Context Based Learning (CBL) District Health Systems (DHS) in Thailand

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1 Context Based Learning (CBL) within and for District Health Systems (DHS) in Thailand Yongyuth Pongsupap, Surakiat Archananuparp, Tawekiat Boonyapaisarncharoen, Somchai Phanumaswiwat, and Patrick Martiny 3 November 2017

2 Background: 1 o Care Development in the Context of Thai DHS Health Care Structure in Thailand Population: 65 millions GNI: US$ 5210 per capita Life expectancy at birth: 74 years Total Health Expenditure: 4.6% of GDP Doctors/Population ~ 4/10,000

3 The need for integrated District Health System Health Care Structure in Thailand Gaps: by-passing HCs PCU (2002): Primary Care Unit; FCT (2015): Family Care Team; PCC (2016): Primary Care Cluster Continuous policy Boosters toward Matrix Team

4 The need for integrated District Health System Managerial Integration Operational Integration PCU (2002): Primary Care Unit; FCT (2015): Family Care Team; PCC (2016): Primary Care Cluster Continuous policy Boosters toward Matrix Team

5 Managerial Integration UC scheme Cabinet resolution Evolution: 2 lines of commands >> Committee >>> Board District Hospital & District Health Office DHDC (1983): District Health Developing Committee Chairman: District Officer (Sheriff) Deputy Chairman: Director of the district hospital Secretary: District Health Officer DHCC (1986): District Health Coordinating Committee (12 persons) Chairman: Director of the district hospital or District Health Officer Secretary: Chairman choose (one from District Hospital; and one from District Health Office) Deputy Secretary: Chairman choose (one from District Hospital; and one from District Health Office) CUP (2545): Contracting Unit for Primary Care (UC scheme: include Bangkok and private), Not include CSMBS, SSS DHCC (2003): District Health Coordinating Committee (10-20 persons): more involvement of stake holders from different sectors DHS movement (2011): UCARE (informal DHBin some districts: District Officer is the chairman) DHB (2016): 73 districts under MOU (MoI, MoPH, NHSO, THPF); DHB (2017): 200 districts, DHB (2017) >>> a formal legal framework 5

6 Evolution: From extended OPDs in HCs >>> To Matrix Teams Operational Integration UC scheme Extended OPDs Doctor and hospital team: go to only remote health centres Cultural Confrontations: hospital culture & family medicine concepts PCUs (2002): Human resource criteria of CUP Doctor and hospital team: go (rotate) to almost every health centre in the district under the condition as PCUs Community Medical Centres CMUs in some urban areas e.g. Ayutthaya, Korat., Hadyai, New constitution Movement of DHS (2011): Matrix Links/Networks FCT (2015): Family Care Team PCC (2016): Primary Care Cluster (2017): Family Doctors -> appropriate proportion with the population Matrix Team >>> Matrix Team: Horizontal, Vertical, and Diagonal Relationships Individual 6

7 The need for integrated District Health System a supportive mechanism for Managerial & Operational Integration

Learning in the Context Significant Inputs Context Based Learning (CBL): formal Introduction & Evolution Identified for Carers Decision trees +

Mainly for HC staff (No Doctor) Curative (not clearly prepared) + Prevention + Health Promotion Polyvalent Team Introduced HC staff with

8 Learning in the Context Significant Inputs Context Based Learning (CBL): formal Introduction & Evolution Identified for Carers Decision trees + Explanation of common diseases For Basic Curative Services Proposed CBL in PhD thesis (2007) Primary Care Practice Learning PCPL Patient-cntred Scale up for DHS dev. Family Practice Learning FPL Person-cntred District Health Management Learning DHML People-cntred Introduced: 1980s 1990s Mainly for HC staff (No Doctor) Curative (not clearly prepared) + Prevention + Health Promotion Polyvalent Team Introduced HC staff with Self-Styled Fam. Doctor New Paradigm: Holistic + Integrated + Continuous Care Ayutthaya Research Project (Demonstration Diffusion) CBL CBL CBL CBL Technical Competencies Shadow Competencies (5) + + Social Competencies Core Competencies (5) Individual-Team-System Identified for Managers

9 Context Based Learning (CBL) PCPL FPL DHML Primary Care Practice Learning PCPL consists of in-service (Hospital, Health Centre, and at Home) training mainly for Health Centre Staff. Family Practice Learning FPL provides (Family) Doctors with skills related to quality patient- & person-centred care and simultaneously skills to support the District Health System and the Family Care Teams (Matrix Team). District Health System Management Learning DHML reinforces health System Actors Partnerships for managing and strengthening the health system Patient-centred Care --- Person-centred Care --- People-centred Care

PCPL Context Based Learning (CBL) Primary Care Practice

and at Home) training mainly for Health Centre Staff.

(gaps of competencies) Initial training: 6 wks for each HC

with Dr from DH After 6 wks: integrated learning activities

from the catchment area of subdistrict of the health centre,

10 PCPL Context Based Learning (CBL) Primary Care Practice Learning PCPL consists of in-service (Hospital, Health Centre, and at Home) training mainly for Health Centre Staff. Technical Competencies: started from individual training needs (gaps of competencies) Initial training: 6 wks for each HC staff Each week 3 days in DH 2 days in HC and comm. with Dr from DH After 6 wks: integrated learning activities into routine activities Social Competencies: Focused on people from the catchment area of subdistrict of the health centre, who admitted in the district hospital. Very useful to increase confidence with patient-family-community

FPL Context Based Learning (CBL) Family Practice

skills related to quality patient- & person-centred

Health System and the Family Care Teams (Matrix Team).

CLU DLU Five weekend workshops within 1 years

Competencies: Holistic Care, Integrated Care,

11 FPL Context Based Learning (CBL) Family Practice Learning FPL provides (Family) Doctors in DH with skills related to quality patient- & person-centred care and simultaneously skills to support the District Health System and the Family Care Teams (Matrix Team). Practice: Routine activities Learning activities FLU CLU DLU Five weekend workshops within 1 years Portfolio Family reports Technical + Social Competencies: Holistic Care, Integrated Care, Continuous Care, Effective Care, Advocate/Coordination, Community Diagnosis, Integrated DHS

DHML Context Based Learning (CBL) District Health

System Actors Partnerships for managing and

Institution LCC: Learning and Coordinating Centre LT:

Learning Shadow Competencies: Self-control, Values,

12 DHML Context Based Learning (CBL) District Health System Management Learning DHML reinforces health System Actors Partnerships for managing and strengthening the health system AI: Academic Institution LCC: Learning and Coordinating Centre LT: Learning Team (Project based learning: formal support for 1 yr.) P: Preceptor (Coach or Supervisor) SL: Sources of Learning Shadow Competencies: Self-control, Values, Communications, Relationships, Powers Core Competencies: Vision, Planning, Working in Team, Leading for Change, Using Mx. Tools

13 Spiraling up through Action and Reflection Participatory Interactive Learning through Actions: PILA Interactions with the policies: In synergistic with different boosters at the policy level CUP & PCU (since 2002) CBL DHS FCT, PCC & DHB 5 (Districts) 5 (Districts) 5 (Districts) PCPL 10 (Districts) 10 (Districts) 10 (Districts) 327 (Districts) 327 (Districts) FPL DHML Introducing Matrix Teams (UCARE) (Teams) (Teams) (Teams) (Teams) (Teams) (Teams) Matrix Teams/Links/Networks UCARE: U = Unity; C = Community Participation; A = Appreciation; R = Sharing Resources; E = Essential Care

14 A Program Theory underlying CBL (PCPL, FPL, DHML) CBL is the development of functional and sustainable relationships between district hospital, first line health services staff and other partners (from even beyond the district limits), as well as within hospital, health center teams and communities, with reference to shared concepts (primary health care, family and community medicine, patient-centeredness, integrated health system, continuous learning and total quality management), for better working together (functional relationship), for continuously learning together (learning relationship), for strengthening the organization together (managerial relationship), in order to make the health system responsive to people s current and emerging demands and needs, including quality care.

15 CBL (PCPL, FPL, DHML): Learning process refers to Participatory Interactive Learning through Action (PILA): CBL concerns all staff and partners, all levels of the district health system; it develops interactions within and between the four levels of care (district hospital, health centre, community and family). CBL starts from routine practice in the learners context: it uses all activities (medical consultation at the health centre, home visits, introduction of guidelines, training, supervision, case conference...). CBL is action oriented: learning from action through doing in one s own context - เร ยน ในส งท ทำ (learn in things you do!) - and learning for action - ทำในส งท เร ยน (do what you learn!). CBL relies on several learning activities (on-the-job inter-service holistic practice, follow-up of selected families, support of health centre staff and communities, implementation of health driving projects, field visits ) and interactions (small group discussions, workshops, field visits ) with support (academics are involved).

16 CBL (PCPL, FPL, DHML): contributions to the systems Gives direct benefit for the members of the district health system : improvement of care quality (people centeredness) and integration of the health system. Leads to social change: Empowerment of the workforce. Networking: sustainable interactions (functional, learning and managerial relationships) between actors at each level of the district health system, between all related levels, and also beyond the boundary of DHS. Organizational development: creation and reinforcement of family care teams, district health boards, district learning and support team. 16

Guideline for FPL Guideline for DHML Spiraling up through Action and

(2016 & 17) Synthesis principles & different experiences of PCPL CBL: Context

Learning (Managers) FPL (2012): Family Practice Learning (Carers) PCPL (2007):

development *** Exchanges: Provincial, Regional and National Levels Including

identifying different learning needs: Mangers & Carers under the principle of

17 Guideline for FPL Guideline for DHML Spiraling up through Action and Reflection Interactions with Current Policies: FCT (2015) >>> PCC (2016); DHB (2016 & 17) Synthesis principles & different experiences of PCPL CBL: Context Based Learning [Tested Methods] DHML (2014): District Health Management Learning (Managers) FPL (2012): Family Practice Learning (Carers) PCPL (2007): Primary Care Practice Learning (Carers) PCPL (2011): scale up for DHS development *** Exchanges: Provincial, Regional and National Levels Including demonstration visits for different actors and policy makers Started identifying different learning needs: Mangers & Carers under the principle of CBL Gaps: Expected VS Existing Competencies >>> Identified learning activities: mainly learning in the context of DHS

18 Interactions with current Policies Complementary Learning Methods Context Based Learning: CBL (Learning within and for DHS) Current Policies District Health System: DHS (Area-based & People-centred System) District Health System Management Learning: DHML Family Practice Learning: FPL District Health Board: DHB Primary Care Cluster: PCC (Family Care Team: FCT) Primary Care Practice Learning: PCPL

19 Interactions with current Policies A direction of Primary Care development toward Patient-, Person-, & People-Centred Care in the Context of DHS

20 CBL (PCPL & FPL): complementary learning method A way forward in the New Constitution: Empanelment (Patient-, Person-, and People-Centred Care) Family Doctor: GMR (Global Medical Records) District Hospital Health Centre Sub-District Village Family Village Health Volunteers Family members & Relatives Individual PCU (2002): Primary Care Unit; FCT (2015): Family Care Team; PCC (2016): Primary Care Cluster Continuous policy Boosters toward Matrix Team Systematic Link: The name of Doctor with the name of the Population -> a clear Matrix Team (Horizontal/Vertical Team including Diagonal relationships -> Person-Centred Care)

21 CBL (DHML): complementary learning method District Health Board (DHB) A way forward in the New Constitution: Empanelment (Patient-, Person-, and People-Centred Care) Family Doctor: GMR (Global Medical Records) District Hospital Health Centre Sub-District Interactive Synergies Village Family Village Health Volunteers Family members & Relatives Individual Matrix links in DHS: teams, networks, participation/collaboration -->> Extended Matrix Teams Systematic Link: The name of Doctor with the name of the Population -> a clear Matrix Team (Horizontal/Vertical Team including Diagonal relationships -> Person-Centred Care)

22 Conclusions CBL (PCPL, FPL, DHML): can reinforce patient centeredness, primary care and family medicine, and district health system in Thailand; is a learning system which bridges health professionals and health and not-health professionals, professionals and communities, health care and educational systems, from all levels of care; is in line with new management approaches which empower field actors. It is both large scale implementation and research. and is to be transformative learning: it aims at transforming individuals emotional style, a cognitive transformation starting from what is already known; it produces change agents, able to reflect on their working environment and to modify it.

23 Challenge and prospects More evidence related to CBL to be produced. The Program Theory underlying CBL: to be refined and tested. => Implementation research on a developing health system model for primary care in Thailand Sketch for a Program Theory of CBL (De Man & Van Olmen, 2017)

24 Reference 1. Davidson RJ (2012). The emotional life of your brain. London: Hodder & Stoughton. 2. Panich V. Transformative Learning. Bangkok: S.R. Printings and Mass Products, Yongyuth Pongsupap, Somchai Phanumaswiwat, Surakiat Achananuparp, Tawekiat Boonyapaisarncharoen, Patrick Martiny (2017). Context Based Learning for District Health System Integration and People-Centeredness. Working paper. 4. Pongsupap Y and al (2016). District Health Management Learning: A big leap forward to people-centred district health system in Thailand. The Journal of Public Health and Development, 14 (3): 3-12.

25 Thank You

Experience of people-centred care in Thailand

Experience of people-centred care in Thailand From demonstration diffusion to policy transformation Yongyuth Pongsupap MD, MPH, PhD Context Population: 65 million Majority of health care providers: public