| 4. In which ways is the initiative creative and innovative?
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Pilot project (2001-2005)
In 2000 a feasibility study was done by RCP and DOH and indicated the possibility to pilot the project in Bangkok where children have a high dental caries problem and there is a low of fluoride in drinking water. RCP agreed to be the main organization to co-ordinate all involved parties, to develop and produce fluoridated-milk for children participating in the project and to train other dairies when the project was expanded.
In 2001 RCP, DOH, TU, WHO and the Borrow Foundation (BF) signed an agreement to be partners in this project and on 16 May 2001, the initiative was executed officially.
A steering committee, consisting of policy makers from involved organizations, was set up to provide policy and to drive the project forward. The subcommittees were set up to work on academic, promoting, monitoring, evaluating and reporting of the project.
The Food and Drug Administration (FDA) was asked for cooperation and agreed to temporally give annual permission for fluoridated-milk production for qualified dairies to produce and supply to schoolchildren participating in this project only. The packaging of fluoridated-milk had to be different from regular school milk and highlight the fluoride content.
RCP personnel were trained by TU experts in the scientific method of adding fluoride to milk and further developed an appropriate procedure of fluoridated-milk production for Thailand. A 200-milliliter plastic bag of pasteurized fluoridated-milk contained 0.5 milligrams of fluoride.
Having been informed of the project and of the oral health benefit of children by the meeting and documents all 14 schools and their 14,000 students that received school milk from the RCP previously decided to participate in this project and parents allowed their children to drink fluoridated-milk by signing a formal consent form.
For monitoring and evaluation, two schools in this project and two control schools (consuming plain school-milk) were chosen to be samples for the study. A baseline urine fluoride excretion study was done and showed the need for fluoride intervention and surveillance to be done yearly. The baseline oral health were collected and followed up annually for 5 years.
In June 2001 fluoridated milk was first produced and delivered to schools. In 2004, UHT-fluoridated-milk was produced for school holidays.
The dairy measured the fluoride concentrations in every batch of fluoridated-milk and the DOH and TU double-checked samples monthly.
Teachers promoted and encouraged all children to drink fluoridated-milk at school regularly and recorded the consumption per day. An annual teachers meeting was held by the RCP and DOH to learn and to share experiences on the project and the health promoting school program.
Data on monitoring and evaluation was analyzed. Results showed the total coverage of children with high consumption days, high standards of fluoridated-milk products, optimal total fluoride intake and effectiveness on caries reduction.
Implementation phase (2005-2010)
The project expanded massively in Bangkok and extended to the provinces with more dairies involved. The DOH, RCP and FDA developed a working group called the ‘Central Team’. The roles were to assist them set up the foundation of their schemes and strengthen the scheme for project sustainability. For the new scheme development, Central Team would also assist and facilitate for a feasibility study.
A national network group of milk fluoridation was set up. The chief dental officers of each project were members and used techniques of sharing experiences and helping each other to strengthen every project. A network strategy was also applied at provincial level and for the dairies that produced fluoridated milk together.
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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RCP assisted the DOH in developing, monitoring and evaluating the pilot project of “fluoridated milk, equitably caries prevention for Thai children" and during implementation.
RCP: produced fluoridated-milk supplies for school children participated in the pilot and developed a fluoridated-milk production manual. Setting up the training course on fluoridated- milk production and being consultant for the dairies.
DOH: informed and produced documents of the project and fluoride for oral health benefits of schools, parents and students and the public. Monitored and evaluated the project.
TU: trained the RCP on scientific techniques on adding fluoride to milk. Consultation for the project staff and provided the knowledge on fluoride and oral health to dental personnel.
WHO: provided international experiences on the monitoring and evaluation techniques for the project staff.
BF: financial support and acted as academic facilitator.
FDA: permission for fluoridated-milk production and monitored the dairies.
National Primary Education Committee Office (OPEC): providing the budget for
school milk.
Local authority: decision making to choose and provide fluoridated-milk for schools.
The dairy: improved to get and maintain the GMP Codex and also maintained good standards of fluoridated milk products and delivered to school.
School: monitored the children to drink fluoridated milk properly and informed parents of the fluoridation.
The parent: Allowed the children to drink fluoridated milk at school and provided unsweetened milk at home.
Central team: Consisted of RCP and in the assistance of DOH and FDA to work on new dairy development, dairies visit and annual meeting and also holding the annual teacher meeting. Central team also assisted provincial public health in preparing the feasibility study and developing new provincial project.
Bangkok Metropolitan Administrative (BMA) and the provincial health authorities: took responsibility in developing provincial project and managed the project on a day-to-day basis.
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| 6. How was the strategy implemented and what resources were mobilized?
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Pilot project
The initiative was implemented largely through the reconfiguration of existing resources. The schemes were delivered by the provincial health authorities, incorporated into their oral health strategies, under the auspices of RCP and DOH
Development grants have been provided by the BF. However the program has been established on a sustainable basis. There is no additional cost for supplying children with fluoridated-milk as the national school milk program provides milk free of charge to children aged 4 – 12 years and fluoride is simply added to this existing supply. The initiative involved minimal disruption to schools as there were well established systems already in place for the administration of school milk by local authorities and also the distribution of milk by staff in schools.
For human resources, personnel of every involved organization who worked for this project routinely would not receive any extra salary. This included RCP, DOH, TU, FDA, and schoolteachers. They all devoted themselves to more work and responsibilities to achieve the target, the improvement of children’s oral health. The money was paid for outsiders who worked for the monitoring and evaluation study.
WHO and TU were the main technical resources for DOH and RCP. The training courses were arranged for the personnel to learn and update the essential knowledge. Technical support was also by self-learning from WHO books and guidelines that were sent from WHO offices and available on the WHO website, such as Milk fluoridation for the prevention of dental caries and Fluoride and oral health. DOH and RCP then transferred and simplified the knowledge to dental personnel and the dairies. The cost was part of the meeting or training course.
BF contributed financial support for the preparing of the RCP dairy plant to produce fluoridated milk and also the fluoride measuring equipment directly. Moreover, financial support was required for public relations, teacher meetings and the monitoring and evaluation of the project. The agreed funding was transferred to DOH and DOH managed to spend as agreed and reports the progress annually.
Implementation phase
All financial support from BF was directed to DOH. Part of the funding was for DOH management as per agreed activities. Another part was for the development of provincial projects. Agreed funding would be sent from DOH to each province and the provincial health authority would manage the fund to spend on the activities as agreed (public relations, launching the project, monitoring and evaluation) and report annually to DOH. Funding was higher in the first year and when the scheme was settled then routine activities might be integrated into the existing heath promoting school program.
The dairies paid for the preparation on GMP Codex, the milk plant to produce fluoridated milk and routine expenses on production. BF supported a set of fluoride measuring equipment for every new dairy.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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1. The consumption rate of children drinking school milk is higher. Teachers strongly committed themselves to managing all children to drink fluoridated milk regularly for good teeth together with good health. From the reports it showed a higher consumption rate, this result corresponded with the children’s questionnaire and school observations.
2. 20 dairies maintained GMP Codex. Dairies were asked for GMP Codex, the international standard certification that was above the standard of general school milk, to join in fluoridated milk production.
3. Innovation of fluoridated milk production, both pasteurized and UHT. RCP developed the standard fluoridated milk production and control procedures and produced a manual. RCP became the training center for all dairies to produce fluoridated milk when the project was expanded. All dairies performed to a high standard.
4. Teachers have developed better skills in encouraging children to drink non-sugary milk since the milk fluoridation project started. By this project, the DOH proved children could be provided with fluoride supplements for caries prevention automatically with no health personnel required.
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| 8. What were the most successful outputs and why was the initiative effective?
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An annual dairy visit by RCP, FDA and DOH was undertaken to monitor the performance of every dairy. Random monthly checks of fluoridated milk from school and dairies were also done to monitor the work of the dairy. If the dairy couldn’t perform to a good standard they wouldn’t obtain production permission from the FDA.
Urine fluoride excretion studies in young children aged 4 years both receiving fluoridated milk and normal school milk was performed once a year. The results showed that in children exposed to fluoridated milk, levels of fluoride increased into the optimal level for caries prevention.
A study on the effectiveness of fluoridated milk for caries prevention was done in 2 sample schools whose children drank fluoridated milk (160-170 days a year) and two control schools. Oral health and related data was collected every year. The results showed 34.4% of caries reduction in children. No side effects were found.
In a teachers meeting in 2005, all schools asked the RCP to continue this project and expand to rural areas to benefit all Thai children. This showed the high acceptance of this project.
Telephone numbers, e-mail and postal addresses of project staff were made available for parents and teachers to contact to get information and knowledge of the project. To maintain the high performance of the dairies, RCP played the role of telephone consultant and also prepared spare fluoride measuring equipment for them to borrow when technical malfunctions occurred.
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| 9. What were the main obstacles encountered and how were they overcome?
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The problem of children not wanting to drink the milk was discussed and it was agreed that every school would study how to solve this issue. In every annual meeting since then, the success experiences were presented and exhibited. Small group discussions were organized to share experiences on this issue to help teachers improve their students.
At the beginning the school milk auction process was opened to all dairies competition. It depended on the decision of the local authority to choose school milk for their children. Because not all dairies could product fluoridated milk so this had created the disruption of fluoridated milk supplied to children in the project. Adding fluoride in specification of school milk and providing formal letter asking for corporation had been done to ensure the continuity of fluoridated milk drinking. In 2009, the process changed to “the quota” then the dairies those produced fluoridated milk were allocated to the projects.
Problems also occurred regarding VAT for selling fluoridated milk. In 2006, the project was expanded and more dairies became involved. The Department of Revenue, Ministry of Finance asked all dairies to pay VAT on fluoridated school-milk by the law that any agent added into milk couldn’t be called plain milk and had to pay additional tax. This would cover since they started selling fluoridated milk until the present time. The price of school milk did not included VAT and the dairies couldn’t take responsibility and would stop producing fluoridated-milk. The Ministry of Public Health and WHO wrote formal letters to the Minister of Finance asking for VAT exemption for selling school fluoridated- milk for the better oral health of Thai children. After two years, fluoridated-milk was exempted from VAT.
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