Building CAPD network
Buntharik Hospital

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Thailand first initiated a health care reform called the "Universal Coverage" scheme (UCS) in 2002, and it has expanded the health benefit to cover renal replacement therapy (RRT) for end stage renal disease (ESRD) since early 2008 while the civil servant medical benefit scheme (CSMBS) and the social security scheme (SSS), the two pre-existing schemes, have included RRT in their benefit packages since 1985. The continuous ambulatory peritoneal dialysis (CAPD) was chosen as the treatment modality of choice, under the "CAPD-first" policy, on the ground that it could be administered on a “self care” basis at homes, thus saving travel costs for hemodialysis. Ubon Ratchathani, a province in the Northeastern Thailand, has a population of 1.8 million. Among its population, 1.4 million (80%) are covered by the UCC, 257,720 (14%) by the SSS, and 11,2469 (6%) by the SCMBS. Most of the residents live in the rural areas of district or sub-district regions. There are 26 hospitals throughout the province, including 1 provincial, 2 military, 3 private, and 20 district hospitals. Primary care units (PCUs), located at sub-district areas, are primarily responsible for health promotion and disease prevention. District hospitals provide treatments for less complicated diseases, while provincial hospitals care for more advanced cases, including patients with ESRD. There were 2 full-time nephrologists, and 2 CAPD nurses in 2008 working in the provincial hospital and the numbers of nephrologist and CAPD nurse slowly increased to 4, and 4 in 2012, respectively. A recent national survey showed that the average access coverage rate to CAPD among the UCSs with ESRD has reached a plateau at about 30-36% since 2010. This suggested that the workloads had reached the current staffs' maximal capacity to absorb the current number of ESRD patients. The number of patients will continue to grow, outpacing the staff workforces, due to the growing trends of chronic diseases, the country's lack of effective prevention programs, and the aging population. The long travel distances from the rural district or sub-district areas to the CAPD centers has contributed substantially to the low access coverage rate. The survey also showed that the expenditure on traveling due to routine follow up and unnecessary referrals accounted for more than 10% of many household incomes - a catastrophic expenditure for the poor and underprivileged UCSs. Many patients declined to have CAPD in the first place because of not being able to afford to pay for appropriate home environments and facilities necessary for CAPD, i.e., closed room for CAPD fluid exchange, tap water, etcetera, and many due to lack of care givers. CAPD also creates environmental problems caused by lack of proper disposal management which predisposes to infection spreading, i.e., viral hepatitis, and HIV infection. Four daily exchanges of peritoneal fluid are required and thus large amounts of CAPD bags, and transfer sets for disposals accumulate. Some disposals were burned resulting in air pollution, some were left abandoned in the patients' backyard and were taken away by animals, and some were used as play toys by children.

B. Strategic Approach

 2. What was the solution?
Who proposed the solution? Being the first district hospital of the country to provide CAPD service since the inception of the CAPD first policy, the Buntharik hospital proposed the district "CAPD network", the multilevel, integrated health care approach, among all district hospitals across Ubon Ratchatani province in late 2008. The main objectives of the initiative were as follow: 1 To resolve health inequity in accessing the high cost RRT services among the marginalized UCSs population 2 To improve quality of care for CAPD by emphasizing the role of multilevel health care teams and the rational use of efficient integrated services 3 To address issues of concern related to delivery of CAPD service, i.e., environmental issues How did the initiative solve the problems? Access coverage to CAPD Major barriers preventing the delivery of CAPD in Ubon Ratchathani province were excessive CAPD center staffs' workloads and the catastrophic expenditure related to CAPD treatment. Prior to the implementation of the district CAPD network, all CAPD procedure including Tenckhoff catheter (TK) implantation, CAPD education and training, were carried out at the Ubon Ratchathani provincial hospital by CAPD nurses and other multidisciplinary teams. The CAPD education and training is a time-consuming process including 13 steps, e.g., education regarding kidney failure, principles of CAPD, infection control, hand washing technique, wound care, and nutrition, etcetera, are required. On most occasions, each process has to be repeated over and over again to ensure that the patients/care givers correctly follow the instructions to produce better clinical outcomes. In addition, each patient/care giver has to be trained one by one at a time and the overall training processes require at least 5-7 man-days. The CAPD nurses were also assigned to do other tasks, i.e., out-patient follow up of the old CAPD cases, routine laboratory testing, caring for patients admitted due to complications, coordinating with suppliers to ensure that CAPD fluid/erythropoiesis stimulating agents (ESA) are timely delivered to the patients, monthly reporting of the patients' status, sending laboratory results to the national health security office (NHSO), and home visiting. These excessive workloads far exceeded the current staffs' capability to handle and the Ministry of Public Health (MOPH) failed to provide leadership to address this problems. The care providers coped by keeping ESRD patients on a long waiting list, so many died from uremia before receiving dialysis. The district CAPD network resolved these issues by task shifting, i.e.; TK catheter implantation, CAPD education/training, out-patient follow up, routine laboratory tests, care for minor complications (including wound care, non-complicated peritonitis) to district hospitals, and ESA injection, and home visit to PCUs. Since the district health system has a definite catchment population with appropriate size, the tasks shifting of CAPD to district and sub-district levels resulted in less provincial staffs' workloads, less unnecessary referrals to the provincial hospital, less traveling distance to CAPD centers and thus less expenditure on transportation. Quality of care The district CAPD networks provided essential elements for quality improvement; for example, the administrative and regulatory bodies carrying out research-based information not only for administrative or policy making purposes, but also for patient management. These evidences were used to benchmark performances and the lessons learned from pitfalls/best practices could be used for continuing quality improvement. Environmental problems The community participation played a major role in solving issues of concern related to environmental problems. The extensive communities' involvement, including the elected local administrative organizations, increased the awareness of infection spreading within communities and allowed for transparent and accountable policy making, and measures such as rules, regulation, and legislation to prevent this threat under each community's own context.

 3. How did the initiative solve the problem and improve people’s lives?
The initiative is unique in the following ways: 1 The district CAPD network was implemented upon the pre-existing well-established primary health care network. The delivery of CAPD to the marginalized population from the most remote area of the country now becomes possible. 2 The CAPD network used local resources sharing for problem solving. The shortage of human resource was the main impediment to access to CAPD among UCSs and the situation was made worse by misdistribution of staffs between regions of the country, with the worst in Northeastern Thailand. Human resources sharing was applied as follows: Nephrologists: As the consultants for all district CAPD networks, the nephrologist played an important role in setting guidelines designed to meet different levels of health systems' needs. They also acted as clinical monitoring team leaders, and regulators. CAPD nurses: As leaders of the home care teams, the CAPD nurses played roles in knowledge transfer and technical support within and between CAPD networks. 3 The CAPD network applied multi-sectoral approach and community driven process to resolve issues of concern in CAPD. By introducing information exchanges among stakeholders, the populations' health became everyone's business. Coordination between multi-sectors resulted in transparency, accountability, efficiency, and long term sustainability.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
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.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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.
 6. How was the strategy implemented and what resources were mobilized?
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.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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.

 8. What were the most successful outputs and why was the initiative effective?
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.

 9. What were the main obstacles encountered and how were they overcome?
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.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Impacts 1 Access coverage to CAPD among UCSs with ESRD The annual CAPD incident cases per 1 million UCS population in Ubon Ratchathani province rose sharply from 3.6 in 2007 to 41.4, 134.3, and 226.4, 255.0, and 228.6 in 2007, 2008, 2009, 2010, 2011, and 2012, respectively. This many-folds increase in access coverage rate was very much higher than province from other regions of the country. 2 Clinical outcomes of CAPD 2.1 All cause mortality The probability of death among UCSs with ESRD in Ubon Ratchathani was 46% (95% CI: 22% to 75%) higher when compared with the CSMBSs before 2008. This probably reflected the low access coverage rate to renal replacement therapy among UCSs. The patients with ESRD who had CAPD were 68% (95% CI: 59% to 76%) less likely to die from any causes than those who did not have CAPD. The improved life expectancy was obvious after 2008. The probability of death among UCSs was comparable to the CSMBSs, i.e., 2% (95% CI: -13% to 19%). Comparing to other provinces across the country, the survival probability of patients with ESRD in Ubon Ratchathani who had CAPD was similar to those from other provinces, i.e., 4% (95% CI: -18% to 13%) of CAPD patients in Ubon Ratchathani lived longer, but this was not statistically significant. However, we observed a better trend after 2 years of dialysis treatments. This probably suggested favorable effects of the initiative for this complex disease. 2.2 Peritonitis rate (infection of the peritoneal cavity) The peritonitis rate among CAPD networks varied from 30 months per episode to 56 months per episode. This was better than the average national peritonitis rate (28 months per episode), and minimal target (20 months per episode) recommended by the international guidelines. 2.3 Quality of life Although nearly all of the UCSs who had CAPD were from low socioeconomic status, their functional status compared favorably to CSMBSs on hemodialysis. A recent survey showed the EQ5D (quality of life assessment tool for Thais) score of 0.80 (0.30), and 0.81 (0.33) for UCSs and CSMBSs, respectively. 3 Household expenditures The district CAPD networks resulted in a decline in the incidence of catastrophic health expenditure. According to the national survey, the average annual expenditures related to CAPD treatment which included transportation costs, hospital service costs, and accommodation costs (excluding dialysis costs) were 56,992 to 85,488 Baht (US $ 1,839 to 2,758), and 7092 Baht (US $ 209) for hemodialysis, and CAPD, respectively. In Ubon Ratchathani case, the expenditure ranged from 600 to 3500 Baht (US $ 19 to 113). How the impact was measured ? Data used for the analysis of access coverage and clinical outcomes were obtained from the same source as that used for the paper of prognostic factors of CAPD in Thailand [1] and the epidemiological study of chronic kidney disease in Thailand cohort (pending for publication). In brief, data extracted from the UPHO database were linked to the CAPD registry and death registry databases. The peritonitis rate and the patients' household expenditures were analyzed from routinely collected data from each district CAPD network, and the home visit report forms. Reference 1. Vejakama, P., A. Thakkinstian, A. Ingsathit, P. Dhanakijcharoen and J. Attia: Prognostic factors of all-cause mortalities in continuous ambulatory peritoneal dialysis: a cohort study. BMC Nephrol 2013, 14: 28.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Financial and economic sustainability Since 2008, the "CAPD first" policy has spread its roots to form the firm and sustained foundations within health care systems in Thailand. Many actions attributable to the long term financial and economic sustainability were as follows: At national level - The NHSO's long-term financial plan for "CAPD first" policy was designed to comply with the projected gross domestic product (GDP). It also established long-term ESRD prevention measures, i.e. nation-wide salt reduction campaigns; nation-wide population screening program for chronic diseases such as diabetes, hypertension, and chronic kidney disease (CKD); health promotion programs for high-risk populations; CKD clinic establishment, and more. Despite the lack of firm evidence on their effectiveness, it is expected that the number of ESRD patients will plateau in about a decade. The medicine and supplies cost containment measures, i.e., central tendering and bulk purchasing, have resulted in more than 2, and up to 5 folds reduction in CAPD fluid and ESA costs. The saved budget could be used for the long-term benefit of the people. At local level - The Ubon Ratchathani CAPD networks, like other CAPD units throughout the country, will be financially supported by the NHSO in the long run. As the staff experiences grow year by year, more efficient resources utilization will be achieved; for example, less CAPD related complications and thus less expenditure for treatments and referrals. This once "not worth doing" therapy has now yielded profits and allows for the hospitals to spend money on quality improvement process and other important health issues. Social, cultural and environmental sustainability The development of strong stakeholder relationships, the strong participatory community approach emphasizing the roles of diverse local cultural values, local wisdoms of the respective communities, the multi-sectors' advocacy to improve equity of access to renal replacement therapy, the responsible use of resources and their wastes management, have resulted, to some extents, in sustainable initiatives. Institutional and regulatory sustainability At national level, the institutional structures of the NHSO who play administrative and regulatory roles determines the initiative sustainability. At local level, the UPHO, in addition to its existing health administrative and regulatory structure, has created the recognized regulatory bodies - the UCAPDQAC. The UCAPDQAC is responsible for establishing regulatory policy, monitoring clinical outcomes, and conducting evidence-based research. These regulatory processes support the initiative sustainability through enhanced transparency. Transferability In 2009, 2 district CAPD networks were replicated in Si Sa Ket province - the province with 1,2 million population adjacent to Ubon Ratchathani province. Later that year, 3 more provinces within the region adopted the CAPD network implementation. It was then realized that establishing CAPD in district hospitals was feasible, so the NHSO then encouraged the establishment of CAPD in district hospitals across the country. CAPD networks have also been established in other settings: for example, in Chiangmai province where the CAPD networks has been established since 2008. Most provincial hospitals’ CAPD networks are within the region, but a small proportion of district CAPD networks have been formed. Considerable success has been reported.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
Lessons learned The delivery of high cost/complex services in the resource limited scenario provides valuable lessons for other settings. Firstly, capacity building in the district health systems to provide comprehensive CAPD services to its catchment population, task shifting between multi-disciplinary teams and multilevel health care systems, resources sharing, and partnership building - including working with private sectors, while establishing effective referral systems to ensure equal access to quality care are essential. The initial phase of the CAPD first policy saw high staff workloads that demanded alternative approaches in order to satisfy the increase in patient demand. Secondly, community-wide participation is important. The community pride, sense of ownership, and social obligations, obtained from information sharing between stakeholders, are the main driving forces beyond the financial motivation for implementing, and sustaining the initiative. The environmental issues which are difficult to handle by current responsible organizations can be effectively managed by communities under their own contexts. Thirdly, incorporating the initiative to pre-existing health financing systems is vital. This approach allows for the pre-existing health financing, the key element of universal coverage, to be strengthened and the limited resources to be efficiently used. Fourthly, evidence-based impact assessment and monitoring are necessary to ensure that equity, efficiency, and effectiveness are achieved. The research evidence is critical for the fine-tuning allocation of resources according to health needs across all levels of health services, the quality of care improvement to meet the demand standard, and the balance of equity, quality and cost effectiveness. Fifthly, leadership is the key to success. Strong leadership is needed to resolve the initial conflicts and fierce resistance to changes by different interests, to seek for multi-sectoral collaboration, to facilitate community-wide participation, and to ensure future continuous quality improvement of the initiative. Future recommendations Despite the recent NHSO's encouragement to establish the CAPD in district hospitals across the country, the true functioning CAPD network is far away from achievement. Building such network like Ubon Ratchathani CAPD network takes times and its effectiveness depends on the adoption of the initiative which needs to be tailored to each province's own context. The story of success which is still lacking elsewhere, underpinned by solid evidenced-based research analysis, needs to be reproduced and demonstrated in other provinces/settings. This would create trust and confidence among stakeholders to pursue the implementation of the initiative.

Contact Information

Institution Name:   Buntharik Hospital
Institution Type:   Government Agency  
Contact Person:   Phisitt Vejakama
Title:   Dr.  
Telephone/ Fax:   6645201297 dial 111
Institution's / Project's Website:  
Address:   200 Moo 1 T.Pon-ngam
Postal Code:   34230
City:   Buntharik
State/Province:   Ubon Ratchathani

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