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The "triangle that moves the mountain" and Thai alcohol policy development: four case studies.

The alcohol policy process is one of the most complicated public policy arenas, perhaps because it involves many policy actors who attach different values and interests to alcohol consumption and related problems. Governments generally have four interests with regard to alcohol. These are the contribution of alcohol to the economy, and to fiscal interests, the effect on labor productivity, and the consequences of consumption, particularly for public health and social order (Makela & Viikari, 1977). Alcohol consumption and related-impacts have implications for most, if not all, individuals in the society. This legitimizes the participation in the policy process of multiple stakeholders, who engage in the process with their own values, interests and patterns of relating to others, as they draw attention to, argue and trade off their preferences with policymakers.

In most societies, the alcohol policy process is influenced by many values and interests. The fundamental incompatibility between economic and political values and health-oriented values, therefore, is easily recognized (Babor, 2002). Modern governments try to strike a balance between maximizing benefits and minimizing detriments. However, government values with regard to alcohol are neither neutral nor homogeneous. Interests and responsibility are often split among different government departments (Osterberg and Karlsson, 2001; Room, 1999). Conflicts within departments and between different levels of government are also common (Room et al., 2002).

Moreover, alcohol policy has been formulated, strengthened, weakened and repealed over time. Swings from one extreme to another, in term of strictness, have been witnessed in the past century. The social climate, or how people think about drinking problems and alcohol policy (Partanen & Montonen, 1988), significantly shapes policy outcomes. The iterative changes in alcohol policy also reflect competing influences on the alcohol policy process, from ideological conflicts in problem definition to the policy evaluation process.

Thailand has been a democratic constitutional monarchy since 1932. His Majesty the King exercises his authority through three mechanisms: legislative, government and judiciary. Since becoming a nation state, the Thai government has centralized power and developed a strong bureaucracy to control development in line with the modernization paradigm. The Thai administrative system has undergone a fundamental transformation from a centralized bureaucracy to a democracy. However, the bureaucracy or civil service still has a significant role in Thai politics. The coalition between politicians and bureaucrats, including the civil service and the military, is the key factor for Thai social and political reforms (Bowornwathana, 1997). Meanwhile, citizen movements, including nongovernment organizations (NGOs) and community workers, are fragmented and have had minimal involvement in the policy process, especially prior to 1997.

Currently most ministries have a foothold in alcohol issues, the main responsibility being shared by the Ministries of Finance, Interior, Education, Public Health and the Royal Thai Police Office. The National Alcohol Consumption Control Committee (NACCC), combining representative from ministries and other experts, was established in 2004. However, the development of alcohol policy would most likely depend on the individual interests and the competency of these authoritative elites, rather than their collective capacity.

Alcohol consumption in Thailand increased significantly between 1961 and 2001, the recorded adult per capita consumption rising from 0.26 liters to 8.47 liters of pure alcohol (World Health Organization, n.d.). Many factors contributed to this dramatic rise, including economic growth which transformed Thailand from a low to a middle income country, and a modernized lifestyle, as well as a shift from unrecorded to recorded consumption. The upsurge in Per Capita Gross Domestic Product (GDP) (Thamarangsi, 2005), relatively static and decreasing prices for popular beverages in relation to incomes, and high levels of physical availability played a major part (Thamarangsi, 2006). Cultural change, in particular the fading of the Buddhist faith, which discourages alcohol use among its followers, occurred alongside the increasing popularity of European-style drinking culture. Beer consumption, for instance, showed a sevenfold increase between 1981 and 2000 (World Health Organization, n.d.). However, information on the increase in consumption had not been publicized until recently. Road traffic crashes are the alcohol-related problem of most concern for the Thai government. It was the second highest cause of death, at 13,116 deaths in 2002 (Wibulpolprasert, 2005).

The concept of the triangle that moves the mountain

Professor Prawase Wasi, one of the most well-known medical, public health and social scholars in Thailand, has promulgated the concept of the Triangle that Moves the Mountain since 1997. He synthesized the concept from the political reform process that brought Thailand a whole new constitution, B.E. (Buddhist Era) 2540 (1997) (Wasi, 2005a). The entire process for the new constitution originated from a comparative study of the constitutions and laws of numerous countries by 15 researchers, supported by the Thailand Research Fund. This project identified and publicized the opportunity to improve the existing constitution. People from all sectors were extensively involved in the process, especially through public hearings and brainstorming. The constitution, drafted by the people, was then passed on to be enacted by the House of Representatives and House of Senators. Citizen participation in politics and administration, particularly in human rights, was certainly prioritized in this constitution. Previously such involvement in this process had been almost impossible for nonpolitician and nonelite people in the Thai context (Wasi, 2000).

In order to move the immovable "mountain," a metaphor for extreme difficulty including complicated social problems and social inertia, Professor Wasi indicates that it is necessary to strengthen the three interconnected angles or sectors; knowledge, social movements, and political involvement.

The first task is to generate relevant knowledge, which can be achieved through many mechanisms. The whole problem-solving process, in fact, could also be considered as the learning-by-doing practice for stakeholders, or so called "participatory learning through action" (Wasi, 2005a). Without knowledge, societal power would be scattered and incapable of moving in the right direction (Wasi, 2005b).

The second task is facilitating a social movement to support the transformation of knowledge into policy. The combination of knowledge and a social movement will vocalize the demand and guide the appropriate solution(s) for policymakers, at the political angle.

The last angle is to fortify the authoritative aspect, the government. This requires capacity building in both the political and bureaucratic sectors, using suitable mechanisms. These include cooperative cross-organizational working among the relevant public sectors, and the involvement of policymakers in technical and social actions.

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Movements in the three sectors must be connected together in order to effectively generate society's ability. The concept of the Triangle that Moves the Mountain has been applied nationwide to various problems, including poverty, the environment, the economy, education, agriculture and public health. Furthermore, many also employ this concept to address local and community problems.

Methodology

This article describes and analyzes the implications of the strategic concept, the Triangle that Moves the Mountain, drawing on four case studies in the Thai alcohol policy arena from 1990s to 2006. It is essential to understand that the concept of Triangle that Moves the Mountain is a strategy for policy advocacy, rather than a tool to analyze the public policy process. Each case study contains a description of backgrounds and movements in each of three sectors, as well as an introduction and analytical summary. Lessons learned from these four case studies are synthesized at the end of the article.

Although the first case study, the process of the establishment of the Thai Health Promotion Foundation, commenced a long time before the concept was developed and propagated, the process was analysed retrospectively and is shown to be in line with the concept (Siwaraksa, 2005). In the other cases, it is evident that policy players in the health and social sectors applied this strategic concept to conduct their movements.

Case study 1: The establishment of the Thai Health Promotion Foundation and its contribution (2001)

Background

Thai Health Promotion Foundation or ThaiHealth is a statutory public organization, working within government but free from bureaucracy. ThaiHealth identifies itself as a part of civil society, with a mission to empower movements to promote the well-being of Thai citizens, by acting as a catalyst for projects that change values, lifestyles, and social environments for the better. Established by the Health Promotion Foundation Act B.E. 2544 (2001), ThaiHealth was designed to provide financial support for health promotion activities (Thai Health Promotion Foundation, n.d.-b), particularly in areas hard to reach by conventional bureaucratic systems. Uniquely, it receives a dedicated budget from a direct and specific process--an earmarked 2% of tobacco and alcohol excise taxes.

Knowledge

The process started with a series of studies on tobacco control policy in the late 1980s, particularly on tobacco taxation and price elasticity. Research showed the advantage of increasing the excise tax to prevent youth smoking without decreasing state revenue. These domestic findings were reinforced by international experiences, a body of knowledge outlined in the World Development Report and by the World Health Organization. This knowledge management process led to a tobacco tax increase in 1993, the first ever taxation increase for health purposes in Thailand (Siwaraksa, 2005).

The Health System Research Institute (HSRI) subsequently managed a research series to find a secure and sustainable financial source for antitobacco campaigns. This was perhaps a response to the decrease in allocated budget from the Ministry of Public Health (MoPH) during the mid-1990s (Supawongse, Bursai, & Thanapathara, 1999). The knowledge movements at this stage enabled key Thai antitobacco people to recognize the possibility of a dedicated tax initiative, along the lines of the WHO-recommended Victorian Health Promotion Foundation in Australia. This triggered HSRI to review the legislative process leading to the establishment of health promotion foundations in 11 countries (Boonphinon, 1997).

After several rounds of working group meetings, the proposal for establishing a Thai health promotion fund was tabled to the Committee for the Implementation of the Fiscal and Financial Master Plan for Social Development in 1997. In this draft bill, the health promotion foundation was to receive funding from part of the tobacco excise tax only. Unfortunately, political change and an economic crisis in 1997 froze all legislative progress (Siwaraksa, 2005). Furthermore, some lawyers argued that the concept of a health promotion foundation and an earmarked tax contradicted the fiscal discipline principle and the Public Organization Act B.E. 2542 (1999).

Social movement

Social mobilization played an essential role in the establishment of ThaiHealth, particularly in the early phase. Since 1986 antitobacco NGOs, especially the Rural Doctor Foundation (RDF), had widely publicized information on the negative impacts of smoking and advocated for rights of nonsmokers. In 1987, the 3,000 km Run-for-No Smoking Campaign was conducted by RDF and the Rural Doctor Society. It received strong nationwide support, including from health professional organizations, the Buddhist Monks Organization, mass media, local governments, health volunteers and academics. Over 6 million people signed an open-letter to MoPH calling for a stronger antitobacco policy.

Later, during the years 1988-1991, protests against foreign cigarette companies were organized, after the U.S. Cigarettes Exporter Association applied pressure and forced Thailand to liberalize its tobacco market (Supawongse et al., 1999). The protests provided the opportunity for the Thai antitobacco movement to connect with international players, especially the Asia Pacific Association for the Control of Tobacco. Many foreign and international antitobacco organizations expressed their concern to the Thai Prime Minister (PM). Overall, antitobacco movements since the 1980s have changed social perceptions about tobacco, causing smoking to be seen as a public rather than individual issue and creating awareness of nonsmoker's rights. A survey that found that 70% of the population supported tobacco tax increases simplified the decision-making process in 1993 (Siwaraksa, 2005).

Political involvement

Knowledge activities were closely supervized by politicians and high-level bureaucrats. By working together, academics and policymakers from different departments were able to solve the conceptual conflicts, particularly around the funding mechanisms and fiscal discipline issue. The National Tobacco Consumption Control Board and the Office of Tobacco Consumption Control (OTCC) were instituted in 1989 and 1990 respectively. Both were the key coordinating platform and agency for stakeholders from different backgrounds and organizations.

In 1998 the cabinet decided to repeal the concession system for alcohol production and distribution. An increase in alcohol-related problems was raised as a potential impact of the campaign to liberalize the alcohol business. The Minister of Finance was urged to explore mechanisms for mitigating the negative consequences. The Ministry of Finance working group, chaired by the Director-General of the Excise Department, consequently proposed the Campaign Fund for Cessation of Alcohol and Tobacco Consumption project. The fund was to receive 1%-2% of alcohol and tobacco excise taxes, on a nonadditional or nonearmarked basis. The objectives of this fund were to distribute information and support training, research and related activities.

A study was conducted to compare and analyze the two proposals; HSRI's to establish a foundation and the Ministry of Finance's. Later on in 1999, the idea of merging the two proposals was raised in the National Social Policy Commission, chaired by the PM. The commission set up a multidisciplinary ad hoc group, including representatives from political parties, to consolidate the two proposals and resolve the legal and administrative obstacles. Finally, the Health Promotion Foundation Act was approved by the Cabinet in 1999 and by the House of Representatives in 2001.

Contribution of ThaiHealth to the alcohol policy arena

ThaiHealth has adopted the concept of the Triangle that Moves the Mountain as its operative strategy. Three main modules in the Master Plan are to extend the power of "wisdom," social participation and policy mobilization (Thai Health Promotion Foundation, 2006). Alcohol consumption certainly qualifies as a major health risk factor. ThaiHealth developed its Alcohol Consumption Control Program with the primary purpose of reducing consumption and harm, promoting sensible attitudes particularly among youth, supporting alcohol control bodies, and strengthening research capacity (Thai Health Promotion Foundation, n.d.-a).

In the knowledge sector, in September 2004 ThaiHealth and HSRI established the Center for Alcohol Studies (CAS) as a national research and knowledge management institute for the reduction of consumption and alcohol-related harms (Center for Alcohol Studies, n.d.). Since then, CAS has been the core for Thai alcohol-related knowledge activities, including transforming and disseminating technical information to the general population in appropriate formats.

To extend the power of social participation, ThaiHealth has woven together individuals and groups who share concern on alcohol issues. Formerly these groups were confined to, and mainly isolated in their own areas of interest, such as religion, youth, accidents, domestic violence and poverty. ThaiHealth supported the establishment of the StopDrink Network as the coordinating body for these like-minded groups; 144 organizations from various sectors nationwide have been connected so far (StopDrink Network, n.d.). The alcohol consumption reduction campaigns of ThaiHealth and StopDrink have been widely welcomed. This campaign uses various methods to target different groups. The campaign mottos such as "Stop drinking--Stop poverty" and "Quit drinking in the Buddhist Lent period," have been quickly taken up.

For political involvement, ThaiHealth has supported the capacity-strengthening project for public agencies, particularly the Tobacco and Alcohol Consumption Control Unit (TACCU) of the MoPH. Due to this support, TACCU were able to set up the Tobacco and Alcohol Hotline Center to strengthen regulatory enforcement, as well as to conduct the social campaigning programs. ThaiHealth has also supported the Ministry of Interior's alcohol-free temple campaign to ban drinking within temple boundaries (Buddhist temples are venues for socialization in the Thai context, particularly in rural areas). In addition, because its supervisory board includes a number of politicians, ThaiHealth has been able to create forums for direct policy advocacy.

Analysis

The establishment of ThaiHealth reflects the continuous and comprehensive movements for over a decade in three interconnected sectors, which is in line with the concept of the Triangle that Moves the Mountain.

The establishment of ThaiHealth commenced from very small beginnings as studies on tobacco taxation, probably aimed only at a tax increase. But the people involved kept nibbling at this issue and carried the process far beyond the original intent. It then opened up opportunities to explore other health finance innovations. The tobacco excise tax increase and establishment of ThaiHealth would not have occurred if there had not been key players in each area; HSRI created knowledge, RDF initiated social movement, and OTCC mobilized policy. They worked closely in finding the window of opportunity. Academics and technocrats, working together with those in authority from various sectors, were the key in removing obstacles. Furthermore, the knowledge exchange between domestic players and foreign experts and organizations was also significant in the process.

There are arguably three main factors for ThaiHealth's early success in applying the concept of the Triangle that Moves the Mountain in the alcohol policy arena. These are flexibility, financial security and effective strategies. ThaiHealth enjoys relative autonomy, which allows it to facilitate and coordinate partnerships in both the public and private sectors. ThaiHealth's complementary role in coordinating, rather than replacing, existing structures/agencies is widely and positively accepted. ThaiHealth has supported the establishment and operation of new players to strengthen the capacity in each angle, namely CAS in the knowledge management sector, the StopDrink Network for social mobilization, and TACCU for political involvement. These agencies later became key actors in Thai alcohol policy development.

Case study 2: Alcohol advertising regulation--round 1 (2003)

Background

Before 2003, alcohol promotion was mainly controlled by non-specific regulation, including regulation under the Food Act B.E. 2522. Advertising of food products requires permission from the Food Committee, to prevent misguided ideas which may lead to undesirable effects (Food Act B.E. 2522, 1979). The only alcohol-specific control was that prohibiting advertising of beverages containing more than 15% alcohol, or mainly distilled beverages, on television before 10 pm. This was enforced by the Government Public Relations Department (PRD), which supervizes television and radio broadcasting (Health System Reform Office, 2003). Being relatively regulation-free, the Thai population has been exposed to high levels of alcohol promotion over time. The alcohol advertising budget for the broadcast media had grown 7.4 times between 1989 and 2003 (Wibulpolprasert, 2005). In 2001, alcohol promotions were broadcast most frequently on news and sports television programs. (Thai Health Promotion Foundation and Stopdrink Network, 2003).

Political involvement

The policy process started from concerted concern about losses from road traffic crashes, which were estimated to cost around 2.3%-3.5% of GDP in 2001 (Thai Health Promotion Foundation and Stopdrink Network, 2003). The PM upgraded the road safety program as a national agenda and established the Road Safety Management Center (RSMC) to work as the road safety think tank. The RSMC then developed a draft strategic plan on road safety. Regulation of alcohol promotions, increases in drunk-driving penalties and the strengthening of minimum purchasing age legislation were addressed in this plan (Krungthep Thurakit Newspaper, 2003a). After approval in principle by the Cabinet, the RSMC organized a workshop for academics, NGOs and bureaucrats to develop a detailed plan. The policy recommendations resulting from the workshop cover four aspects of alcohol advertising control: (1) sites of promotion, disallowing billboard promotions in areas near educational institutions; (2) times of broadcast promotions, banning on-air advertisements between 5 a.m. and 10 p.m.--known as a "partial ban"; (3) the content of promotions, including prohibition of drinking persuasion and using celebrities as presenters; and (4) the attachment of compulsory warning messages (Matichon Newspaper, 2003a).

The proposed alcohol advertising resolution was strongly opposed by the alcohol industry and the sports sector. Although it had been uncommon in Thailand, alcohol producers and importers had formed an alliance. The industry alliance argued that regulation of advertising is a downstream solution and would not reduce either consumption or harms, while causing possible negative impacts on the national economy and on sports (Thansetthakij Newspaper, 2003). They proposed a self-regulation system as an alternative approach. The advertising regulation was twice taken off the agenda for Cabinet meetings, with no reason given. Lobbying by the alcohol industry was claimed to be the main cause (Shitanon, 2003; Matichon Newspaper, 2003d), but this was denied by key persons in the Cabinet (Krungthep Thurakit Newspaper, 2003b; Phoojadgarn Newspaper, 2003). Finally the cabinet approved the proposal on July 29, 2003. However, broadcasting of professional sports that contain alcohol promotions, such as logos on sports uniforms, was exempted due to technical difficulties. The movement to control the promotion of alcohol also led to the readoption of a minimum purchase age law at the end of 2003.

Knowledge

Meanwhile, there was a big leap in knowledge on alcohol policy in three areas just in time to feed into road safety policy formulation. These were knowledge of the Thai consumption situation, and concerning drink-driving countermeasures, and international experience of alcohol policy effectiveness. Dr. Yongyuth Kajorntham, at the last stage of his life, was the key person during this period. Using the WHO database, he distributed the stunning data that Thai per capita consumption ranked fifth in the world at 13.59 liters of pure alcohol in 2000 (later in 2005, WHO revised Thai adult per capita consumption in 2000 down to 8.40 [Center for Alcohol Studies, 2006]).

Dr. Kajorntham also translated and synthesized international experience on the effectiveness of alcohol policies and benefits into a format relevant to the Thai context. These documents were then used for subsequent policy movements. One of the important reports, frequently referred to, is the Effectiveness of Alcohol Consumption Control Measures, published by one of ThaiHealth's associates in 2004 (Kajorntham, Kajorntham, & Sornphaisarn, 2004).

Knowledge advancement increased the justification for policymakers and health advocates to carry on. It also lent support to the public health position in the heated debate with the alcohol industry and its allies on various media. Two pieces of information largely supported the decision to strengthen advertising control in 2003. The first was findings on the difference in consumption level and in road traffic mortality among high income countries with and without alcohol advertising control (Saffer, 1991). The second was the evidence that support from the alcohol industry to the sports sector was not as vital as claimed.

Social movement

The road safety program, under the campaign "Don't Drive Drunk," had been broadly accepted and was the significant entry point to alcohol policy for many stakeholders. After the concept of advertising regulation was publicized, NGOs and key people in civil society, particularly from the road safety, ethics and religion, youth, community and health sectors, clearly voiced their support. Thai opinion leaders, along with 49 organizations, signed the supporting statement to the government (Posttoday Newspaper, 2003). All these movements were formulated during the pre-Buddhist Lent period, which is well-known as a period for alcohol abstinence. As another significant context, 2003 is the first year ThaiHealth launched and promoted the Quit drinking in the Buddhist Lent period campaign.

This social support created pressure on involved stakeholders, including calls for a quick, clear and uninfluenced ruling when the decision was postponed (Saiyood, 2003). A survey shows that 88% of the population wanted more responsibility tro be shown by the alcohol industry (Phoojadgarn Newspaper, 2003). A public opinion poll indicated that 41.1% believed in the benefits of a partial ban, while 38% did not and 25% were undecided (Khao-sod Newspaper, 2003).

Evidence discrediting industry self-regulation of marketing was distributed by one of the most famous Thai Buddhist monks, Phra Payom Kalayano. He described an experimental study showing how easy it is to buy alcohol on religious days when sales are prohibited; 700 orphans were employed as hidden observers at selling points (Matichon Newspaper, 2003c). Later on, key NGOs were invited to join the advertising surveillance committee (Matichon Newspaper, 2003b).

Analysis

The government was under pressure to do something effective to reduce the incidence of road crashes. The insertion of the advertising regulation into the road safety plan was a significant step, and was done strategically. A review of international experience in controlling alcohol promotions, particularly the effect on crashes, was the foundation of the process. However, a survey showed that less than half of the population were convinced by the evidence of the benefits of advertising control in 2003.

Perhaps most importantly, information on per capita consumption, using the catch phrase fifth highest in the worM, shocked stakeholders and the general population, and provided strong support for the movement to ban alcohol advertising. The social movement not only supported the policy content, but also put pressure on the decision-making process, particularly when the decision was rescheduled, probably due to industry lobbying.

Again, the significant movements of the three sectors are seen: politicians in setting the policy direction through their commitment, the Road Safty Management Center in mobilizing public agencies, social networks in creating public support, and Dr. Yongyuth Kajorntham in disseminating knowledge. It should be noted that the alcohol industry had begun to form its own network in response to the threat. Consequently, the advertising control movements also created spill-over effects that became significant later during the second round of action on the advertising ban in 2006.

Case study 3: Alcohol advertising regulation--round 2 (2006)

Background

Responsibility for the 2003 partial ban regulation enforcement was shared by three public agencies, namely the Food and Drug Administration (FDA), the Government Public Relations Department and the Office of the Consumer Protection Board (OCPB). The alcohol industry had complained of enforcement inconsistencies, particularly in subjective judgments. In addition, the alcohol industry and advertising agencies continued calling for self-regulation, and calling for the regulation to be lifted by making the argument that the 2003 decision failed to halt the road traffic death toll in the 2004 New Year period (Thansetthakij Newspaper, 2004).

After the partial ban took effect, the alcohol industry had largely shifted their promotions to unregulated forms of advertising. For example, after 2003 the budgets for mobile advertisements such as ads-on-vehicles and for on-site promotions at venues increased by 583% and 148% respectively (Krungthep Thurakit Newspaper, 2005)

Meanwhile, the Ministry of Public Health (MoPH) had been in the process of drafting the bill on alcohol beverage control, designed to be the first alcohol bill targeting health (Futrakul, 2006). The draft content includes establishing alcohol policy agencies at the national and provincial level, increasing the minimum purchase age and a comprehensive prohibition on alcohol promotion, known as the "Total ban."

In the meantime, an option for separating the sections on promotion control and making them the responsibility of the FDA was circulated among, and later approved by, the National Alcohol Consumption Control Committee (NACCC) subcommittee. This strategy was seen as an easy way of fast-tracking control of marketing, in contrast to the lengthy process of enactment of the entire bill.

Knowledge

Alcohol promotion-related studies during 2003-2006 can be roughly categorized into three areas: tracking of promotion exposure, studying effects of promotion, and measuring social opinion on the regulation of promotion. Advertising surveillance projects had repeatedly found high levels of exposure of the Thai population to alcohol advertising across many forms of media, including advertising of surrogate products, "hidden promotion" and promotion at times when advertising is not allowed. For example, after the partial ban, alcohol promotion was seen on television up to 167 times daily on each channel (Khao-sod Newspaper, 2006a). In another survey, Bangkok residents reported that they were exposed to alcohol promotion an average of 5.9 times a day, and most frequently on television (Bangkok Today Newspaper, 2005). These findings probably reflected the inadequacy of the 2003 partial ban regulations. This position was supported by data from relevant officials. For instance, an alcohol company consented to be fined daily rather than remove its advertising (Nation Newspaper, 2006).

Studies on the effects of promotion, particularly among youth, and review of international experience strengthened the justification for a comprehensive ban. A survey found that 71.4% of the youth audience for broadcasts of the 2006 soccer World Cup, funded solely by ThaiBev, appreciated their support and wanted to repay the sponsors. This occurred even though the promotion was limited to pre- and postmatch and halftime, and included only corporate images (Phoojadgarn Newspaper, 2006a).

However, there are also findings to the contrary. Two studies suggested that an advertising ban would not make drinkers quit, with one researcher accusing the government of being at a loss for ways of reducing alcohol-related harms (Krungthep Thurakit Newspaper, 2006; Matichon Newspaper, 2006b). Another study was publicly released just 1 day before the final public hearing event. In the wake of this, many key people in the alcohol policy arena expressed their scepticism about alcohol industry support for these studies, either direct or indirectly, by questioning the methodology and the process of drawing conclusions and recommendations, as well as the undeclared source of funding. [Phoojadgarn Online Newspaper, 2006]

Political involvement

The political process leading to a complete ban on advertising can be divided into two phases. During the first period the movement was mainly in response to high levels of exposure to advertising and to the input of the NACCC working group. The second wave was the process after the Military Coup in September 2006.

A year after the implementation of the partial ban, the Cabinet passed a resolution urging relevant agencies to strengthen enforcement and warning the alcohol industry to improve its practice, defining violations of the ban as irresponsible (Posttoday Newspaper, 2004). Key people in the alcohol industry also warned "black sheep" violators against the possibility of tougher regulation (Nation Newspaper, 2006). Later on, the Health Minister tabled the NACCC alcohol advertising regulation strategy to the Cabinet on January 24, 2006. The Cabinet approved it in principle. The PM urged the MoPH to recheck the legality of the legislative and enforcement process, and also stated that controlling measures should not be too extreme (Thaipost Newspaper, 2006). Subsequently the NACCC, chaired by the Health Minister, announced its plan to prohibit the advertising of alcohol and surrogate products in all media, including point of sale promotions. The easiest way achieving this without coming into conflict with other laws was to declare alcoholic beverages as a product harmful to consumers under FDA authority, which requires specific regulation. The alcohol industry and sports sectors expressed their disagreement by describing the negative impact of the total ban on the national economy. The industry also called for compensation for negative results, if they were to happen (Matichon Newspaper, 2006a).

Within 1 week, on January 28, the PM made a big U-turn during his opening address to a sporting event. He stated that a total advertising ban is unrealistic, and would cause harm particularly to national sport. "Although Thailand is a Buddhist country, we have to strike a happy medium, neither too weak nor too strong, and have to learn from other countries. The extremists have to open their eyes to see what is going on in the real world." (Khao-sod Newspaper, 2006c) This strong position was then fully supported by other cabinet members. As a result the MoPH stated that he was going to put a hold on the process and that he needed more time to consider the plan (Phoojadgarn Newspaper, 2006d). Subsequently progress on the alcohol marketing control strategy seemed to lose pace. Many rounds of public hearings were conducted as part of the new bill drafting process; there was a total advertising ban agenda but nothing came of it.

After the political coup on September 19, 2006, the new Health Minister, Dr. Mongkol Na Songkhla, quickly resurrected the plan for total prohibition of alcohol promotions. He was the former MoPH Permanent Secretary and a former member of the Committee of Knowledge Management and Social Capital Section of ThaiHealth. The proposed total advertising ban was well-supported among the agencies involved, including the ministries of Education and Justice and the OCPB. Perhaps because the timing coincided with a period of political reform and there was wide social support for the ban, the resistance seemed to be fairly quiet. A public hearing was conducted at the MoPH, on October 16, 2006. Representatives of the alcohol industry consented, with a requirement for consistent and fair enforcement from the relevant agencies. Comprehensive regulation of alcohol promotion was adopted the next day and would come into force early in December 2006.

The new regulations were to ban: (1) promotion of alcohol and surrogate products on television, radio, billboard, in the print media and through the internet on a round-the-clock basis; (2) promotions using outdoor and indoor displays and decorations, including product logos and names on staff clothing; (3) lucky draws, giveaways and other promotional campaigns; and (4) beverage displays that can be seen from outside the permitted area of sale.

During this period, alcohol producers and their allies from the restaurant, hotel and retail sectors established the Federation on Alcohol Control of Thailand (FACT) as their policy advocate. At its launch, FACT claimed its right to participate in the policy process and stated that the total ban on advertising limits human freedom (Thai PR.net, 2006). Later on, FACT claimed that 30,000 people would lose their jobs because of the new controls on the promotion of alcohol and that they were considering taking the MoPH to the administrative court (Chinmaneevong, 2006). FACT is considered to be the first fully-fledged Thai Social Aspects Organization (SAO).

Before the FDA regulations came into force, a group of alcohol companies made a submission to the Council of State (CS), the government's legal consultant agency, questioning the legitimacy of the proposed regulations. This was sent through the PM, as only public sectors are allowed to contact the CS. The alcohol industry pointed out two potential legal faults with the regulation. First, that according to the Food Act 1979 alcohol is a food, and as such the FDA has no authority to ban alcohol advertising if the promotions do not exaggerate its scientific properties. The second issue was the legitimacy of transfer of authority from the OCPB to the FDA under the Consumer Protection Act. At the same time, FACT also consulted the Lawyers' Council of Thailand on the same issues.

In late November, the CS ruled that the FDA regulations were not legitimate because of both issues, and their decision was supported by the President of the Lawyers Council of Thailand (D. Grailit, 2006). Consequently the MoPH had to postpone the enforcement of the new regulations and appealed to the CS to review its decision in early December. There was debate in the media as legal experts expressed their conflicting opinions on the legitimacy of the regulations, some calling on the CS to consider the intention rather than the letter of the law (Bunnag, 2006).

In late December the CS finally ruled that the transfer of authority was legitimate, but that the FDA regulation did contradict the Food Act 1979, and was thus unenforceable (The Council of the State, 2006). After the failure of their shortcut, the MoPH decided to wait and use the process of promulgating the Alcohol Consumption Control bill to strengthen alcohol advertising regulation.

Social movement

With regard to alcohol promotion regulation, polls have shown increasing social support over time, particularly when compared to the 2003 period. A survey in 2005 found that 63.8% of the population agree with the advertising ban, and 61.2% believe that alcohol promotion affects youth drinking (Bangkok Today Newspaper, 2005). Another survey in 2006 confirmed that 65.7% of residents in big cities support the total ban measures (Thairath Newspaper, 2006). This increase, to some extent, could reflect the changing social climate on alcohol and alcohol policy.

Many social sectors expressed their dissatisfaction with the role of the PM in freezing the advertising ban process. This included the representatives from 50 youth organizations who reminded the PM of his promise, announced on Children's Day 2006, to get rid of businesses that cause harm to youth (Khao-sod Newspaper, 2006d). In September 2006, 200 youths rallied to protest against the alcohol billboard on Thailand's tallest building, which explicitly breached the regulation banning advertising near educational institutions.

The social movement became livelier after the political changes. Religious networks had strongly supported the ban during public hearings. Phra Phayom Kalayano even stated that he would pray for this process and requested those who disagreed with alcohol control to end their resistance: Alcohol is the gateway to sin, if we don't support (the advertising ban), what on earth should we support? (Phoojadgarn Newspaper, 2006c). (A Monk's request is very powerful in Thai Buddhist culture.) Subsequently, many networks and organizations expressed their support, including people with disabilities, women, children and youth, and community and factory workers. At the last public hearing, 84 organizations nationwide expressed their gratitude to the Health Minister for continuing to push the advertising control issue.

After the regulation was defined as illegitimate in the first review, representatives of many social sectors, including religious figures, women and youth, expressed their disappointment and urged the CS to reconsider their ruling. They asked the CS to prioritize the public interest and to focus on the intention of the law.

Analysis

There were two cornerstones for the whole process. First, the knowledge identified that the 2003 regulation could not effectively protect the Thai population, particularly youth, from alcohol advertising. This inadequacy was confirmed by the experiences of enforcement agencies. And it triggered relevant stakeholders to reconsider the situation. The second point is that cooperation between the knowledge and political sectors enabled them to identify the fast track to strengthening the law to regulate promotion.

Although advertising control later gained more public support, the movement in the first period was mainly confined to public sectors, and the social movements sector was relatively quiet. Perhaps because public concern was not voiced strongly at this time, policymakers felt able to change their position on alcohol promotion. In the second phase, the determined character of the Health Minister, who already had strong connections with both MoPH bureaucrats and ThaiHealth officers, as well as massive and explicit social support, were the key factors for success.

However, the alcohol industry showed development in its strategy for participation in the policy process by establishing the SAO and by its technical advocacy. Crucially, the industry and its SAO found the legal loopholes and successfully submitted their complaint through powerful channels whose rulings are binding on public agencies like MoPH.

Case study 4: Movements against listing of the alcohol industry on the Stock Exchange of Thailand (2005-2006)

Background

In early 2005, Thai Beverage Public Company Limited (ThaiBev) was invited by the Securities and Exchange Commission (SEC) to be listed on the Stock Exchange of Thailand (SET). ThaiBev is the biggest alcohol producer in Thailand with a share of more than 90% of the domestic spirits market in 1999 and 64% of the beer market in 2001 (Nikomborirak, 2002). Its products cover nearly all beverage segments, including spirits, drinking water, soda and "Chang" beer (Chang means Elephant, a symbolic animal for Thailand). The main reason for the listing, according to the Director and Executive Vice President of ThaiBev, was to raise finances to allow for effective competition in the international market. He also claimed that this could boost the Thai economy, by increasing the SET market cap to 200 billion Baht (Prachachat Thurakit Newspaper, 2005c). When criticized, ThaiBev strongly insisted on its right to be listed, claiming there would be no effect on Thai alcohol consumption.

Before being listed, companies have to be approved by two committees, the SEC and SET Board of Governors. The legal eligibility of an alcohol business for listing is ambiguous. SEC announced in 2000 that only companies that generate economic and societal benefits can be listed (Securities and Exchange Commission, 2000). Later on, SEC adopted another resolution during the heated and ongoing debate in 2005. This resolution explained further that "unqualified businesses are those that could not contribute benefit to the economy and to society such as weapons, gambling and tobacco." This SEC position was criticized as showing the green light to ThaiBev (Srimuang, 2005).

Social movement

The first response to the ThaiBev listing came from a religious network, led by General Chamlong Srimuang, a political reformist and ex-Deputy Prime Minister. Thousands of Buddhist monks and their supporters rallied on the streets, demanding that the SEC reject the listing. The protesting coalition expanded to include youth, the Muslim network and health-oriented sectors. Later on, a list of 50,000 people and 172 organizations opposing the alcohol industry listing was submitted to the Ministry of Finance (Matichon Newspaper, 2005a). Representatives from the Anti-alcohol Youth Alliance had a hot debate in the media. At a crucial time during the second round of the decision process, 20,000 people participated in a 9-day street protest in front of the SET building. It should be noted that these movements were not directed specifically against ThaiBev, but against all alcohol companies.

On the other hand, there were social moves to support the ThaiBev listing, particularly in the business sector. Debate became particularly heated when ThaiBev announced the alternative plan, being listed on the Singapore market instead. Economists predicted losses to the national economy if that were to happen, including opportunities for market expansion (Matichon Sudsubda, 2006). ThaiBev also publicized its arguments and the potential positive outcomes of its listing by buying exclusive coverage in the media. Furthermore, a group of elephant keepers supported by ThaiBev for the upkeep of their elephants rallied on the street to support the listing process (Phoojadgarn Online Newspaper, 2005). Antilisting protesters were charged by the leader of the proindustry group with obstructing traffic; the case was eventually dismissed (Matichon Newspaper, 2003c).

Knowledge

Critically, knowledge of the effect of an alcohol company listing on stock exchange market is rare. After a brief period of research and brainstorming among academics and technocrats on the pros and cons of listing, Center for Alcohol Studies (CAS) published a document explaining why an alcohol business should not be listed. This document lent support to the prevailing social movement, particularly in forums of debate. Many meetings and debates were organized. These platforms linked the knowledge movement directly to those in authority.

Apart from the negative impacts of alcohol consumption and increasing consumption trends, CAS argued that the SET listing would rapidly increase the alcohol industry's financial capacity, which would then increase marketing budgets leading to increased consumption. Second, the number of stakeholders and their sense of belonging to the industry would be expanded and the government, who commonly sees the stock index as a national economic indicator, may be reluctant to launch any policy that could harm the alcohol industry (Center for Alcohol Studies, 2005). Moreover, CAS compared consumption and the strictness of alcohol policies in other countries with the extent of alcohol companies being listed on the stock exchange.

Political involvement

As a rule, the approval process for listing must be completed within 45 days of application. In the case of ThaiBev, however, the decision was postponed repeatedly. The SEC claimed that they needed more time to study the potential effects of the listing. Key players in authority were more likely to support the ThaiBev listing, including the secretary of the SET Board of Governors, who claimed that there was no reason to protest (Khao-sod Newspaper, 2005), and the SET manager who had declared that he would do anything to list ThaiBev on the SET, and would resign otherwise (Prachachat Thurakit Newspaper, 2006). Following the first postponement, ThaiBev consultants lobbied each board member intensively (Prachachat Thurakit Newspaper, 2005b).

The decision became a hot potato, being passed around the authorities involved. SEC asked the Cabinet to state its position (Prachachat Thurakit Newspaper, 2005a). The PM decided to leave the decision to the Ministry of Finance and SEC (Matichon Newspaper, 2005b), and the new Minister of Finance announced that he would not interfere in the SEC decision (Khao-sod Newspaper, 2006b). Later on, the SEC decided to hold up the decision making process when the Minister of Finance, as chair of SEC, stated that he needed more data (Matichon Newspaper, 2005c).

In early 2006 ThaiBev came up with another option, requesting SEC permission to be listed on the Singapore market, as invited by the Board of Directors and Committee of the Stock Exchange of Singapore (Phoojadgarn Newspaper, 2006b). The SEC approved the request on January 16, 2006, which should have alleviated some pressure. After being listed on the Singapore market, however, ThaiBev reaffirmed its willingness to be dually listed on both the Thai and the Singapore markets. The dual listing concept was fully supported by the new SET manager (Matichon Newspaper, 2006c).

Analysis

The listing of an alcohol company on the stock exchange market is probably not a conventional alcohol policy issue, but it could indirectly affect both the consumption situation and the alcohol policy process. The impacts of listing are arguably unknown and unclear. The brainstorming workshop and review of international experiences by CAS helped bring a clearer understanding to the public. However, many still were not convinced about the direct effects on the consumption situation of the listing of an alcohol company on the stock market. Many were more concerned with the obvious short-term benefits, particularly the opportunity to boost the national economy.

Despite the strong position of and the well-organized social movement among religious and youth-oriented networks, the antilisting movement encountered opposition from numerous sectors. These include business, economists, and those in authority, namely SEC, the SET manager and the Cabinet. In this case ThaiBev and their allies created a more comprehensive movement, combining proactive information dissemination with direct lobbying and on-street support. The unexpected alternative plan was strategically proposed. Although the movement against the listing was based on unclear information, the collaboration between the knowledge and social sectors was strong enough to create social pressure on policymakers, making them hesitate to make any clear and firm decision.

Synthesis and conclusion

This section demonstrates the lessons learned from the implications of the Triangle that Moves the Mountain concept on the process of Thai alcohol policy development, through four case studies. The four case studies show how Thai stakeholders in the alcohol policy arena had applied the concept in strengthening the power of the knowledge, social movement and political sectors. The important movements in each sector according to the concept are summarized in the Table.

The lessons learned, synthesized from the four case studies, are categorized into three groups; the use of the strategy, the connection among process elements, and the key factors influencing the process outcomes.

1. The use of the Triangle that Moves the Mountain concept

The case studies confirm that alcohol policy development is a complicated process, interfacing with multiple and influential stakeholders and competing values. Achievement in alcohol policy advocacy, therefore, is as difficult as moving a mountain for an isolated individual. Case studies also demonstrate the fruitful results of connecting movements in these three sectors, although applying the strategy cannot guarantee success. This strategy has largely supported Thai alcohol policy development, and it has high potential to be effective for other countries. However, some issues should be noted in applying the strategy.

All three sectors should be strengthened on a parallel and synergistic basis. Limited movements in one or two sectors seem to be inadequate, particularly where the vectors of movement in the three sectors are not in line. In case study 4, for example, synchronization between the social movement and knowledge sectors was powerful in creating pressure on policymakers and making them hesitate to allow a ThaiBev listing on the stock exchange.

Although all three sectors are important, the influences of each sector are diverse and vary over time. There are specific situations in which some actors and some movements are more influential than others. For example, the political commitment was arguably the most significant factor for the development of the 2003 advertising regulation in case study 2, while it was the strong social movement against ThaiBev listing that was most important in case study 4. The 2006 advertising control issue in case study 3 demonstrates the difference in impact between the pre- and postcoup periods. With no explicit social movement, the process in the precoup period was limited to politicians and bureaucrats. Weak social support allowed policymakers to hold up the policy development. In the postcoup period, strong social support and political commitment proved able to restart the course.

As is common in developing countries, local knowledge on alcohol consumption and related problems and on alcohol policy, and particularly on the effectiveness of alcohol policy interventions, is scarce. Where importation of knowledge is unavoidable, it must be presented in a format relevant to the context. Striking a balance between domestic and imported information is important. And information should be used strategically, the attention-grabbing terminology such as the fifth highest in the world in case study 2 for instance.

The alcohol policy process is a continuous procedure with no start or end point. The case studies show the complicated linkages among elements of the policy process in each of three sectors, and among stakeholders. Furthermore, the benefits of strengthening the three sectors are not confined to a particular event or area. This article describes alcohol policy developments that have utilized benefits from movement in other arenas. The legislative process to establish ThaiHealth in case study 1, for instance, largely related to the antitobacco social movement and progress in technical knowledge on tobacco taxation. ThaiHealth then catalyzed the process of advertising controls. Evidence of violations of alcohol advertising regulations in 2004-2005 led to policy revision in 2006.

The case studies show the growing complexity of the policy process, as seen for example in the actions of the alcohol industry in establishing SAOs and blocking the introduction of alcohol advertising bans in case study 3, which in turn stimulated a corresponding social movement and knowledge activities around alcohol policy issues. These are newly introduced approaches in the Thai alcohol policy process, where direct involvement by authoritarian elites has been more traditional. In addition, players on the health side had strategically addressed and echoed the social support for policy advocacy, including public poll surveys.

2. Inter- and intrasectoral connections of the process elements of the strategy

The development of alcohol policy chiefly relied on the coordination at the macro level among the three sectors, as well as at the micro intrasectoral level. Good relationships and attitudes among people in the three sectors are significant, particularly in the conventionally top-down and isolated cultural context. For instance, if people in authority see a social movement as chaotic or NGOs as troublemakers, productive coordination is unlikely to occur.

At the macro level, collaboration among the three sectors is essential to conduct in-line and in-time movements to support and synergize each other. Effective and regular communication, including mechanisms to link coordinators and other stakeholders, are vital in enhancing the movement impact. These approaches include the opportunity to work together, and through official mechanisms such as RSMC and NACCC, in case studies 2 and 3. It is also evident from the case studies that information from knowledge activities has to be distributed to public at the right time and in the right format, in order to guide the social movement. For example, the data on consumption per capita and the benefits of advertising control were publicized at the appropriate time during the decision-making process in case study 2. Further, social movements need to be well organized, reaching a critical mass and be politically visible in order to create clear support and powerful pressure for policy mobilization.

At the micro level, it is clear that movement in each sector is definitely not homogeneous. Members from both health and industry alliances may have individual areas of interest as well as common areas and directions. Internal coordinators and facilitators, therefore, can direct the movement. Case studies show that many players had taken the facilitator roles in each sector. In case study 2, ThaiHealth acted as the facilitator by itself, including coordinating with public agencies through the RSMC mechanism. Then, StopDrink Network and CAS proactively played facilitating roles for social movement and knowledge management respectively in case studies 3 and 4. For the ThaiHealth establishment process in case study 1, however, movements in three sectors were relatively unorganized, without an explicit facilitator.

3. Key factors for the use of the concept

Apart from the coordination and synergy of movements in the three sectors, windows of opportunity and timing of the movements are critical factors for the outcomes. The end of the alcohol production concession brought the chance to develop the mechanism to earmark part of alcohol excise tax for ThaiHealth, instead of using only the tobacco excise tax like other health promotion foundations. In case study 2, the recommendations to regulate alcohol advertising were purposely submitted, through the RSMC, to policymakers under pressure. The political change in 2006 brought in the new Health Minister with personal experience and interest in alcohol policy, who then revitalized the frozen process in case study 3.

The mass media plays a major role in alcohol policy. Although not the only way, media is the main communication channel for movements in each of three sectors. Particularly, movements in the knowledge and social sectors largely require the mass media to gain attention from political and bureaucratic officials.

Lastly, the alcohol policy process is closely associated with its context. Religious beliefs and cultures played a significant role in Thai alcohol policy development. Key religious persons and networks were fundamental for the establishment and operation of the StopDrink Network, and were critical for the social movement against ThaiBev's listing on the stock exchange market. The process of 2003 advertising regulation was particularly accelerated in the pre-Buddhist Lent period, which is the high time for a social climate against drinking.

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AUTHOR'S NOTE: I want to thank Professor Sally Casswell and Lisa Morice of the Center for Social and Health Outcomes Research and Evaluation (SHORE), Massey University, New Zealand: Dr. Suwit Wibulpolprasert and Dr: Viroj Tangchareonsathien of the Ministry of Public Health-Thailand, for their assistance.
TABLE
Movements in knowledge, political and social sectors,
and key contextual factors

                   Knowledge management

Establishment      * International experiences and
of ThaiHealth        legal knowledge on financial
                     mechanism for health promotion
                     and dedicated taxation
                   * Tobacco taxation

Advertising        * Consumption situation
regulation 2003    * Effectiveness of alcohol
                     policy and advertising
                     control measure

Advertising        * Loopholes and inadequacies
regulation 2006      of the partial ban regulation
                   * Effectiveness of advertising
                     control measure

Listing of an      * CAS publication
alchool company    * Policy debates
on the stock
exchange

                   Political improvement

Establishment      * Collaborative works
of ThaiHealth        across departments
                     and disciplines

Advertising        * Raising road traffic
regulation 2003      injury as a national agenda,
                     and RSMC establishment
                   * The involvement of
                     policymakers in RSMC
Advertising        * The involvement of
regulation 2006      policymakers in NACCC
                   * Personal interests
                   * Legal complexity

Listing of an      [Postponement and
alchool company    transfer of decision-making,
on the stock       although many key persons
exchange           seemed to support
                   the listing]

                   Social mobilization        Contexts

Establishment      * Antitobacco              * Repeal of
of ThaiHealth        movements                  alcohol
                                                production
                                                concession

Advertising        * Support from the         * Buddhist
regulation 2003      religious sector           Lent
                   * Social pressure on         period
                     the decision for
                     postponement
Advertising        * Social support through   * Military coup
regulation 2006      public survey results,   * Movement
                     and by opinion leaders     against the
                   * Movements of the           regulation by
                     StopDrink Network          alcohol
                                                industry and
                                                its SAO
Listing of an      * Street demonstration     * Invitation
alchool company    * Expanding social           from the
on the stock         pressure from religious    Singapore
exchange             to other sectors           Stock
                                                Exchange
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