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

2. Welcome to Thailand

3. Traditional Medicine 1932 1950 1964 1966 1968 1974 1975197819811992199619971999200220012007 Stating Rural Health Services Tropical Diseases Control Programs Wat Boat Project - Sarapee Project - BanPai Project Health Centers Lampang Project Samoeng Project Nonetai Project Expanded Community Hospitals Adopted Health For All Policy Rural Doctors Movement Community Health Volunteers Health Card Project The Decade of Health Center Development (1992-2001) 1985 Health Care Reform Project Economic Crisis Civil Society Movement Universal Coverage Policy Thai Health Fund Starting Primary Care Services National Health Act Primary Care Development Source: Komartra Chungsathiensarp, 2551 Decentralization

4. The History - infrastructure 1913: O-soth Spa = Medical and Public Health Office in some provinces 1913: O-soth Spa = Medical and Public Health Office in some provinces 1932: Suk Sala – with physician (1 st level) / none physician (2 nd level) in high density population area 1932: Suk Sala – with physician (1 st level) / none physician (2 nd level) in high density population area 1954 Midwife Office for ANC in order to reduce infant mortality rate 1954 Midwife Office for ANC in order to reduce infant mortality rate

5. The History - infrastructure Suk Sala (physician) 1954 Health Center 1954 Health Center (1 st level) (1 st level) 1972 Rural Medical Center 1972 Rural Medical Center 1974 Medical and Health Center 1974 Medical and Health Center 1975 Community Hospital 1975 Community Hospital Suk Sala (none physician) 1952 Health Center 1952 Health Center (2 nd level) (2 nd level) 1972 Health Center 1972 Health Center Midwife Office 1982 Health Center 1982 Health Center

6. Primary Care Development Before Alma Ata 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)

7. The First Reform MOPH Reform (1972) Integrating curative services (under medical service department) and preventive health service infrastructure under department of health 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) 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 Provincial Health Office to oversee both curative and preventive services infrastructure in each province

8. The Second Reform Major Policy Reform – PHC (1979) Results of 2 major research programmes Results of 2 major research programmes village volunteers for contraceptive pills distribution in Banglamoong in the Eastern region (1974) village volunteers for contraceptive pills distribution in Banglamoong in the Eastern region (1974) Lampang Project -health volunteers for MCH (1976) Lampang Project -health volunteers for MCH (1976) Main policy shift = Community participation & health as an integral part of socio-economic development Main policy shift = Community participation & health as an integral part of socio-economic development Alma Ata provided opportunities for nation- wide implementation (less resistance) Alma Ata provided opportunities for nation- wide implementation (less resistance)

9. The Third Reform (Health) System Reform Concern over health care financing and needs for financing reform (since 1985) Concern over health care financing and needs for financing reform (since 1985) Second MOPH reform – creating policy mechanism and health system research institute – 1992 Second MOPH reform – creating policy mechanism and health system research institute – 1992 Social security system in place with capitation payment for health insurances Social security system in place with capitation payment for health insurances Health care reform research project supported by EU Health care reform research project supported by EU Health equity and health promotion concern Health equity and health promotion concern

10. Primary Care Development PHC Era 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

11. Primary Care Development PC Model 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

12. Primary Care Development MOPH policies 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

13. Primary Care Development UC Policy (2001) 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)

14. Community Hospital Medical care provider at district level, 120-150 beds Medical care provider at district level, 120-150 beds Roles: 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,

15. Community Hospital under UC CUP – contracting unit for primary care 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

16. 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

17. Health Center – higher expectation The Decade of Health Center Development: Strenghtening primary care services, reduce workload from hospitals Selected urban health centers 1:5 Selected urban health centers 1:5 Acting as “node” - take care of other HCs in the network, referral center Acting as “node” - take care of other HCs in the network, referral center More personnel: More personnel: –Rotated physician from near-by hospital / Routine Medical service (CMU) –Registered nurse, dental hygienist More services – basic dental care, treatment More services – basic dental care, treatment

18. Health Center under UC Strengthening primary care service PCU – catchment 10,000 pop, working 56 hrs/week, easy access PCU – catchment 10,000 pop, working 56 hrs/week, easy access Personnel: one physician, 2 registered nurse, 3 health sciences officers, etc. Personnel: one physician, 2 registered nurse, 3 health sciences officers, etc. Roles: 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 Autonomous PCU in urban area

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

20. At the Cross Roads PCU = HC with no medical doctors (lessons from Ayudhaya) PCU = HC with no medical doctors (lessons from Ayudhaya) PCU = HC with medical doctors on rotation (implemented in selected HC) 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 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) Private Clinics with additional functions, mainly outreached community-based, (lessons from urban HC under UC)

21. Key concerns Do we need “medical doctors” for a PCU? 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.

22. Whatever they are, they are not the same as European GP’s, Whatever they are, they are not the same as European GP’s, they will not provide only clinical services (so called PMC), they will not provide only clinical services (so called PMC), should be more proactively working with community and 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) should be concerned with and play active roles to tackle health as a wholistic concept (PHC and health promotion concept)

23. 3 major lines of development Strengthening PC thru CUP => applicable mostly thru CUP within MOPH (CH, GH, RH) 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) 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). Modified private clinics (adding community-based care).

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

25. Recent Policy: Health Service Development Tambon Health Promotion Hospital: Leverage HC to Tambon Hospital and set up referral system and networking with private sector

26. Tambon Health Promotion Hospital Catchment area - tambon level and networking with other health centers, Catchment area - tambon level and networking with other health centers, 24 hrs services, under supervision from the hospital and referral system, 24 hrs services, under supervision from the hospital and referral system, Polyvalent - skill mix and team work in PP services, Polyvalent - skill mix and team work in PP services, Community participation and internal audit, Community participation and internal audit,

27. Tambon Health Promotion Hospital Coordinate with other partners - central government + local authority + community + private sector, Coordinate with other partners - central government + local authority + community + private sector, Working in community – home ward, Working in community – home ward, Proactive, outreach services based on community health needs, Proactive, outreach services based on community health needs, Care coordination – horizontal and vertical levels and case management system Care coordination – horizontal and vertical levels and case management system

28. Possible future of THPH Strengthened as a subsystem with the CUP Strengthened as a subsystem with the CUP Evolve as CMU within MOPH network Evolve as CMU within MOPH network Evolve as CMU under local administration Evolve as CMU under local administration

29. Next Strengthen MOPH-PC network through Tambon Hospital (CUP-based) Strengthen MOPH-PC network through Tambon Hospital (CUP-based) Redefine Private PC (service models, budget, capacity and HR) Redefine Private PC (service models, budget, capacity and HR) More flexible “performance assessment” framework – too many detailed items at present More flexible “performance assessment” framework – too many detailed items at present Redefine “how to commission” for PC in the future – directly contrating with PCU? Redefine “how to commission” for PC in the future – directly contrating with PCU? –MOPH- Local Administration –Private Sector- Other Public Providers

30. Primary Care Development access and coverage quality of care cost-effectiveness efficient use of resources Community Participation Resource Allocation Private Sector Roles & Regulations Information System Human Resource Allocation/Financing Referral Network & Excellent Center Technology & Pharmaceutical Benefit PC Model and EMS Model Area health board Local Authority PC development and relationship with major system issues