Transcript PRIMARY CARE DEVELOPMENT IN THAILAND

PRIMARY CARE DEVELOPMENT
IN
THAILAND
An interesting case of District Health System
Evolution
SOMSAK CHUNHARAS, MD., MPH.
NATIONAL HEALTH FOUNDATION
June 8, 2009
The Decade of
Starting Primary
Care Services
Health Center
Development
Universal
(1992-2001)
Coverage
Community
National
Policy
Economic
Health Act
Health
Crisis
Volunteers
Adopted
Health For All
Policy
Wat Boat
Project
Health
Centers
Traditional
Medicine
1964
1932
1950
1968
1966
1975 1978
1981 1985 1992 1996 1997 1999 2001
- Sarapee
Project
- BanPai
Project
Tropical
Diseases
Control
Programs
2007
1974
Rural Doctors
Movement
Stating
Rural
Health
Services
2002
Expanded
Community
Hospitals
Lampang Project
Samoeng Project
Nonetai Project
Health
Card
Project
Health Care
Reform
Project
Thai Health
Fund
Decentralization
Primary Care
Development
Civil Society Movement
Source: Komartra Chungsathiensarp, 2551
The History - infrastructure
1913: O-soth Spa = Medical and Public
Health Office in some provinces
 1932: Suk Sala – with physician (1st level)
/ none physician (2nd level) in high density
population area
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1954 Midwife Office for ANC in order to
reduce infant mortality rate
The History - infrastructure
Suk Sala (physician)
 1954 Health Center
(1st level)
 1972 Rural Medical
Center
 1974 Medical and
Health Center
 1975 Community
Hospital
Suk Sala (none physician)
 1952 Health Center
(2nd level)
 1972 Health Center
Midwife Office
 1982 Health Center
Primary Care Development

Before Alma Ata
– 1950 Vertical diseases control program: TB,
hookworm, etc.
– Mobile center in community
– Starting health volunteers for Malaria control
– 1978 “Free” health services for the poor policy
– Expanded health/medical services into rural
area (health center/community hospital)
The First Reform
MOPH Reform (1972)
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Integrating curative services (under medical
service department) and preventive health service
infrastructure under department of health
Creating a main department – Office of Permanent
Secretary to be responsible for comprehensive
health services delivery in all provinces (except
BMA)
Provincial Health Office to oversee both curative
and preventive services infrastructure in each
province
The Second Reform
Major Policy Reform – PHC (1979)

Results of 2 major research programmes
village volunteers for contraceptive pills
distribution in Banglamoong in the Eastern
region (1974)
 Lampang Project -health volunteers for MCH
(1976)
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Main policy shift = Community
participation & health as an integral part of
socio-economic development
Alma Ata provided opportunities for nationwide implementation (less resistance)
The Third Reform
(Health) System Reform
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Concern over health care financing and needs for
financing reform (since 1985)
Second MOPH reform – creating policy
mechanism and health system research institute –
1992
Social security system in place with capitation
payment for health insurances
Health care reform research project supported by
EU
Health equity and health promotion concern
Primary Care Development

PHC Era
– Focus on Community Health Volunteer &
Community Health Communicator in every
community (800,000 CHV all over Thailand)
– Success in community participation/
appropriate technology / intersectorial
collaboration, but less in basic health service
reorientation  strengthening primary care
services
Primary Care Development

PC Model Development
– 1989 Ayuthaya Project – Action Research
testing family medicine model and the 3
concept: continuity of care, Integrated care,
holistic care == integrated health care
– Strong urban health centres were seen as
necessary to take care of people’s health and
reduce unnecessary bypass to big hospitals
– Needs for GP’s were raised as national issues
while in fact studies showed that nurses are
equally well accepted in HC
Primary Care Development

MOPH policies
– 1992 The Decade of Health Center
Development
 Health Center = Primary care unit
 2 types: general HC and large HC; upgraded
infrastructure and facilities
 Capacity building – nursing care
– 1997 “Good Health at Low Cost”
 Strengthening primary care services – accessibility
and efficient
Primary Care Development

UC Policy (2001)
– Strongly implement primary care service = 1st
strategy – equity in accessibility + efficient
health services + increase health promotion
and disease control
– Promote family medicine/family practice in PC
unit (Community Medical Unit)
– 2 main types of providers managed by NHSO
to effect PC – CUP, private clinics in cities
(BMA)
Community Hospital

Medical care provider at district level, 120-150 beds

Roles:
– Provide medical services: diagnosis, treatment both
inside/outside the hospital, and also integrated health
services: PP and rehabilitation, and mobile clinic
– Technical center and supervisor
– Support community participation, self care, promote
QOL with PHC, psychosocial support, human right
protection,
Community Hospital under UC

CUP – contracting unit for primary care
– Main contractor = purchaser (but also be
provider) – one PCU
– Provide medical care to the registered
– Set up supporting system for PCU in the
network: personnel, medicine, medical
devices/ Communication system / monitoringevaluation system / technical support and
quality control
Health Center
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Care Provider at village/tambon level 1,000-5,000
population
Personnel: Health officer, Midwife, Technical Nurse
Roles:
– Integrated Public Health Services: Disease
Prevention, Health Promotion, and treatment
for common diseases
– Support Primary Health Care and Community
Development
– Technical support and administration
– Health Education
Health Center – higher expectation
The Decade of Health Center Development:
Strenghtening primary care services, reduce
workload from hospitals
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Selected urban health centers 1:5
Acting as “node” - take care of other HCs in the
network, referral center
More personnel:
– Rotated physician from near-by hospital / Routine
Medical service (CMU)
– Registered nurse, dental hygienist
More services – basic dental care, treatment
Health Center under UC
Strengthening primary care service
 PCU – catchment 10,000 pop, working 56 hrs/week,
easy access
 Personnel: one physician, 2 registered nurse, 3 health
sciences officers, etc.
 Roles:
– PP services, continuity of care
– Curative care: diagnosis/curative – acute / chronic care, primary
care, EMS – 24 hrs. / coordinating care
– Dental care
– Home visit

Autonomous PCU in urban area
Community-based health care
7.
Health
Promotion
Better
6.
Diseases Community
health
control
5.
Care for
Elderly
1.
Sufficiency
Economy
Strong
Community
4.
Care for
Chronic Diseases
2.
Considerate
Society
3.
Treatment
of common
diseases
At the Cross Roads
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PCU = HC with no medical doctors (lessons
from Ayudhaya)
PCU = HC with medical doctors on rotation
(implemented in selected HC)
PCU = upgraded HC (CMU) – manned by a
“non-rotating” medical doctor (FP) working in
“large HC” with additional facilities
Private Clinics with additional functions,
mainly outreached community-based,
(lessons from urban HC under UC)
Key concerns

Do we need “medical doctors” for a PCU?
– will be very difficult to realise at present.
HC=PCU=10,000 more GP’s!!!!!
– Nurses or public health graduates with
curative training can do as well.
Should we stick to MOPH structure or go for
private GP/FP?
Whatever they are, they should be able to
provide community-based health care.
Whatever they are, they are not the same
as European GP’s,
 they will not provide only clinical services
(so called PMC),
 should be more proactively working with
community and
 should be concerned with and play active
roles to tackle health as a wholistic
concept (PHC and health promotion
concept)
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3 major lines of development
Strengthening PC thru CUP => applicable
mostly thru CUP within MOPH (CH, GH,
RH)
 Directly contracted CMU => for HC that
can meet the NHSO requirement (whether
they are MOPH’s or outside of MOPH)

– Actual implementation not yet start

Modified private clinics (adding
community-based care).
MOPH
Recommended model
For more effective
Strengthening of HC
Thru MOPH CUP
NHSO
PPV
PP OP
PPF/
PCA/
PPC
PCMO
PPC
Board
For contract purpose
Local
Authority
IP Oth
Regional
OP
NHSO
Com Hosp
2nd/3rd Care
Units
Representatives to be Board members
Community
Health
Fund
CMU
Community
Representatives to be Board members
HCs
HCs
Primary Care Unit
Non-MOPH /
Private
Recent Policy: Health Service Development
Tambon Health Promotion Hospital:
Leverage HC to Tambon Hospital and set up
referral system and networking with
private sector
Tambon Health Promotion Hospital
Catchment area - tambon level and
networking with other health centers,
 24 hrs services, under supervision from
the hospital and referral system,
 Polyvalent - skill mix and team work in PP
services,
 Community participation and internal
audit,

Tambon Health Promotion Hospital
Coordinate with other partners - central
government + local authority +
community + private sector,
 Working in community – home ward,
 Proactive, outreach services based on
community health needs,
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Care coordination – horizontal and vertical
levels and case management system
Possible future of THPH
Strengthened as a subsystem with the
CUP
 Evolve as CMU within MOPH network
 Evolve as CMU under local administration
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Next
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Strengthen MOPH-PC network through
Tambon Hospital (CUP-based)
Redefine Private PC (service models, budget,
capacity and HR)
More flexible “performance assessment”
framework – too many detailed items at
present
Redefine “how to commission” for PC in the
future – directly contrating with PCU?
– MOPH
– Private Sector
- Local Administration
- Other Public Providers
Resource
Allocation
Area health board
Local Authority
Community
Participation
Private Sector
Roles &
Regulations
Primary Care Development
• access and coverage
• quality of care
• cost-effectiveness
• efficient use of resources
Human Resource
PC Model
and
EMS Model
Allocation/Financing
Referral Network
&
Excellent Center
Technology &
Pharmaceutical
Benefit
Information
System
PC development and relationship with major system issues