PRIMARY CARE DEVELOPMENT IN THAILAND

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PRIMARY CARE DEVELOPMENT IN THAILAND

• An interesting case of District Health System
  Evolution
• SOMSAK CHUNHARAS, MD., MPH.
• NATIONAL HEALTH FOUNDATION
• June 8, 2009

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Welcome to Thailand
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Towards Health For All - Thailand
The Decade of Health Center Development (1992-2001
)
Adopted Health For All Policy
Starting Primary Care Services
Wat Boat Project
Universal Coverage Policy
Health Centers
Community Health Volunteers
National Health Act
Economic Crisis
Traditional Medicine
1964
1975
1978
1981
1992
1996
1997
1999
2002
2001
2007
1932
1968
1985
1950
1966
1974
Rural Doctors Movement
Health Care Reform Project
Thai Health Fund

• Sarapee
• Project
• BanPai
• Project

Stating Rural Health Services
Expanded Community Hospitals
Decentralization
Health Card Project
Primary Care Development
Tropical Diseases Control Programs
Lampang Project Samoeng Project
Nonetai Project
Civil Society Movement
Source Komartra Chungsathiensarp, 2551
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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
• 1954 Midwife Office for ANC in order to reduce
  infant mortality rate

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The History - infrastructure

• Suk Sala (none physician)
• 1952 Health Center
• (2nd level)
• 1972 Health Center

• Suk Sala (physician)
• 1954 Health Center
• (1st level)
• 1972 Rural Medical Center
• 1974 Medical and Health Center
• 1975 Community Hospital

• Midwife Office
• 1982 Health Center

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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)

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The First Reform MOPH Reform (1972)

• 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

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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)
• Main policy shift Community participation
  health as an integral part of socio-economic
  development
• Alma Ata provided opportunities for nation-wide
  implementation (less resistance)

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The Third Reform(Health) System Reform

• 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

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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

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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 peoples health and
  reduce unnecessary bypass to big hospitals
• Needs for GPs were raised as national issues
  while in fact studies showed that nurses are
  equally well accepted in HC

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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

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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)

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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,

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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 / monitoring-evaluation
  system / technical support and quality control

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Health Center

• 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

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Health Center higher expectation

• The Decade of Health Center Development
• Strenghtening primary care services, reduce
  workload from hospitals
• Selected urban health centers 15
• 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

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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

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Community-based health care
1. Sufficiency Economy
7. Health Promotion
2. Considerate Society
Better Community health
6. Diseases control
Strong Community
3. Treatment of common diseases
5. Care for Elderly
4. Care for Chronic Diseases
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At the Cross Roads

• 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)

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Key concerns

• Do we need medical doctors for a PCU?
• will be very difficult to realise at present.
  HCPCU10,000 more GPs!!!!!
• 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.

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• Whatever they are, they are not the same as
  European GPs,
• 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 gt applicable mostly
  thru CUP within MOPH (CH, GH, RH)
• Directly contracted CMU gt for HC that can meet
  the NHSO requirement (whether they are MOPHs or
  outside of MOPH)
• Actual implementation not yet start
• Modified private clinics (adding community-based
  care).

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MOPH
NHSO
Recommended model For more effective
Strengthening of HC Thru MOPH CUP
PPV
PPF/PCA/PPC
Regional NHSO
OP
PCMO
Com Hosp
Board
PPC
For contract purpose
2nd/3rd Care Units
Local Authority
Representatives to be Board members
Community Health Fund
Primary Care Unit Non-MOPH / Private
CMU
Community
HCs
HCs
Representatives to be Board members
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Recent Policy Health Service Development

• Tambon Health Promotion Hospital
• Leverage HC to Tambon Hospital and set up
  referral system and networking with private
  sector

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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,

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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,
• Care coordination horizontal and vertical
  levels and case management system

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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

• 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 - Local Administration
• Private Sector - Other Public Providers

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Resource Allocation
Area health board
Local Authority
Community Participation

• Primary Care Development
• access and coverage
• quality of care
• cost-effectiveness
• efficient use of resources

Private Sector Roles Regulations
PC Model and EMS Model
Human Resource Allocation/Financing
Information System
Technology Pharmaceutical Benefit
Referral Network Excellent Center
PC development and relationship with major system
issues
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Thank you