4. In which ways is the initiative creative and innovative?
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Capacity building
Manpower development
In May 2008, Buntharik hospital invited the hospital directors from the other 4 district hospitals to discuss the solution to the low access coverage rate to RRT among UCSs with ESRD from the remote areas. Although CAPD were included in the "free of charge" benefit package of the of the UCS, there were many barriers preventing those marginalized population to properly access to this complex treatment. The meeting identified lack of local capacity at district level a challenge and the urgent needs for capacity building. The needs for such mission were then recognized by the Ubon Ratchathani Public Health Office (UPHO) - the official governing body of the whole provincial health system - who later appointed the Ubon Ratchathani CAPD governance board (UCAPDGB).
In order to meet the explosive patients' demand at the beginning of CAPD first policy, the UCAPDGB assigned Buntahrik hospital to organize the short capacity-building workshops. By October 2008, the short course-trained staffs, including registered nurses, general practitioners, and internists were able to provide cares for less complicated CAPD procedures, i.e., wound care, CAPD fluid exchange, ESA injection, intra-peritoneal antibiotics administrations, and home visits, with technical assistance from the Buntharik CAPD teams.
In 2009, the district capacity-building program evolved from less structured approach into formal CAPD training course, with the supports from the UPHO, the NHSO, and the training institutes. By late 2009, 24 registered nurses from all district hospitals, and 4 internists from 4 district hospitals completed the national standard 4-month CAPD curriculum. Four surgeons and four physicians also underwent the hands-on workshops for TK catheter implantation at about the same period. By then, all district hospitals were able to provide CAPD services for the population within their own catchment areas.
Along the developmental milestone, the principle of networking, which composed of partnership building and community engagement, were incorporated by introducing a platform where stakeholders could discuss, share ideas, make decisions on policies, and push forward the action plans they agreed on in the context of each local community. The strategies used for capacity building at district level, albeit less formal, were also applied to sub-district level. The staff from PCUs as well as the village health volunteers which are the essential component of the primary health care network were empowered and became parts of the strong district CAPD networks.
Hemodialysis back up for failed CAPD cases
Approximately 10-20% of CAPD fail annually and thus need to switch to hemodialysis. Since most hemodialysis machines and staff with the skills to operate them were concentrated in the provincial and private hospitals, there was an urgent need to set up hemodialysis units at district hospitals. In response to these urgent needs, most district CAPD networks decided on out-sourcing, run by private entrepreneurs, hemodialysis units, given the state-own hospitals' resources limitations.
Referral system strengthening and quality improvement
To ensure patients' safety, the referral systems needed to be strengthened. The UCAPDGB appointed the Ubon Ratchathani CAPD quality assurance committee (UCAPDQAC) - composed of nephrologists, general practitioners, internists, CAPD nurses, registered nurses, and health workers from PCUs to set guidelines designed to meet different health care levels’ specific needs. Many workshops and conferences were organized to build trust and confidence among CAPD networks and the implementation strategy evolved based on lessons learned from best practices, stakeholder feedback, and evidence-based clinical assessment on an ongoing basis. The use of appropriate technologies, i.e., "Skype", "Oovoo", and more recently "Line" applications resulted in a "two-way" interactive communication and thus reduced unnecessary referrals and allowed for critical cases to be referred to a higher-level health care hospitals in a timely fashion.
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5. Who implemented the initiative and what is the size of the population affected by this initiative?
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Stakeholders actively involved were as follows:
1 The Buntharik hospital played a major role in the design, implementation, evaluation, supervision, and quality improvement process of the CAPD networks.
2 The UPHO was primarily involved in the supervision of the implementation, and resources allocation. It also played important roles in negotiating and reducing conflicts between different interests, and s0 facilitated collaborations between stakeholders.
3 The NHSO was primarily responsible for the design and implementation of the CAPD first policy at national level.
4 The Ubon Ratchathani district hospital directors association (UDDA) contributed largely to the implementation of the initiative. Since the district hospital directors were acting as chair of the Contracting Unit for Primary care (CUP) governing board, resources could be allocated to sub-district areas for capacity building with more ease.
5 The professional associations: In response to the floods of demand on workforce development at the beginning of the CAPD network implementation, the nephrology society and the nurse council of Thailand in collaboration with the training institutes organized extra CAPD training courses for clinicians and nurses.
6 More than 32,000 village health volunteers were involved in the extensive primary health care network in Ubon Ratchathani province. These were empowered with knowledge to be able to provide simple home technical assistance and make surveillance for early CAPD related complications.
7 Patient groups put pressure on the UPHO to promptly respond to the severe shortage of resources by allocating extra budget for capacity building. They also supported attitudinal changes among those who had bad attitudes toward CAPD.
8 The elected Sub-district (Tambol) administrative organizations (TAOs) were encouraged to commit resources to ESRD prevention and to contribute money to community health funds. They were also encouraged to put in place systems to appropriately manage the CAPD waste disposals.
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6. How was the strategy implemented and what resources were mobilized?
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It did not take long at all for the NHSO to successfully implement the CAPD first policy. Twenty six pilot provincial hospitals participated and registered with the NHSO in early 2008 and nearly all provincial hospitals throughout the country did shortly afterward. For capacity building, the NHSO first supported all formal workshops organized by the training institutes, including staff training fees. It also paid for the registered hospitals; 1,000,000 Baht (US $ 32,260) for establishing the CAPD unit; 4,000 Baht (US $ 129 ) per month per each patient started and maintained on CAPD for all CAPD services, including medicine prescriptions, laboratory tests, and admission due to CAPD related complications (excluding TK catheter and ESA which were provided directly by the NHSO); and 60,000 Baht (US $ 1,935 ) per year for other CAPD related activities, e.g., organizing patient groups/community meeting. The operations for TK catheter implantation were paid for through the pre-existing DRG high cost claims directly to the registered hospitals. The NHSO also paid for staffs' incentives, at the rate of 2,000 Baht (US $ 65 ) for each patient operated on for TK implantation to surgical teams; 2,000 Baht (US $ 65) per month for each patient maintained on CAPD by the patient care teams, i.e., nephrologists, CAPD nurses, ward staffs, and home visit teams; 200 Baht (US $ 6.5) per month for each patient having ESA injection to staffs involved.
The implementation of the district CAPD network was not designed or planned by the NHSO initially and the only way the money could reach each CAPD network was through this pre-existing payment system. The Buntharik hospital - the official registered hospital - took this opportunity to act as a clearing house for those emerging district CAPD networks. The money was transferred to each CAPD network in the name of the Buntharik hospital. However, according to the strict rules, the 1,000,000 Baht for establishing the CAPD unit and the 60,000 Baht for other CAPD related activities could only be paid to registered hospitals. The UPHO, with its' strong leadership, allocated extra budget out of its own pocket to the district hospitals - four of which later became qualified registered CAPD hospitals - to establish the CAPD units. By 2011, the UPHO became the sole clearing house for all 20 district CAPD networks in Ubon Ratchathani province.
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7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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To date, eight physicians/surgeons had been trained to perform TK catheter implantation, 4 internists have completed the 4-month CAPD training curriculum. Twenty two registered nurses have completed the 4-month training from the training institutes and twenty four more have finished the hands-on training at the provincial hospital. These certified and uncertified CAPD nurses have worked at the 20 district hospitals across the province, providing care for CAPD patients, i.e., educating, training and coaching the patients/family members, performing routine laboratory tests, providing treatments for CAPD-related complications, giving ESA injections, and monitoring patients' compliance to CAPD prescriptions and medications. They also acted as leaders of "home visit" teams and were in charge of 24-hour hotline calls for patients in their responsible catchment areas who are in need of helps.
More than 400 registered nurses from the PCUs across the province have completed the hands-on workshops organized by each district hospital in collaboration with the UPHO and the NHSO. The refreshing courses which were repeated annually, were adjusted to close the remaining gap of knowledge and to meet the whole Ubon Ratchathani CAPD networks' specific needs. About 32,000 village health volunteers were empowered to be capable of making surveillance for CAPD related complications, checking for patients' compliance, providing mental support to the anxious and desperate CAPD patients, and conducting health promotion and ESRD prevention activities.
By 2011, 20 district CAPD networks had been established in Ubon Ratchathani province. These district CAPD networks combined to make the large unique Ubon Ratchathani provincial CAPD network. The patients with ESRD from the districts and sub-district areas traveled much less far for CAPD services to within or nearby district hospitals. By 2012, more than 500 TK catheter implantations and CAPD trainings had been provided, and thousands of outpatient visits had occurred at district hospitals, and the last but not least, countless home visits by multidisciplinary teams and village health volunteers.
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8. What were the most successful outputs and why was the initiative effective?
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Despite the CAPD registry was set up, by the NHSO, to provide information for strategic management, and regulation at national level, the information were rarely used for monitoring progress and evaluating the activities at local level. The Ubon Ratchathani CAPD network, through the UCAPDQAC, developed methods to use routinely collected data to monitor, assess clinical outcomes and improve quality of care. The monitoring systems were designed to ensure that the initiated implementation could be adjusted in the light of progress, and changing circumstances.
A number of systems have been set up to monitor progress, i.e., 1st reporting system - in addition to the national CAPD registry system. Summary reports were compiled every 3 months for the UCAPDGB. The board met quarterly to discuss the emerging issues, benchmark performances, and augment problem solving. 2nd financing system - all financing systems, including staff pay per performance activities, were regulated and managed by the UPHO. Although the NHSO - the regulating body at national level - was in charge of transferring money directly to the registered hospitals, this proved to be inefficient - it even resulted in conflicts among different interests - for Ubon Ratchathani case. Since networking means that many stakeholders, multi-sectors, and community are involved, flexible, transparent, and accountable resources allocation adapted to meet each stakeholder's satisfaction is crucial. The UPHO, with its leadership role, set up a platform for negotiations among stakeholders to achieve fair resources allocation. 3rd administrative system - through the pre-existing strong administrative systems, the CAPD key performance indexes (KPI), i.e., the CAPD access coverage rate among UCSs and clinical outcomes, have been included in the official administrative process regulated by the regional MOPH since 2011. The administrative process took place every 6 months and allowed for issues to be addressed at a larger scale of regional and national levels.
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9. What were the main obstacles encountered and how were they overcome?
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Main obstacles
Some nephrologists initially opposed this idea of CAPD networking because they believed that CAPD is not a "non-nephrologists" business and that such complicated procedure should be handled by experts and teams specialized in that particular field, ignoring the roles of multidisciplinary integrated cares and community engagements. Some nephrologists even used the "morally sound" reason of presumed inferiority of CAPD to hemodialysis, despite accumulating evidence of comparable effects between the two modalities worldwide, to against the CAPD first policy or CAPD networking, .
The monetary incentives and health financing may be another mechanism preventing the implementation of the CAPD networks. Most nephrologists were paid more for doing hemodialysis than they were for doing CAPD, mostly by private sectors. This physician reimbursement favored one modality over the other - in fact it was probably the main mechanism that made them biased toward hemodialysis. From the hospital directors' views, CAPD was not worth doing, in terms of hospital reimbursement. This budget was not enough for medicine, laboratory tests, and admission for treatment of complications. The hospital directors tried to save money by allocating sub-optimal resources to CAPD units - the amounts just enough to survive, but not enough to meet the growing patients' demands. Most care providers had no choice, but to follow the policy, did only what they could and what they had to do.
Overcoming the impediment
The CAPD networking applied the alternative of comprehensive holistic approach to problem solving. The multi-sectoral partnerships, achieved through information exchange between stakeholders, led to better understandings, respects, and strong commitments to overcome these obstacles. Many factors were attributable to this success; strong leaderships, community pride, common decency, sense of ownerships, and social obligations - the "non-monetary" motivations which worked better in this context.
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