| 4. In which ways is the initiative creative and innovative?
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Restructuring the registration of all inmates to be eligible for each health insurance scheme is a preliminary step for health care provision. Closed collaboration between all correctional institutions and Songkhla Hospital with a good support from the Songkhla Provincial Health Authority accelerates the ID acquirement from relatives within a short period of time. Outreached health care service system organized by multidisciplinary team both from Songkhla Hospital and correctional nurses is initiated on a basis of integrity to ensure the same common goal of dignity and equity of inmates. Voluntary volunteers from inmates to be trained as an auxiliary of health care team are another issue to be raised. Paramedic supports and pharmaceutical assistance are trained. Their practices are under closed supervision. Health education at wings to give rise to effective disease control in the over-crowded space is created by nurses. The screening and investigations of complications of chronic diseases is also a highlight for controlling the severity of diseases.
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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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Songkhla Hospital is a provincial hospital with 508 beds located in Muang District, Songkhla Province. It takes charge of 200,000 inhabitants in the catchment area and also serves as a tertiary care facility for other districts in the province. There are totally 4 prisons and correctional institutions within Muang District. On average, 11,000 inmates which accounts for 5.5% of all inhabitants are taken care by this hospital in case basic care and treatment by prison or correctional nurses could not provide. Proactively management and continuing service system is implemented under the mutual agreement between the Department of Corrections, Ministry of Justice and Songkhla Provincial Health Authority, Ministry of Public Health.
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| 6. How was the strategy implemented and what resources were mobilized?
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Four key strategies to conduct this service provision are as follows:
1) Restructure the correctional institution as a gate keeper and develop efficient referral system
2) Ensure all inmates registered and covered by the governmental health insurance system
3) Connect medical records within a network using IT support.
4) Promote healthy conditions and prevent controllable diseases at the early stage
Phase 1 Preparation Phase: Designation of a working group was done between two parties, Songkhla Hospital and 4 correctional institutions in December 2014. Situation analysis was done and problem identification was addressed. Obstacles and factors influencing the limitation of service provision were reviewed. Then, problem solving was discussed. Mutual operational plan was set up. Due to the limitation of hospital team to rotate all 4 correctional institutions, the hub of health station was decided and the other 3 ones would transfer patients to that hub. Timetable was prepared on every Thursday morning. The renovation of health station is financed by the Department of Corrections. Preparing materials, medical devices, medication, and information system was operated by the hospital. The security system for outreached team was carefully prepared. The IT system was developed for proper connection of medical history between the health station and the hospital. Both hardware and software was invested by the hospital. At Songkhla Hospital, proper waiting area for sick inmates was well considered to lessen stigma of those in open area..
Phase 2 Implementation Process: Grand opening of the project for celebrating His Majesty the King Bhumipol Adulyadej’s Birthday on December 4, 2014 was inaugurated. Outreached services have been provided by a multidisciplinary team once a week regularly. Additionally, oral health services: fillings, tooth removal, and scaling have been implemented twice a year (1,136 cases in 2015 and 987 cases in 2016).
Assessment of sanitation and environmental conditions has also been conducted two times a year. Health promotion activities and mental health screening for all inmates 3 times a year. Preventive measures have been conducted regularly as follows: vaccination (diphtheria, tetanus) once a year, annual screening of complications due to diabetes and hypertension, tuberculosis investigation, and screening cervical cancer by pap smear examination for females once a year. All of abnormalities would be referred to Songkhla Hospital for appropriate treatment
Phase 3 Evaluation and Continuous Improvement: Meetings of the Board Committee have been undertaken every three months. Registration of inmates has been monitored closely every month. In 2015, 8,917(75.69 %) of total inmates (11,781) was registered and the figure has been increasing up to 9,386 out of 10,970 (85.56%) in 2016. The number of patients both at the health station and the hospital was reported to the Board Committee.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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Many stakeholders involved in this project comprising mainly from the Ministry of Justice and the Ministry of Public Health. The International Committee of the Red Cross (ICRC) also involved prior to the project implementation. Early in 2014, the representatives of the Ministry of Public Health; the Department of Corrections, the Ministry of Justice; ICRC; the National Health Security Office, Region 12 Songkhla had a meeting on the health care provision for prisoners in the region and addressed obstacles and constraints of inmate care. Urgent action on relieving health problems of inmates was addressed to the Ministry of Public Health. The policy from the Ministry was then set aside. At the provincial level, the Songkhla Provincial Health Authority and Songkhla Hospital called for a meeting with the representatives from all 4 correction institutions in the area. A three-year project was on mutual agreement.
In practice, not only the staff of Songkhla Hospital, but also staff of nearby health centres take part in regular service provision. Tambon Koh Tao Local Authorities, Tambon Khaoroopchang Local Authorities also accommodate such health related activities in the cells through the local health funds. Regarding HIV and tuberculosis control, the Bureau of Communicable Disease Control and Prevention, Region 12, give hands to perform screening, investigation and laboratory testing.
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| 8. What were the most successful outputs and why was the initiative effective?
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The most successful outputs are as follows:
-Effective accessibility is highlighted. The number of 4.160 cases each year has dramatically been increased as compared to that of 1,040 prior to the project launched.
- Satisfaction of inmates on the service provision was very high (88.49 %). Satisfaction of the Correctional staff is also high at 85.25%.
-Shorter duration at the outreached service (30 minutes per case) has been apparent, whereas the average waiting time at the hospital OPD ward was 170 minutes per case
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| 9. What were the main obstacles encountered and how were they overcome?
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Lack of medical staff is a major obstacle to limit care and need assistance from outside. Even if the collaboration was initiated officially, only 1 surgeon, 1 general practitioner from the hospital voluntarily provides care there. In principle, there should be general practitioners at the primary care unit taking charge of this task, however only 7 practitioners are actually available for 205,000 inhabitants. The proportion of family doctors : population currently 1:29,286 which is far much beyond the standard(1:10,000) The recruitment of family doctors is still urgently needed.
Prior to the outreached service provision, all sick inmates must be transferred to the hospital. There’s no special track at the hospital, either outpatient clinics or inpatient wards. The strict regulation of the Department of Corrections on taking inmates out is that any one inmate must be fettered and two wardens must get along with him. Inmates had to wait for a queue to see a doctor at waiting area. At an inpatient ward, he had to stay at the ordinary compartment and share all resources with others. This manner not only stigmatizes inmates but also bring about serious burdens of wardens.
Another major obstacle of service provision from outside is the security of personnel. In general, medical staff are reluctant to get closed to inmates. The Director of “Songkhla special treatment Correctional” offers a big compartment at a safe building with strong security system. Security guards are on duty at the front of the building to control the waiting area and inside the clinic. Well-behaved inmates get trained to be assistants of medical staff whilst several wardens are on duty to ensure the safety control throughout the performances. Improving the competency of correctional nurses via in-service training and practicing has been implemented in order not to any disturbance during the performances.
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