Fluoridated milk, equitably caries prevention for thai children.
The Royal Chitralada Projects

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
The Thailand National Oral Health Survey in 1994 showed that levels of dental caries (tooth decay) are still increasing, especially in children aged around 6 years old. 85% of them having primary teeth affected with the mean dental caries experience was as high as 5.6 teeth. Moreover 11% of them had already developed dental caries in newly erupted permanent teeth. 54% of children aged 12 years old were affected with tooth decay problem in permanent teeth with the mean dental caries experience was 1.6 teeth nationally (but 2.3 teeth in Bangkok). Unfortunately, 72% of tooth decay was untreated and might lead to tooth loss if access to care was limited, especially for the poor. Severe dental caries can cause pain and difficulty in eating that might lead to absences from school and insufficient growth. The treatment would need expertise and high expenses for parents and the government. Children suffering from dental decay could have reduced their quality of life. Low socio-economic status of parents is one risk factor of dental decay among Thai children. Even though dental decay can be prevented by means of 1) reducing sugar consumption by both amount and frequency, 2) tooth brushing with fluoride toothpaste and 3) applying pit and fissure sealant. National data indicated that most preschool children have high deciduous caries and more than half of primary school children were still suffered from high permanent tooth decay. There was a need to introduce equitable caries prevention measures to reach all children attending school from age 3 to 12 years in order to improve oral health. Optimal fluoride had been used worldwide for more than 70 years for tooth decay prevention. For erupted teeth, fluoride can inhibit the de-mineralization process from acid produced by plague-bacteria and also promote re-mineralization of tooth surface before dental caries developed into cavities. High concentrations of fluoride can also inhibit the growth of dental caries causal bacteria. The WHO Expert Committee on Fluoride and Oral Health in 1997 recommended the implementation of Milk Fluoridation program, one alternative of the cost-effective community based measures with substantial caries prevention effects, in the community with middle to low socio-economic status in addition to the program of tooth brushing with fluoride-toothpaste. Fortunately, the Thai Government, through the Ministry of Education, launched the National School Milk Program in primary schools in 1992. This initiative has provided the opportunity for children to receive milk free of charge to improve nutrition and potential growth. At the beginning the program was limited, but continued to expand to more children. In 2000, public school children aged 4-10 received school milk for 200 school days but at present, all school children in Thailand aged 4-12 receive a pack of milk/day on school days and school holidays (a total of 260 days a year). By law, all children lower than aged 12 must attend school. This provided a good opportunity to add fluoride to school milk for the equitable improvement of the oral health of children.

B. Strategic Approach

 2. What was the solution?
This initiative was proposed by the Royal Chitralada Projects (RCP) incorporated with the Department of Health, Ministry of Public Health (DOH). The aim was to consider the technical aspects of milk fluoridation and through a pilot scheme in Bangkok, to establish the necessary processes and systems that would enable the existing school milk program in Thailand to be used as a vehicle for the delivery of fluoride for caries prevention to Thai children equitably. The strategy of adding fluoride into milk under the strong policy of national school milk program would ensure all school children were exposed to optimal fluoride equitably and continuously for the long term. Using the existing school-milk system, the school would find that fluoridated-milk improved their student’s teeth with no extra workload required. The strategy of fluoridated milk production with simple procedures, good standards and knowledge transferring was targeted to ensure the children’s safety and effectiveness of caries reduction. After first producing fluoridated-milk in Thailand, RCP developed the fluoridated-milk production manual, using their knowledge and experience. When the project expanded, more involved dairies were trained by the RCP using this guideline. Strategy on fluoride monitoring, surveillance and an evaluation study on effectiveness were used to guarantee the safety and benefits for the children. A urine fluoride excretion study in children was done before the project started to confirm the real need of fluoride supplements and was followed up (the surveillance) to be aware of any change of fluoride in the community for safety and to show the optimal level for caries prevention. Regular checking of fluoridated-milk products would confirm the good quality of the dairy. An evaluation study was important to show the benefit for decision making on future expansion. The strategy of working by committee, by integrating and networking were used to seek project cooperation, acceptance and sustainability. There were many involved parties and stakeholders whose lines of command were independent. The better oral health of children, the future of the Thai population, was targeted for working together. A steering committee and subcommittees were set up to provide policy and to drive the project as planned. The milk fluoridation project was integrated as part of the health promoting school program. Working as a ‘network’ was encouraged to enhance cooperation among people working on the ground from all involved parties. Training and technology transferring strategies were applied. At first, academic experiences from the World Health Organization (WHO) were transferred to the DOH on the implementation, monitoring and evaluation of the project. When the project expanded and extended to the provinces, academic aspects and the administration of the project were trained and transferred to the provincial health authority. By the same strategy, RCP was trained by Thammasat University (TU) on the principals of fluoridated-milk production and passed the knowledge and experiences on to all new dairies involved later. Public relations via mass media strategy was done regularly in every way possible, especially an annual report to the Princess, as part of the projects under RCP on Royal Ploughing Day, to inform the public of the milk fluoridation program, the safety, the project activities and oral health benefits for the children. The address and telephone number of the project staffs were available for them to communicate and contact. This will ensure that reliable messages would be given to all involved parties and the public.

 3. How did the initiative solve the problem and improve people’s lives?
The system to produce fluoridated-milk and control quality was developed both pasteurized and UHT types to ensure that every dairies could be in the good standard. The technical aspects including preparing fluoride solution, spraying fluoride into raw milk, measuring fluoride in milk, were set up. Fluoride added to milk is very low in cost and the procedure of fluoridated-milk was not difficult so the dairy readily accepted this project. Milk is a healthy product and with the added benefit of fluoride, this fitted in well with the Health Promoting Schools scheme. The initiative was first introduced in Asia in Thailand. This helped all school children to reach optimal fluoride for caries prevention equitably without socioeconomic barriers, as long as they were still attending school. Fluoride added to milk didn’t make any change from plain milk so children can drink fluoridated-milk as they would plain milk. This would promote the opportunity of higher effectiveness of fluoride on caries prevention. This project was well received among schoolteachers because no extra workload was required in the operation of fluoridated-milk from the routine school milk while their children received fluoride supplements from the milk to reduce caries automatically.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
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.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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.
 6. How was the strategy implemented and what resources were mobilized?
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.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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.

 8. What were the most successful outputs and why was the initiative effective?
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.

 9. What were the main obstacles encountered and how were they overcome?
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.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
By this project school milk has proved to be one of the best vehicles for fluoride supplementation to all children without barriers. It proved to be the most efficient ways. Only at dairy level was there any extra work and the ability of personnel had to be put in and also costs were added in producing fluoridated milk from plain milk. One dairy can deliver fluoridated milk containing optimal fluoride for caries prevention to children in very large numbers, even in the city or remote rural areas. Addresses and telephone numbers were available for people to contact for get information of the project and ask questions. This helped children to maintain healthy teeth until they grew up and improved oral hygiene habits. From 34.4% of caries reduction from this project, DOH could massively reduce budget and manpower on treatment or clinical preventive measures. The reduction was based on receiving milk 160-170 days a year. The WHO stated that the effectiveness of fluoridated milk to prevent caries was higher when the child received milk more days. Now the total days school milk was provided increased to 260 days (covering school holidays), and as a result more benefits can be expected. This project is a dental caries preventive measure. Together with the existing supervised tooth brushing program and an effective diet consultant program, the children will grow up without any fillings in their teeth. They are truly healthy children with healthy teeth. That is the goal of quality of life. It has seen an improvement in the standards applied in dairies supplying school milk. All dairies that produced fluoridated milk were upgraded to the premium standard of management with GMP Codex requirements. This is customer protection automatically for their other milk products available in the market. Dairies with international certification guarantees can also export their product legally. Children that participated in this project would be trained to form the habit of not adding sugar to milk. Any habit formed at a young age will continue into adult life. This will have a long lasting benefit to their lifestyle on eating and diet. A healthy life style would reduce the risk for threatening diseases such as obesity, DM, hypertension and heart disease. Quality of life was impacted directly. An appropriate fluoridated milk manual was developed by RCP for dairies in Thailand. This is an opportunity for national expansion and a wonderful opportunity for all Thai children. The better the coverage, the more impact will be felt by society and the country. Working by integration and network targets to the improvement of children was formed, sustained and shared were some of the most successful strategies in this project. Milk fluoridation was successfully integrated into the wider health promoting school program that is a national program so not only the dental personnel worked for it, but the Office of Provincial Health Authority worked for it too. The milk fluoridation project integrated a strong and sustainable national school milk program automatically by adding fluoride into school milk. All systems of school milk were covered in the milk fluoridation project and were well accepted because this project helped children get better oral health. The initiative enabled the BMA and provincial health authorities to extend their work in the prevention of dental disease, using milk as a vehicle for the delivery of fluoride to children on an equitable basis in accordance with the recommendations of the WHO. A national network for the head of the provincial health authority was formed and sustained. They can learn from each other to develop their provincial projects without more pressure for the Central Team. This provided the opportunity for the project to expand nationwide.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
The ‘model’ developed in Bangkok has proved to be transferrable and scheme have since been implemented in 8 provinces. The pilot project was in Bangkok involved 300,000 children, 100% coverage of schools under the BMA. The project was also extended to more provinces more since then. Now the project has been implemented in eight provinces covering more than 1,000,000 children. Moreover, four provinces including three politically sensitive provinces, which have the highest caries problem in the South, are in preparation to be implemented in the project. The systems for the production of fluoridated-milk and quality control have been established on a sustainable basis. Milk is offered free of charge in schools to all children aged 4-12 years. The cost of adding fluoride to milk is very modest and can be absorbed by the dairies involved. This has enabled fluoridated-milk to be supplied at the same price as non-fluoridated milk. The National Policy has supported the expansion of the milk fluoridation project throughout the country. The preparation for national implementation would include the following issues. Fluoride mapping should be available for consideration, areas of high fluoride content had to exempt. Urine fluoride studies in children should be done to confirm the real need for fluoride intervention before starting the program and follow up checks to ensure project effectiveness without side effects. Dental personnel should be trained to understand clearly the use of fluoride for caries prevention. GMP Codex, the requirement for the dairy to produce fluoridated milk, should be promoted for all dairies in the school milk business. The availability of qualified companies to give certification should also prepare to reduce the burden of the FDA. Permanent permission of the dairy to produce fluoridated milk should be considered instead of temporary permission. This will reduce the workload of the FDA and allow dairies to develop themselves to obtain permission Integrating fluoridated milk monitoring at the dairy into the routine work of the local FDA should be considered. In this case, the intensive training course and guidelines of the checklist should be prepared to gain the confidence and ability of the local FDA. RCP should develop the efficient method of dairy’s training to reduce their workload. Self-learning and self-assessment packages using modern technology may be considered. Setting up more training centers in the qualified dairies or private organizations might be considered. Stricter quality performance monitoring measures should be developed to standardize training centers. The specification of school milk should be adjusted to allow local authorities to decide to choose fluoridated milk in the area that the milk fluoridation project was implemented without yearly formal letters from the governor to request fluoridated milk. International replication was also possible. The milk fluoridation project is open to all interested countries to visit and train in Thailand. Mongolia is now on preparing to start a milk fluoridation project after visiting Thailand received a training course from RCP.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
The milk fluoridation project was expanded in the implementation phase rapidly, exceeding expectations. The system set up at the beginning was considered for small sites on the basis of integration into routine roles of personnel. The technical aspects of milk fluoridation and the establishing of procedures and systems for the production of fluoridated milk and quality controls in the development of the scheme in Bangkok had transferred to other provinces. The need for training at RCP was greater when the project extended and more dairies became involved. This included existing dairies whose personnel moved or changed job. The extra work on training courses was expected to be done in between other routine work. These created a silent overload and pressure on the trainer themselves and also created the risk of low performance of the dairies under the project. Fortunately no bad examples happened. Most of the knowledge on milk fluoridation for caries prevention was in English including the WHO manual. This made it harder for dental personnel and everyone to learn properly, especially when they had other work to do. The need for the Central Team to assist in this issue was greater than expected. It was learnt that available documents and knowledge should be translated into Thai and the extensive training course on this issue should be done for the dental personnel to be more confident and could provide greater knowledge in the issue. Equipment for fluoride measuring is made in America and of course, the procedure is in English. This also created difficulty for dairy personnel. The problem was less if they knew English well, but could create serious problems by not understanding English properly. It was learnt that a translation of the manual would reduce the burden of both trainee and trainer dairy personnel and help provide a longer shelf life for the equipment. When the project is implemented widely, systems should be revised for sustainability. The private sector will be encouraged to become more involved.

Contact Information

Institution Name:   The Royal Chitralada Projects
Institution Type:   Government Agency  
Contact Person:   PATHUMMA BUTDEE
Title:   Develop and management Section  
Telephone/ Fax:   +(66)2 282 1150-1 ext 4304
Institution's / Project's Website:  
E-mail:   bpathumma@yahoo.com  
Address:   Dusit Palace, Rajawithi Rd.
Postal Code:   10303
City:   Dusit District
State/Province:   Bangkok

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