swimming and water sports
Class 3: reservoir where wasted water is drained from some activities. Water can be used
for;
- consumption by passing a normal disinfecting process and general quality
improvement process
- agricultural purpose
Class 4: reservoir where wasted water is drained from some activities. Water can be used
for;
- consumption by passing a normal disinfecting process and special quality
improvement process
- industrial purpose
Class 5: reservoir where wasted water is drained from some activities. Water can be used
for only;
- transportation

19

Table 15 Income forgone from premature death caused by Diarrhea & Food Poisoning
Diarrhea & Food Poisoning
Number of
productive
years lost due
to premature
death (n)

Calculated income foregone from premature death at each age interval based on GDP per capita 1999 (baht)

0-4

5-14

15-24

25-34

35-44

45-54

55-64

2.0

9.5

19.5

29.5

39.5

49.5

59.5

1,129,800.00

2,400,825.00

2,118,375.00

2,259,600.00 3,813,075.00

1,098,416.67

2,334,135.42

2,059,531.25

2,196,833.33 -

1,067,905.09

2,269,298.32

2,002,322.05

2,135,810.19 -

1,232,911.26 1,038,241.06

2,206,262.26

1,946,701.99

2,076,482.12 -

1,198,663.73 1,009,401.03

2,144,977.19

1,892,626.94

2,018,802.07 -

1,165,367.51 981,362.12

2,085,394.49

1,840,053.97

1,962,724.23 -

1,132,996.19 954,102.06

2,027,466.87

1,788,941.36

1,908,204.11 -

1,101,524.08 927,599.22

1,971,148.35

1,739,248.54

1,855,198.44 -

1,070,926.18 901,832.58

1,916,394.22

1,690,936.08

1,803,665.15 -

10

1,041,178.23 876,781.67

1,863,161.05

1,643,965.63

1,753,563.34 -

11

1,012,256.62 852,426.63

1,811,406.58

1,598,299.92

1,704,853.25 -

12

4,402,724.32

984,138.38 828,748.11

1,761,089.73

1,553,902.70 -

13

4,280,426.42

956,801.20 805,727.33

1,712,170.57

1,510,738.74 -

14

4,161,525.69

930,223.39 783,346.01

1,664,610.28

1,468,773.77 -

15

4,045,927.75

904,383.85 761,586.40

1,618,371.10

1,427,974.50 -

16

3,933,540.87

879,262.08 740,431.22

1,573,416.35

1,388,308.54 -

17

3,824,275.85

854,838.13 719,863.69

1,529,710.34

1,349,744.42 -

18

3,718,045.96

831,092.63 699,867.48

1,487,218.39

1,312,251.52 -

19

3,614,766.91

808,006.72 680,426.71

1,445,906.76

1,275,800.09 -

20

3,514,356.72

785,562.09 661,525.97

1,405,742.69

1,240,361.19 -

21

3,416,735.70

763,740.92 643,150.25

1,366,694.28

1,205,906.72 -

22

3,321,826.37

742,525.90 625,284.96

1,328,730.55

23

3,229,553.42

721,900.18 607,915.94

1,291,821.37

24

3,139,843.60

701,847.39 591,029.38

1,255,937.44

25

3,052,625.72

682,351.63 574,611.90

1,221,050.29

20

Number of
productive
years lost due
to premature
death (n)

Calculated income foregone from premature death at each age interval based on GDP per capita 1999 (baht)

26

2,967,830.56

663,397.42 558,650.46

1,187,132.23

27

2,885,390.83

644,969.71 543,132.39

1,154,156.33

28

2,805,241.08

627,053.89 528,045.38

1,122,096.43

29

2,727,317.72

609,635.73 513,377.45

1,090,927.09

30

2,651,558.89

592,701.40 499,116.97

1,060,623.56

31

2,577,904.48

576,237.47 485,252.61

1,031,161.79

32

2,506,296.02

560,230.88 471,773.37

33

2,436,676.69

544,668.91 458,668.55

34

2,368,991.22

529,539.21 445,927.76

35

2,303,185.91

514,829.79 433,540.88

36

2,239,208.52

500,528.96 421,498.08

37

2,177,008.29

486,625.38 409,789.80

38

2,116,535.84

473,108.01 398,406.75

39

2,057,743.17

459,966.12

387,339.89

40

2,000,583.64

447,189.28

376,580.45

41

1,945,011.87

434,767.36

366,119.88

42

1,890,983.77

422,690.49

43

1,838,456.44

410,949.09

44

1,787,388.20

399,533.83

45

1,737,738.53

388,435.67

46

1,689,468.02

377,645.79

47

1,642,538.35

367,155.63

48

1,596,912.28

356,956.86

49

1,552,553.61

347,041.40

50

1,509,427.12

337,401.36

51

1,467,498.59

328,029.10

52

1,426,734.74

53

1,387,103.22

21

Number of
productive
years lost due
to premature
death (n)

Calculated income foregone from premature death at each age interval based on GDP per capita 1999 (baht)

54

1,348,572.57

55

1,311,112.23

56

1,274,692.44

57

1,239,284.32

58

1,204,859.75

50,339,037.31

34,054,764.91

21,675,736.24

1,906,537.50

Total

116,327,984.24

32,903,787.03 27,858,604.13

Table 16 Income forgone from premature death caused by Dysentery

Dysentery

Number of
productive
years lost due
to premature
death (n)

Calculated income foregone from premature death at each age interval based on GDP per capita 1999 (baht)

0-4

5-14

15-24

25-34

35-44

45-54

55-64

2.0

9.5

19.5

29.5

39.5

49.5

59.5

0.0

0.0

0.0

0.0

141,225.0

70,612.5

0.0

0.0

0.0

0.0

0.0

137,302.1

68,651.0

0.0

0.0

0.0

0.0

0.0

133,488.1

66,744.1

0.0

0.0

32,445.0

0.0

0.0

129,780.1

64,890.1

0.0

0.0

63,087.6

0.0

0.0

126,175.1

63,087.6

0.0

0.0

61,335.1

0.0

0.0

122,670.3

61,335.1

0.0

0.0

59,631.4

0.0

0.0

119,262.8

59,631.4

0.0

0.0

57,975.0

0.0

0.0

115,949.9

57,975.0

0.0

0.0

56,364.5

0.0

0.0

112,729.1

56,364.5

0.0

10

0.0

54,798.9

0.0

0.0

109,597.7

54,798.9

0.0

11

0.0

53,276.7

0.0

0.0

106,553.3

53,276.7

0.0

12

207,187.0

51,796.8

0.0

0.0

103,593.5

0.0

0.0

13

201,431.8

50,358.0

0.0

0.0

100,715.9

0.0

0.0

22

Number of
productive
years lost due
to premature
death (n)

Calculated income foregone from premature death at each age interval based on GDP per capita 1999 (baht)

14

195,836.5

48,959.1

0.0

0.0

97,918.3

0.0

0.0

15

190,396.6

47,599.2

0.0

0.0

95,198.3

0.0

0.0

16

185,107.8

46,277.0

0.0

0.0

92,553.9

0.0

0.0

17

179,965.9

44,991.5

0.0

0.0

89,983.0

0.0

0.0

18

174,966.9

43,741.7

0.0

0.0

87,483.4

0.0

0.0

19

170,106.7

42,526.7

0.0

0.0

85,053.3

0.0

0.0

20

165,381.5

41,345.4

0.0

0.0

82,690.7

0.0

0.0

21

160,787.6

40,196.9

0.0

0.0

80,393.8

0.0

0.0

22

156,321.2

39,080.3

0.0

0.0

0.0

0.0

0.0

23

151,979.0

37,994.7

0.0

0.0

0.0

0.0

0.0

24

147,757.3

36,939.3

0.0

0.0

0.0

0.0

0.0

25

143,653.0

35,913.2

0.0

0.0

0.0

0.0

0.0

26

139,662.6

34,915.7

0.0

0.0

0.0

0.0

0.0

27

135,783.1

33,945.8

0.0

0.0

0.0

0.0

0.0

28

132,011.3

33,002.8

0.0

0.0

0.0

0.0

0.0

29

128,344.4

32,086.1

0.0

0.0

0.0

0.0

0.0

30

124,779.2

31,194.8

0.0

0.0

0.0

0.0

0.0

31

121,313.2

30,328.3

0.0

0.0

0.0

0.0

0.0

32

117,943.3

29,485.8

0.0

0.0

0.0

0.0

0.0

33

114,667.1

28,666.8

0.0

0.0

0.0

0.0

0.0

34

111,481.9

27,870.5

0.0

0.0

0.0

0.0

0.0

35

108,385.2

27,096.3

0.0

0.0

0.0

0.0

0.0

36

105,374.5

26,343.6

0.0

0.0

0.0

0.0

0.0

37

102,447.4

25,611.9

0.0

0.0

0.0

0.0

0.0

38

99,601.7

24,900.4

0.0

0.0

0.0

0.0

0.0

39

96,835.0

24,208.7

0.0

0.0

0.0

0.0

0.0

40

94,145.1

23,536.3

0.0

0.0

0.0

0.0

0.0

41

91,530.0

22,882.5

0.0

0.0

0.0

0.0

0.0

23

Number of
productive
years lost due
to premature
death (n)

Calculated income foregone from premature death at each age interval based on GDP per capita 1999 (baht)

42

88,987.5

22,246.9

0.0

0.0

0.0

0.0

0.0

43

86,515.6

21,628.9

0.0

0.0

0.0

0.0

0.0

44

84,112.4

21,028.1

0.0

0.0

0.0

0.0

0.0

45

81,775.9

20,444.0

0.0

0.0

0.0

0.0

0.0

46

79,504.4

19,876.1

0.0

0.0

0.0

0.0

0.0

47

77,295.9

19,324.0

0.0

0.0

0.0

0.0

0.0

48

75,148.8

18,787.2

0.0

0.0

0.0

0.0

0.0

49

73,061.3

18,265.3

0.0

0.0

0.0

0.0

0.0

50

71,031.9

17,758.0

0.0

0.0

0.0

0.0

0.0

51

69,058.8

17,264.7

0.0

0.0

0.0

0.0

0.0

52

67,140.5

0.0

0.0

0.0

0.0

0.0

0.0

53

65,275.4

0.0

0.0

0.0

0.0

0.0

0.0

54

63,462.2

0.0

0.0

0.0

0.0

0.0

0.0

55

61,699.4

0.0

0.0

0.0

0.0

0.0

0.0

56

59,985.5

0.0

0.0

0.0

0.0

0.0

0.0

57

58,319.3

0.0

0.0

0.0

0.0

0.0

0.0

58

56,699.3

0.0

0.0

0.0

0.0

0.0

0.0

5,474,258.1

1,699,333.2

0.0

0.0

2,270,317.7

677,366.8

0.0

Total

24

Table 17 Income forgone from premature death caused by Enteric Fever

Enteric Fever
Number of
productive
years lost due
to premature
death (n)

Calculated income foregone from premature death at each age interval based on GDP per capita 1999 (baht)

0-4

5-14

15-24

25-34

35-44

45-54

55-64

2.0

9.5

19.5

29.5

39.5

49.5

59.5

0.0

0.0

0.0

70,612.5

0.0

0.0

0.0

0.0

0.0

0.0

68,651.0

0.0

0.0

0.0

0.0

0.0

0.0

66,744.1

0.0

0.0

0.0

0.0

0.0

0.0

64,890.1

0.0

0.0

0.0

0.0

0.0

0.0

63,087.6

0.0

0.0

0.0

0.0

0.0

0.0

61,335.1

0.0

0.0

0.0

0.0

0.0

0.0

59,631.4

0.0

0.0

0.0

0.0

0.0

0.0

57,975.0

0.0

0.0

0.0

0.0

0.0

0.0

56,364.5

0.0

0.0

0.0

10

0.0

0.0

0.0

54,798.9

0.0

0.0

0.0

11

0.0

0.0

0.0

53,276.7

0.0

0.0

0.0

12

0.0

0.0

0.0

51,796.8

0.0

0.0

0.0

13

0.0

0.0

0.0

50,358.0

0.0

0.0

0.0

14

0.0

0.0

0.0

48,959.1

0.0

0.0

0.0

15

0.0

0.0

0.0

47,599.2

0.0

0.0

0.0

16

0.0

0.0

0.0

46,277.0

0.0

0.0

0.0

17

0.0

0.0

0.0

44,991.5

0.0

0.0

0.0

18

0.0

0.0

0.0

43,741.7

0.0

0.0

0.0

19

0.0

0.0

0.0

42,526.7

0.0

0.0

0.0

20

0.0

0.0

0.0

41,345.4

0.0

0.0

0.0

21

0.0

0.0

0.0

40,196.9

0.0

0.0

0.0

22

0.0

0.0

0.0

39,080.3

0.0

0.0

0.0

23

0.0

0.0

0.0

37,994.7

0.0

0.0

0.0

24

0.0

0.0

0.0

36,939.3

0.0

0.0

0.0

25

Number of
productive
years lost due
to premature
death (n)

Calculated income foregone from premature death at each age interval based on GDP per capita 1999 (baht)

25

0.0

0.0

0.0

35,913.2

0.0

0.0

0.0

26

0.0

0.0

0.0

34,915.7

0.0

0.0

0.0

27

0.0

0.0

0.0

33,945.8

0.0

0.0

0.0

28

0.0

0.0

0.0

33,002.8

0.0

0.0

0.0

29

0.0

0.0

0.0

32,086.1

0.0

0.0

0.0

30

0.0

0.0

0.0

31,194.8

0.0

0.0

0.0

31

0.0

0.0

0.0

30,328.3

0.0

0.0

0.0

32

0.0

0.0

0.0

0.0

0.0

0.0

0.0

33

0.0

0.0

0.0

0.0

0.0

0.0

0.0

34

0.0

0.0

0.0

0.0

0.0

0.0

0.0

35

0.0

0.0

0.0

0.0

0.0

0.0

0.0

36

0.0

0.0

0.0

0.0

0.0

0.0

0.0

37

0.0

0.0

0.0

0.0

0.0

0.0

0.0

38

0.0

0.0

0.0

0.0

0.0

0.0

0.0

39

0.0

0.0

0.0

0.0

0.0

0.0

0.0

40

0.0

0.0

0.0

0.0

0.0

0.0

0.0

41

0.0

0.0

0.0

0.0

0.0

0.0

0.0

42

0.0

0.0

0.0

0.0

0.0

0.0

0.0

43

0.0

0.0

0.0

0.0

0.0

0.0

0.0

44

0.0

0.0

0.0

0.0

0.0

0.0

0.0

45

0.0

0.0

0.0

0.0

0.0

0.0

0.0

46

0.0

0.0

0.0

0.0

0.0

0.0

0.0

47

0.0

0.0

0.0

0.0

0.0

0.0

0.0

48

0.0

0.0

0.0

0.0

0.0

0.0

0.0

49

0.0

0.0

0.0

0.0

0.0

0.0

0.0

50

0.0

0.0

0.0

0.0

0.0

0.0

0.0

51

0.0

0.0

0.0

0.0

0.0

0.0

0.0

52

0.0

0.0

0.0

0.0

0.0

0.0

0.0

26

Number of
productive
years lost due
to premature
death (n)

Calculated income foregone from premature death at each age interval based on GDP per capita 1999 (baht)

53

0.0

0.0

0.0

0.0

0.0

0.0

0.0

54

0.0

0.0

0.0

0.0

0.0

0.0

0.0

55

0.0

0.0

0.0

0.0

0.0

0.0

0.0

56

0.0

0.0

0.0

0.0

0.0

0.0

0.0

57

0.0

0.0

0.0

0.0

0.0

0.0

0.0

58

0.0

0.0

0.0

0.0

0.0

0.0

0.0

Total

0.0

0.0

0.0

1,480,559.9

0.0

0.0

0.0

27

Reference
Bureau of Environmental Health, Department of Health., Annual Report on Situation of
Quality of Water in Thaiuland, 1997-2000.
Epidemiology Division, Office of the Permanent Secretary for Public Health, Summary
Report on Disease Surveillance, 1998, Ministry of Health, 1999.
Grendell JH, McQuaid HR, and Friedman SL. Current Diagnosis & Treatment in
Gastroenterology. International edition. LANGE medical book. 1996.
Jaroonvej N. Tropical Diseases. 2nd edition.
Murray, Christopher J.L., and Alan D. Lopez, eds. The Global Burden of Disease:A
Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and
Risk Factors in 1990 and Projected to 2020 (Global Burden of Disease and Injury
Series, Volume I). Cambridge, Mass.:Harvard School of Public Health on behalf of
the World Health Organization and the World Bank.
National Statistical Office, Report on Health and Welfare Survey 1996. Bangkok Aksom
Thai Press, 1997.
National Statistical Office, Report on Households Economic and Social Status Survey
1996, Bangkok Aksom Thai Press, 1998.
Siripen Supakankunti and Wattana S. Janjaroen Economic Analysis of Health Card Project
in Thailand: Case of Chiang Mai Province, 2000.

28