PRIMARY CARE DEVELOPMENT IN THAILAND An interesting case of District Health System Evolution SOMSAK CHUNHARAS, MD., MPH. NATIONAL HEALTH FOUNDATION June 8, 2009

Welcome to Thailand

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

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

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

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

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 Roles: 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 / monitoring-evaluation system / technical support and quality control

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

Health Center – higher expectation The Decade of Health Center Development: Strenghtening primary care services, reduce workload from hospitals 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 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

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)

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)

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).

Primary Care Unit Non-MOPH / Private NHSO Recommended model For more effective Strengthening of HC Thru MOPH CUP PPV OP IP PP Oth PPF/PCA/PPC Regional NHSO OP PCMO PPC Board Com Hosp 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

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, 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

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

Primary Care Development access and coverage quality of care 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

Thank you