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 sector Thai culture of care seeking, hospital and private clinic centred. Importance of «PHC» in the context of DHS: health centre in every sub-distict, district hospital in every district Main partners to develop people-centred care Inputs of international and Thai researchers (ITM-A, Mahidol University, IHPP, HSRI, etc.) MoPH Thai universities Sector Facility unit bed Regional hospital 25 17,233 Provincial hospital 69 22,585 Public District hospital 736 28,366 University hospital 15 8,792 Health Center 10,848 - Private hospital 322 33,678 Private Private clinic 346 - Drug store 17,017 -

Background: hospital & specialist bias 1888 First Hospital 1921 Rockefeller Foundation train specialists Doctor means hospital doctor Ambulatory care in after-hours private clinicby hospital doctors GPs work in hospital, seen as not-yet-specialists Good medicine: HOSPITAL & TECHNOLOGY 1990s Introduction of people-centred primary care An article in the newspaper

People-centred care

Proposed framework

Elements of refrom strategy: interventions & interaction Production of a model for first level health service (people-centred primary care) & Diffusion of this model Universal coverage scheme: Policy definition National Health Security Office as a regulation / coaching body Training of family doctors and district «family» doctors for care management Promotion of integrated health district along with reinforcement of capacities: Context Based Learning (CBL)

Field model development Start up and test a variety of formats of FP in different circumstances Optimise strategy & tool boxes Capacity & knowhow Professional legitimacy And identity Promote offer: Production Insert FP in university curricula Prime Movers In province: Urban HC In province: Rural HC In hospital OPD In private clinic In universities Nurse Family Practice In Bangkok Publication Evaluation Expert inputs Demonstration/ visibility Stimulate demand Promote professional Demonstration visits Course Media, Civil society orgnisation Promote Offer: Recruitment Professional organisation: prestige, protection, perspective Promote demand: policy makers Structure, financing mechanism, career Promote demand: population Popularise notion of family doctor Dissemination & Transformation into policy

Different Health Centres New toolboxes Registration (census) Information system: Individual and family continuous records Referral system: home - health centre - hospital Payment: a flat rate per-episode of illness Regular community meeting and a new way of working (doing medicine) Beyond prescribing: listen, understand, negotiate Home visits Home care Follow up of hospitalised patients

Systematic evaluation and transformation of toolboxes into guidelines Instructions for systematic home-visits (registration, home care); Follow-up by the health centre physician of those patients referred to hospital; Procedures and guidelines for ensuring continuity of care for chronic patients; Guidelines for rationalisation of information systems built around family folders; Strategies to establish co-management and participation of the population;

Field model development Start up and test a variety of formats of FP in different circumstances Optimise strategy & tool boxes Capacity & knowhow Professional legitimacy And identity Promote offer: Production Insert FP in university curricula Prime Movers In province: Urban HC In province: Rural HC In hospital OPD In private clinic In universities Nurse Family Practice In Bangkok Publication Evaluation Expert inputs Demonstration/ visibility Stimulate demand Promote professional Demonstration visits Course Media, Civil society orgnisations Promote Offer: Recruitment Professional organisation: prestige, protection, perspective Promote demand: policy makers Structure, financing mechanism, career Promote demand: population Popularise notion of family doctor Dissemination & Transformation into policy

Ensuring visibility Taking advantage of location of Ayutthaya, visits by Politicians High officials Health personnel Students Health personnel from neighboring countries Ayutthaya These demonstration visits use standardised and tested guidelines for observation of activities for understanding the difference between the demonstration models and the routine reality. 1992

Ensuring visibility: 3294 visitors and 255 trainees in 36 months Number of visitors 0 1-50 51-100 101-150 More than 150

Promote offer: production & recruitment Introduced Family Practice in the university curricula Worked through the sub-committee on medical training of the medical council to develop the curricula Adopted by universities for their residency training 200 in 6 years Established organisations and institutions of Family Practice Royal College of Family Practitioners Family Practice Departments in nearly all universities

Promote demand: initial efforts Increase demand by the population Micro-level efforts Invite people from nearby to participate community meetings of already established centres No major impact Awareness among policy makers Invite and show Incubation period, no major policy effects yet

Expansion by demonstration and diffusion: from 10,000 to 600,000 inhabitants Number of prime mover family practices 70 60 50 57 61 40 36 30 20 10 0 1 2 3 3 4 5 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 Year 13

Transformation into Policy Scaling up: the Universal Coverage policy

People centred primary care as a key Pressure for universal coverage: access for all MOH technocrats the Health Care Reform Office Civil society pressure Political buy-in element of the UC policy UC policy: Key features: Flat rate per episode; PCUs: registration and gatekeeping; Same toolboxes People- centred primary care: available model

1400 The great leap forward: from 600,000 to 12,000,000 N prime mover people-centred primary care (family practices) 1200 1164 1243 1221 1209 1000 800 600 400 200 0 Prime mover family practices 1 2 3 3 4 5 13 36 57 61 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 UC policy:

Conclusion Lessons: Build a model and show what it means in reality Link up with political pressure Challenges: Consolidate family practice (HCs and DHS) Status and career Professional identity Production Quality improvement Primary care development in the context of district health care system: Context Based Learning (CBL) Maintain pressure for quality and access Ensure all the above are synergetic

Proposed framework Window of opportunity Field model development

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