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Keywords:

  • primary healthcare;
  • universal health coverage;
  • health policy;
  • Thailand;
  • rural province

SUMMARY

  1. Top of page
  2. SUMMARY
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGEMENT
  9. References

In 2001, the universal health coverage policy was adopted by Thailand with primary healthcare (PHC) as the major focus of the policy. In order to understand the structural and institutional factors affecting the implementation of PHC in rural Thailand, a qualitative study, utilising individual interviews with national and provincial policy decision makers, community health directors, heads of hospital primary care units, chiefs of district health offices, heads of health centres and community representatives, from one rural province was undertaken. Findings showed that the sustainability of PHC service provision under the administration of community hospitals is problematic as barriers exist at the policy and operational levels and access to PHC for all citizens may not be achieved until these barriers are addressed. Furthermore, although PHC needs to be acknowledged and implemented by all stakeholders within the health industry and government, the roles and responsibilities of the stakeholders in health services management at the district level need to be clarified. Copyright © 2012 John Wiley & Sons, Ltd.


INTRODUCTION

  1. Top of page
  2. SUMMARY
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGEMENT
  9. References

In 2001, the government in Thailand launched the universal health coverage (UHC) policy. The aim was to reform the Thai health system so that it would provide health services to all, especially to the 18.5 million uninsured Thais, who were mostly underprivileged and living in rural areas (Towse et al., 2008:1). The strategies used to reform the health sector under the UHC policy included the adoption of per capita funding, the reorientation of service delivery from hospitals to primary care units and promoting consumer rights (Bureau of Policy and Strategy, 2007: 32). Although the implementation of PHC in Thailand has resulted in significant, positive changes, it has also faced many challenges and problems. For example, the health status of the Thai people has improved dramatically due to medical advances and the expansion of public health facilities, as well as to more effective and responsive health programmes. At the same time, Thailand has undergone significant economic development and has also experienced many of the health challenges facing countries in transition.

Background to the study

In 2002, the National Health Security Act was enacted to ensure the sustainability of the UHC in terms of policy, financing and institutional support (Bureau of Policy and Strategy, 2007: 32). The major element in this reform project was to expand the coverage of primary health services to enhance accessibility to essential healthcare for the population (Jongudomsook, 2005). The primary care unit (PCU), which is the front-line health facility and located close to the community and workplace, is meant to be the most accessible health facility (Health Care Reform Project Office, 2001). The PCU must also provide comprehensive and integrated care, which includes curative care, health promotion, disease prevention and rehabilitation, as well as ensuring the transfer of patients to secondary and tertiary hospitals when required.

In Thailand, a contracting unit for primary care (CUP) can comprise a stand-alone unit or a network of small PCUs. The policy promotes networking of PCUs across the public-to-public or public-to-private sectors. The budget for the UHC policy is allocated to provinces according to the number of people registered as beneficiaries. Resources are re-channelled to the PCUs on the basis of the registered members, and a per capita payment is pre-paid each year to the CUPs to cover the minimum benefit package. It is a requirement of the government that all public hospitals participate in this project, and some private hospitals also participate as well. The project encourages hospitals, as CUPs, to either establish PCUs or upgrade the quality of medical services at health centres (HCs) located in their areas. The purpose of these is to act as outreach centres, and they are expected to be close to residential or work areas so that people can access them easily (Wibulpolprasert, 2007).

Thailand implemented PHC using two different approaches that aim to encourage people to use health services at local HCs and district hospitals, rather than going directly to the provincial or upper-level hospitals. The first approach involves implementing PHC that is delivered by health workers at HCs or rural health facilities (Bureau of Policy and Strategy, 2007). The government made HCs the front-line health services to cover all sub-districts, and it also increased the number of health professionals, including doctors and nurses, who would provide care to rural people at the district hospitals (Pachanee and Wibulpolprasert, 2006) while health workers or public health officers would provide care at the HCs (Phoolcharoen, 2005). The second approach focuses on community participation where local resources can be mobilised to ensure the accessibility of healthcare for underserved people, and the services are maintained by the community. The local resources consist of groups of health volunteers known as Village Health Volunteers. According to Lawn et al. (2008: 924), the district health system has been recognised as ‘the most appropriate unit to implement primary health care in terms of management, implementation, and community dialogue, as well as integration with other sectors’, and this has been successfully demonstrated to a certain degree in Thailand.

As previously mentioned, Thailand has achieved excellent outcomes from implementing PHC; and according to Acin et al. (2011: 521), ‘investments in primary health care in the 1970s have led to benefits in the long term’. For example, there has been a significant reduction in maternal and infant mortality rates and communicable diseases, and an increase in coverage related to family planning, sanitation and nutrition (UNICEF, 2010; Vapattanawong et al., 2007; Rohde et al., 2008; World Bank, 2009). According to Rohde et al. (2008: 955), ‘Thailand prioritised maternal, newborn, and child health even before Alma-Ata, and beginning with community workers was able to increase coverage for immunisation and family planning interventions, and nutrition promotion’. More improvements, however, are needed to meet the social, economic and political changes, the emerging health problems and the more complex health needs of the 21st century. Several barriers have also been identified in the literature regarding the implementation of PHC in Thailand.

According to Ramsasoota (1997: 3), some Thai health professionals and managers do not recognise the importance of equitable access to healthcare and prioritising the most in need. Supradit (2001: 3) believes that health workers do not always understand the concept of PHC and the rationale for the decentralisation of healthcare. Furthermore, the concept of PHC has different meanings in different countries and is often confused with primary care (Cueto, 2004; Health Care Reform Project Office, 2001). In a study conducted by Taytiwat et al. (2010: 1), the findings identified several barriers that limit the role of the community hospital director (CHD). The study also found that CHDs need to ‘be more flexible, more outgoing to the community, patient centred, trained in public health administration, and they must have the necessary power to carry out their tasks’ (Taytiwat et al., 2010: 18).

Some authors believe that the centralised, bureaucratic management style of the Ministry of Public Health (MoPH) is another barrier to the successful implementation of PHC (Leerapun et al., 2000: 71). However, others such as Jongudomsook (2005: 28) and Pagaiya and Noree (2009) point out that a weakness of the primary healthcare system in Thailand is at the HC level, where there is a scarcity of resources and a shortage of qualified health professionals. Even though the MoPH has continuously increased over time the numbers of doctors and other health personnel working for primary care at community hospitals (CHs) and HCs (Bureau of Policy and Strategy, 2011), it is still not sufficient or effective as the workload for primary care visits at CHs and HCs have also increased enormously (Wibulpolprasert, 2011:303), as shown in Tables 1 and 2. Table 1 illustrates that the number of doctors, for example, in CHs has increased from 3583 to 3919 between 2007 and 2010. The biggest increase has been in registered nurses working at HCs, with the numbers growing from 2433 in 2007 to 7611 in 2010. However Table 2 reveals significant increases in numbers of out-patient visits both at CHs and at HCs from 58.9 and 60.2 million visits to 69.9 and 85.8 million visits, respectively, over the period of 2005 to 2009.

Table 1. Number of doctors and other health personnel working for primary care at district and sub-district levels in Thailand 2007–2010
Types of health human resources2007200820092010
CH.HC.CH.HC.CH.HC.CH.HC.
  1. Source: Adapted from Bureau of Policy and Strategy (2011).

  2. Note: CH., community hospital; HC., health centre. Most of the doctors working at the CHs have a role of providing primary care at CHs and HCs. They have outreach clinics at some HCs mostly once a month. This table does not show the number of registered nurses and other health personnel working at the CHs.

Doctor3583397744393919
Registered nurse2433615868997611
Public health academician7818920413 10112 867
Community health officer8755742587848970
Table 2. Number of out-patient visits at the community hospitals and health centres in Thailand, 2005–2009
PlacesNumber of out-patient visits (million visits)
20052006200720082009
  1. Source: Adapted from Wibulpolprasert (2011:303).

Community hospitals58.957.461.365.269.9
Health centres60.260.963.972.285.8

According to Hughes and Leethongdee (2007: 1006), the shortage of medical doctors not only affects the quality of care at the CHs but also obstructs the UHC policy aim of building the capacity of rural HCs. The majority of the medical staff works in CHs, whereas the PCUs are located in the sub-districts. Finally, Evans et al. (2006) believe that there must be appropriate preparation for organisational and community development to ensure that healthcare reform fits with the specific organisational culture, whereas Bowornwathana (2004: 248) argues that reform requires cultural change and a long-term, rational strategy.

Therefore, the aims of this study were to identify the major challenges and barriers to the delivery of PHC at the district level in Thailand from CHD and health services stakeholders and to present their views on strategies that could help facilitate sustainable primary health services administered from the CH. This study formed part of a larger study that explored the roles of the CHDs and their working world and to establish how they viewed the UHC policy, PHC and their role in implementing such policies at the district and sub-district levels in Thailand.

METHOD

  1. Top of page
  2. SUMMARY
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGEMENT
  9. References

In this study, an interpretive framework, utilising a case study research design, was chosen as the most appropriate design because it could provide a rich, thick description of the phenomenon under study. The study was primarily descriptive and exploratory in nature and relied on multiple sources of data. Evidence was gathered through in-depth interviews with the CHDs and health services stakeholders described in the succeeding texts. The triangulated data and the interpretive nature of this qualitative study provided a deep understanding of the barriers at a time of change in health services delivery at the primary healthcare level. Data triangulation was achieved through individual interviews and focus group discussion, where in the focus group discussions, selected informants reviewed the key issues and themes emerging from the earlier interviews. The information from these informants was used to present a consensus view of the roles of the CHDs in implementing health reform in the rural areas. Triangulation was also achieved through the use of ‘multiple analysts’ (Patton, 1999:1193), where the researchers independently analysed and interpreted the data to confirm the key themes.

Setting

The study was conducted in the north-eastern region of Thailand in the province of Nakhorn Ratchasima. This province was chosen because (i) it consists of rural poor people living outside a city and who constitute a large percentage of the population; (ii) it has the greatest number of districts and, as a result, the greatest number of CHs that vary in size and which reflect the complexity of responsibility of CHs; and (iii) according to the Nakhorn Ratchasima Provincial Health Office (2006), this province is one exemplar of PCU development for the nation.

Sample

The study population consisted of healthcare professionals and health workers in the Nakhorn Ratchasima plus policy decision makers at the national and provincial levels. The 43 participants were recruited utilising both purposive and snowballing sampling strategies and consisted of three national and provincial policy decision makers (BO), eight CHDs, eight heads of hospital PCUs (HHPCU) who report to the CHDs, eight chiefs of district health offices (CDHOs), eight heads of HCs who report to the CDHOs and eight community representatives such as village volunteers, chiefs of villages or representatives of local government. In the province of Nakhorn Ratchasima, there are 26 CHs that are classified by level of care and number of hospital beds: (i) basic level: 30-bed hospitals; (ii) intermediate level: hospitals with 30, 60 and 90 beds; and (iii) high level: 120-bed hospitals. The CHDs were selected from 8 of the 26 sites, on the basis of the hospital level of care, the number of beds and the number of needy people served under the UHC policy by that CH. The selected sites were as follows: (i) 3 of 11 basic hospitals; (ii) 4 of 12 intermediate level hospitals; and (iii) 1 of 3 high level hospitals.

Data collection

Data collection for this study was conducted by the principal investigator of this study, a Thai academic and medical officer, from February to July 2006. Following sample recruitment, the participants were contacted to arrange interviews that were conducted during their working day. The purpose of the study was explained at the beginning of each interview, and participants were asked to sign a consent form. A semi-structured interview schedule was adopted as the major method of data collection. The interview schedule consisted of questions that explored participants' work and experiences in relation to the UHC and PHC policies, their perceptions of the barriers to the delivery of PHC at the district level and their views regarding potential strategies that could help facilitate sustainable primary health services administered from the CH. Prompting questions were used to obtain a more in-depth response or to clarify responses to the questions in the interview schedule. The interviews, conducted in the Thai language, ranged in duration from approximately 30 min to over 2 h. At the conclusion of the 43 interviews, it was considered that saturation had occurred and data collection ceased.

Data analysis

The interviews were recorded and transcribed, and thematic analysis was deemed the most appropriate analytic technique for this study as it would identify key concepts and themes in the data. Prior to data analysis, the transcripts were translated into English by the principal investigator and validated by a Thai academic with several years experience in translating manuscripts from the Thai to the English language and vice versa. The qualitative data analysis software package, NVivo 7 (QSR International Pty Ltd, Melbourne VIC Australia), was used to sort, code, organise, store and retrieve data. Each transcript was first read in its entirety, and then all the transcripts were read several times to obtain an overall sense of each case study. During this stage, significant concepts were highlighted on the transcripts along with other important sections. After re-readings, the major concepts were listed, collated and coded. Strategies to ensure rigour and trustworthiness of the data included comparison of the coded concepts by two other researchers, and discussion of any differences was undertaken until agreement was reached. The coded concepts were then grouped together to formulate major themes and sub-themes with each theme describing an aspect of the phenomenon under study and which was shared by all the respondents. To ensure confidentiality of the participants, the data are presented by using the descriptors of CHD, BO (Bureaucratic officer), CDHO and HHPCU.

Tables 3-6 provide a summary of the demographic data from the key informants in this small study. This information includes age, gender, education levels, years of experience in healthcare and years of experience in the participants' current position.

Table 3. Demographic profile of national and provincial bureaucratic officers
PositionLevelGenderAge (Yrs)EducationExperience in the current position (Yrs)Experience in healthcare (Yrs)
  1. Note: BO, bureaucratic office; BSc, bachelor of sciences; M, male; MD, doctor of medicine; MPH, master of public health; MoPH, Ministry of Public Health; PHC, primary healthcare; Yrs = years.

BO 1NationalM54BSc, MD, MPH328
BO 2NationalM56BSc, MD, MPH (PHC Management), Thai Board of Preventative Medicine230
BO 3NationalM54BSc, MD, MPH, Thai Board of Preventative Medicine, Thai Board of Family Medicine, Cert. for Executives in Health Administration (MoPH)327
Table 4. Demographic profile of community hospital directors
PositionGenderAge (Yrs)EducationExperience in the current position (Yrs)Experience in healthcare (Yrs)Position in CUP Board
  1. Note: BSc, bachelor of sciences; B Pharm, bachelor of pharmacy; CHD, community hospital director; CUP, contracting units for primary care; F, female; M, male; MD, doctor of medicine; MPA, master of public administration; MoPH, Ministry of Public Health; Yrs, years.

CHD 1M56BSc, MD Thai Board of Surgery, Cert. for Executives in Health Administration (MoPH)1929Chair
CHD 2M42MD, Thai Board of Preventative Medicine, Cert. for Hospital Administration, Cert. For middle health managers (MoPH)617Deputy
CHD 3M47MD, Cert. for Hospital Administration1828Chair
CHD 4M42MD1518Chair
CHD 5M49MD, Thai Board of Paediatrics, Thai Board of Preventative Medicine, Thai Board of Family Medicine, Cert. for Hospital Administration1428Chair
CHD 6F41MD, Thai Board of Family Medicine, MPA1317Chair
CHD 7F38B Pharm, MD59Deputy
CHD 8M33MD, Thai Board of Family Medicine, MPA49Chair
Table 5. Demographic profile of heads of hospital primary care unit
PositionGenderAge (Yrs)EducationExperience in the current position (Yrs)Experience in healthcare (Yrs)Position in CUP Board
  1. Note: Asst. Head, assistant head; B Nursing, bachelor of nursing; BPH, bachelor of public health; CUP, contracting units for primary care; F, female; HHPCU, head of hospital primary care unit; M, male; M Nursing, master of nursing; MPH, master of public health; Yrs, years.

HHPCU 1F42M Nursing420Board member
HHPCU 2F44B Nursing1123Board member
HHPCU 3M49MPH226Board member
HHPCU 4M42BPH120Board member
HHPCU 5F48B Nursing2425Board member
HHPCU 6 (Asst. Head)M36BPH615Board member
HHPCU 7F39B Nursing1717Secretary
HHPCU 8F40B Nursing, MPH819Board member
Table 6. Demographic profile of chiefs of district health office
PositionGenderAge (Yrs)EducationExperience in the current position (Yrs)Experience in healthcare (Yrs)Position in CUP Board
  1. Note: BPH, bachelor of public health; CDHO, chief of district health office; CUP, contracting units for primary care; F, female; M, male; MPH, master of public health; Yrs, years.

CDHO 1M52BPH830Deputy
CDHO 2M55MPH730Chair
CDHO 3M51BPH929Deputy
CDHO 4M55BPH731Deputy
CDHO 5

(assistant)

M40MPH1119Board member
CDHO 6M57Cert. for health worker1038Deputy
CDHO 7M40BPH321Chair
CDHO 8M53BPH332Deputy

RESULTS

  1. Top of page
  2. SUMMARY
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGEMENT
  9. References

The respondents described the major challenges in implementing PHC within the context of the UHC policy and within the Thai rural context. These challenges included the following: (i) the demand for increased curative services; (ii) the workforce shortage at the primary care level; (iii) the bureaucratic management style of the Thai health system; and (iv) the disparity between responsibility and authority. According to the respondents, the challenges make it difficult for the CHDs to achieve the aims of the UHC policy and sustain PHC provision at the district and sub-district levels.

Demand for increased curative services

According to a senior male CHD, the UHC policy has increased the demand by people for curative services.

We thought that the number of patients at the PCU (HC) would have increased and those at the hospital would have decreased, (instead) the number of patients at the hospital is still increasing.’

(CHD 5)

A senior male CHD added that most of the patients who go directly to CHs have common diseases and this can create a heavy workload for staff.

You will see that eighty percent of out-patients in the community hospital have a respiratory or digestive tract disorder, both of which are not that serious that they need to be seen by the doctors. As a result, the doctors have to waste their time with patients who could have been taken care of at the primary health care facility.’

(CHD 1)

Another CHD informant said that although hospitals have been trying to upgrade HCs, this has not always been successful.

The hospital has been trying to solve this problem by improving the capacity of the health centres in order to assure patients that they can rely on the health centres. This solution has only been partially successful.’

(CHD 6)

However, a senior male CHD pointed out that the problem is that the district health services system emphasises curative care, whereas more emphasis could be placed on disease prevention and health promotion.

It seems we make a small mistake by providing them only with medical services, when we should also encourage them to look after themselves. The villagers are very happy to have the UHC gold card, and they know to use it only for medical services. They don't know how to protect themselves from getting diseases.’

(CHD 5)

On a similar note, several respondents spoke of the need for people to self-care. For example, a young male CHD believed that patients see their health needs in terms of medical care, with ‘health needs, in terms of self-care, receiving little attention’. (CHD 8)

Respondents also spoke about the reasons for patients not being responsible for their self-care. According to one respondent,

Most people understand what the health care services provide, however, they are not prepared to be responsible for their self-care. They would say that health care should be the responsibility of public health officers, the local government or the district officers. For example, when there's an epidemic they would say the doctors and the Village Hospital Volunteers should be responsible for disease prevention. People don't have the concept of self-care. There are no rules or laws to force them to take care of themselves.’

(CDHO 6)

Furthermore, a senior male CDHO pointed out that the priority of people living in rural and remote areas is economic survival, rather than their health.

I think they are not well educated, and there's an economic crisis; people have to make a living from working, they pay attention to their jobs rather than self-care. The economy is not so good, the villagers have low incomes, and most of them are employees.’

(CDHO 6)

A young male CHD, who worked in a remote area, expressed similar observations with the lack of self-care in the community, which he believed is the result of the poor economic situation of villagers: ‘There is still a major hurdle, the people's poor financial situation’. (CHD 8)

However, a young female CHD argued that the CHDs could do more to make people understand what they need to do for their self-care.

Perhaps we have not helped the local people to think the way we do. They may think about how to make their living and not about whatever we want them to consider. This is difficult.’

(CHD 7)

As previously mentioned, the interviews in this study were conducted with healthcare providers, so the data are only reflective of their perspectives. A recommendation for further research could be to obtain the views of a sample of people living in this province to obtain their perceptions of the concept of self-care.

Workforce shortage at the primary care level

All the informants believed that the major problem in implementing the UHC policy and PHC is the shortage of health personnel. As one senior CHD reported,

It is difficult to be successful, because we have found the shortage of manpower is the limitation, and the health workers cannot acquire the necessary knowledge to cope with the situation, so that the Hospital is flooded with patients just as usual.’

(CHD 5)

One senior male CHD suggested that the problem regarding the shortage of health personnel was more severe than that of the lack of funding.

There is the difficulty of the shortage of health personnel. We cannot assign health personnel to the PCUs, which is very awkward. The budget issue is less severe than that of human resources.’

(CHD 3)

A senior male CHD argued that besides the number of health professionals required, there is a need for knowledgeable health personnel to meet the health needs of people in the local areas.

We require more health personnel who are knowledgeable academically. I think we need more knowledge regarding health promotion, we need people who have specific knowledge of, for example, occupational health. So far, there are no occupational health personnel at all.’

(CHD 4)

Another CHD respondent pointed out that the system of medical education does not support PHC in Thailand and that doctors do not take the lead in the improvement of PHC.

We have a small number of doctors in Thailand. We have even less doctors who are skilled in Family Medicine and who love primary care work. It is because of the medical education system which does not regard this issue to be important.’

(CHD 8)

According to the respondents, the shortage of health professionals is not only due to a limited number of training places but also to other factors such as retaining staff in rural and remote districts. A young male CDHO made the following comment:

As a result of the remoteness, most of the executives come here on their way to other areas. This is always the case for both executives and staff. Those who still work here are rarely focused on good service. Everybody waits here in order to leave.’

(CDHO 7)

A senior male CDH believed that the shortage of doctors has prevented the improvement of medical services at the PCUs and HCs.

If we had enough doctors, we could assign some of them to work regularly in the PCU, which would improve the curative services at the PCUs. However, we can't meet their {the PCUs} needs because the doctors can only visit the PCUs occasionally.’

(CHD 3)

The respondents also acknowledged a severe shortage of registered nurses as a major barrier. A senior male CHD pointed out that the

shortage of doctors affects the hospital. When there are not enough doctors, the nurses have to be involved in the provision of curative services. There is a shortage of nurses and they feel stressed’.

(CHD 3)

Finally, a senior national bureaucrat pointed out that the shortage in the workforce personnel at the primary care level is problematic, because there is still confusion as to what type of health personnel should actually be involved at the primary medical care level.

We have to be clear, at the primary medical care level, whether we want medical doctors or not, where nurse practitioners will work, and what roles the health centres will have; what are the roles of nurses and what are the roles of the health workers. I think that all of those need to be explored further.’

(BO 1)

Bureaucratic management style of the Thai health system

According to a senior male CHD, the CHDs lack the power to initiate their own ways to achieve the goals, because the MoPH is overcentralised and typical of the Thai style of managing.

In fact, the MoPH should have determined the goals, but we [the Hospital Directors] should have been empowered to choose our own ways to reach those goals. At the moment, the bosses like to draw a line for the subordinates to follow. They like to give directions; if they say left you must go left, if they say right you must go right. It is that bad!

(CHD 4)

A young female CHD concurred, saying that this overcentralisation occurs not only at the ministerial level, but also throughout the whole system. She said that when she had to carry out the Family Health Leader (FHL) project ordered by the PCMO, she lacked the necessary independence to implement it: ‘Like this year's policy on FHL [Family Health Leader], we were required to follow the steps 1, 2, 3, 4.’ (CHD 7)

A senior female HHPCU said that the overcentralisation of the policy from the MoPH makes it impossible for her to carry on her work at a PCU effectively, as the policy does not fit with the situation at that local level:

Meanwhile other activities are too prescriptive to apply; for instance, at the moment we are assigned to promote health care in children from 0 – 6 years old [the children at this age should do exercise]. I can't remember the number, but there is an expected percentage of achievement. Instead of having the freedom to execute the health promotion programme by myself, I have to follow the designed programme [from the MoPH]. I will only be the data gatherer [data specified by the MoPH] and will report that data to the policy makers at higher levels. I feel frustrated; it's not practical.’

(HHPCU 7)

A senior national bureaucrat asserted that the MoPH is rigid, overcentralised and has a monopoly in terms of health policy:

However, at present, the policy has only been carried by the MoPH and this leads to activities that belong only to the MoPH. I think the MoPH is only a part of the system so to some extent it can't compete or chase the growing private sector or others [other ministries with responsibilities for medical provision] … It means that we don't need to limit the referral of patients to only MoPH tertiary care; we can send the needy to other hospitals that belong either to other Ministries or to the private sector. The present situation is one of central overcrowding. For instance, when you want to refer your cardiac patients for heart operations, at present you can only refer them to the MoPH tertiary care hospitals, even though there are many tertiary care hospitals available that belong to medical schools, the army, or the private sector.’

(BO 1)

Another senior male CHD told the story regarding the patronage system and the lack of transparency and accountability when he worked at the district level:

‘… the health worker is an example of a person supported by his patron at the MoPH. The patron might be someone who used to work in Korat [PHO]. His subordinates would tend to support him to advance his career, because he could be helpful to them in the future.’

(CHD 5)

Disparity between responsibility and authority

The respondents all spoke about the disparity between the authority and responsibility of the CHDs and their stakeholders who are engaged in the provision of PHC services at district and sub-district levels. The CHDs believe that the aim of the UHC policy is to encourage CHs, DHOs and HCs to all work towards an integrative, united approach, but most CHD respondents in this study believed that the district health system still lacks integration. As one CHD pointed out,

In reality, there is no integrated health care system. We are not working harmoniously, because we are not the same family. We are working independently instead. We don't look after our people's health in a truly holistic way.’

(CHD 3)

A young female CHD and a senior male CHD provided examples of different working styles between hospital and HC staff.

Instead of coming together and helping each other to improve the overall performance, it turned out we worked alone {for the medical services}; they {the HC staff} just disappeared and I don't know why.’

(CHD 7)

Hospital staff who work at the HC when assigned to do community services don't want to go into the community and when the HC staff share the population in the catchment area with hospital staff, the hospital staff don't want to be involved in the community services, because they are trained to provide medical treatment in the centres, not in the community. This is one more aspect of the difference between the two organisations.’

(CHD 5)

Another respondent, a senior provincial male bureaucrat, also highlighted the disparity between the health personnel.

I think that health officers in health centres are taught about and born with the holistic concept of health. This means they can work more closely with the community than doctors and officers in hospitals can. I think that doctors don't understand this feeling of working closely with the community.’

(CHD 5)

A senior provincial male bureaucrat said that decisions made at the CUP Board level are dominated by the CHDs. The conflict in working under the CUP Board arises because the CHDs pay more attention to their hospitals, rather than to the overall health facilities in the district.

We sent the budget directly to the CUP Board, of which the Hospital Director is the most powerful {member} and they can influence the others. The Director wanted that budget to be extra {funding} for the hospital and not for the health centres. Consequently, health officers working in health centres did not receive their salaries and overtime payments.’

(BO 3)

A senior male CHD respondent argued that working under the CUP Board structure would only be effective when there is one single authority to control HCs. ‘It,(the ‘Two Becomes One’ policy, is not practical, because we {the hospital}need to have the administrative authority to supervise and monitor them {health workers}.’ (CHD 2)

All the respondents agreed with this CHD respondent with a female CHD making the following suggestion.

They {the MoPH} should clarify this issue. For example, they should let the Community Hospital take care of Health Centres, and let the District Health Office be the only organisation to set standards. We can't do very much unless we reorganise the district health services system.’

(CHD 7)

According to the respondents, a second level of disparity also exists between the CH and the municipality and local governments at sub-district level regarding the authority and responsibility for the provision and administration of PHC services. For example, a senior HHPCU reported an overlap in responsibility for community health between the hospital PCU and the municipality. This reflects a disparity between the responsibility and authority of the CH and the municipality, as well as a conflict between the two organisations in terms of the mismatch in their respective populations and funding and the lack of integration.

There is an overlap in responsibility regarding community health between the municipal authority and the Hospital PCU, because both cover the same area. According to the Municipal Act, the municipal authority is responsible for community health.’

(HHPCU 3)

DISCUSSION

  1. Top of page
  2. SUMMARY
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGEMENT
  9. References

The aims of this study were to identify the major challenges and barriers to the delivery of PHC at the district level in Thailand from CHDs and health services stakeholders and to present their views on strategies that could help facilitate sustainable primary health services administered from the CH. The respondents discussed three specific challenges; and as a result, two major areas of concern were identified, which include (i) structural interests and (ii) organisational cultural contexts.

Structural interests

The findings from this study suggest that despite some significant improvements since the implementation of PHC, further improvement is needed regarding rural healthcare reform in Thailand, specifically the health needs of the rural poor.

Thailand adopted the PHC concept and the World Health Organization goal of ‘Health for All by the Year 2000’ and incorporated them into the 4th National Social and Economic Development Plan (1977–1981) following the declaration of the concept of PHC at Alma Ata in 1978 (Bureau of Policy and Strategy, 2007). Some MoPH health programmes, such as the PHC programme at the village level and the ‘Healthy Thailand’ project launched in 2005, are related to PHC. These MoPH programmes emphasise health promotion and disease prevention and aim to achieve the Millennium Development Goals (Bureau of Policy and Strategy, 2007). In the Nakhorn Ratchasima province, the ‘Sustainable Health for All’ programme aims to cover the basic health needs of the people (Nakhorn Ratchasima Provincial Health Office, 2006). Health policies, including the abovementioned programmes, could be more integrated within the UHC policy, and a more streamlined, united approach needs to be taken with human resource production and development, funding distribution at the local level, and health services provision.

The results of this study showed that the first level of disparity between authority and responsibility is at the district health team level. With the CHs acting as CUPs and responsible for per capita funding, the CHDs have to establish a prototype PCU in their sub-districts and at the same time collaborate with CDHOs to improve the quality of healthcare provision at all HCs located at the sub-district level. Under the UHC policy, the CUP Board structure is intended to promote collaboration; however, it is essentially the same structure as the former District Health Collaborating Committee, which has since been renamed the District Health Administration Committee to promote a sense of a united district health team for the three health organisations, CH, DHO and HCs, at district and sub-district levels. There is a slogan for this project titled Two Becomes One, which refers to having health organisations from two distinct functional lines working together as one united team. According to the CHD respondents in this study, this strategy has not been fully effective, and further understanding of the existing problems is required if this new initiative is to be successful.

The second level of disparity between authority and responsibility for PHC service provision exists between the CH and the municipality and local governments at the sub-district level. As a CUP, a CH is expected to oversee all health services. As the results showed, however, at the district level, the municipality is responsible for some health services. For example, each municipality own an HC, which is located in the same sub-district area as the hospital. The municipal HC and the CH PCU both provide PHC services to the sub-district population, but the coordination between the HC and the CH is informal and fragmented. Furthermore, the three levels of local government, that is, provincial, district and sub-district, are loosely connected to each other, which also hampers cooperation.

The responsibility for integrating health activities at the local level rests with either the health workers or the Village Health Volunteers through their contact with the local government that provides funding to them. The healthcare at this level is also fragmented, and this again highlights the influence of Thai cultural elements embedded in bureaucratic practices and relationships between individuals and between individuals and organisations.

The findings also showed that support of the UHC policy and PHC by specialists and new medical graduates working in hospitals is minimal as they focus on curative care with little emphasis on health promotion and disease prevention. These findings reflect the findings in the study of rural general practitioners in Australia by Evans et al. (2006: 175), which found that some doctors only focus on curative care. According to De Maeseneer et al. (2008: 811), a concerted effort is needed with recruitment, education and retention of primary healthcare workers, and universities and higher education institutions ‘should continue to demonstrate their social accountability by training appropriate providers’.

Organisational cultural contexts

The results of this study also found that the CHDs, at the time of the study, were dissatisfied with the patronage healthcare system in Thailand and the lack of transparency and accountability within the Thai bureaucracy. In addition, they believed that decision making in the Thai bureaucratic system should be more focused on the health needs of the people. According to the CHD respondents, working under such a bureaucratic system limits their capability to successfully implement the UHC policy. They were also uncomfortable with overcentralised regulations, red tape, too much hierarchy and a lack of coordination between the different agencies and levels. Rural health reform in Thailand could be more effective if the CHDs and their stakeholders understand how organisational culture and traditional cultural norms influence their strategic involvement and the implementation of organisational change in the Thai social system (Carney, 2006; Hallinger and Kantamara, 2000).

Three main recommendations arose from the findings of this study. First, the roles and responsibilities of CHDs, as district health services managers, and other stakeholders who take part in district health services management should be clearly determined. Second, the CHDs need a collaborative management role as a facilitator for PHC in their districts with clearly defined skills and knowledge base. Third, possible ways to support the professional management role for CHDs to sustain PHC services for the rural poor include formal preparation and training in hospital management and primary healthcare, ongoing professional development, financial incentives and a formal mentoring scheme.

There were limitations to the study that require mentioning. First, the participants were chosen using snowball and purposive sampling strategies, and the small non-random sample limits generalisation of the findings to the wider population. Second, the perceptions of the respondents were limited to a small sample in the north-eastern region of Thailand, so they may not be reflective of the population of health professionals' perceptions in the north-eastern region or from other regions in Thailand.

CONCLUSION

  1. Top of page
  2. SUMMARY
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGEMENT
  9. References

In conclusion, CHs in Thailand operate in a dynamic and changing socioeconomic and political environment that is both complex and costly, and there are many challenges that influence the successful implementation of rural healthcare reform. This qualitative study has shown that although the aim of the UHC policy is to increase the accessibility of quality care for all people, especially the underprivileged, there has been some resistance from the dominant structural interests, which have impeded the implementation of PHC. In addition, the organisational culture will require a more democratic and adaptable approach to meet the needs of rural people. Thus, it is hoped that the valuable insights of the respondents in this study will shed some light on helping to close the gap between policy reform and successful implementation of primary healthcare in Thailand.

References

  1. Top of page
  2. SUMMARY
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGEMENT
  9. References
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