“Health Care Services for Inmates in Correctional Institutions, Songkhla Province”

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Inmates become more focused currently on not only their dignity, but also the quality of life. According to the data of the Department of Correctional Institution Thailand, from 2014 to 2016, the total number of inmates was relatively high at 322,998; 311,623; and 306,043, respectively. Songkhla Province is the centre of the southernmost of Thailand and is the regional centre of the Correctional Institutions. There are 5 prisons and correctional institutions with over 10,000 inmates each year. This over-crowded situation could more or less affect the living and health conditions. Sickness and injuries are inevitably common, whereas only 1 or 2 nurses in each institution are on a regular basis. Patients with severe or critical conditions need to be referred to a hospital. However, due to the complicated procedure for official permission, it is evident that their health has been worse and some of them become critically sick and dead. In addition, physical and environmental conditions in prisons and correctional institutions are another major factor which affects the emergence and spread of infectious diseases such as AIDS, tuberculosis, diarrhea, and dengue hemorrhagic fever. Songkhla Hospital is principally in charge of taking care of all inmates in 4 institutions located at Muang District in Songkhla. Facing a large number of critical conditions of those sick inmates, the initiative to improve health services and preventive measures was undertaken. Mutual collaboration of the relevant authorized network was introduced and regular meetings to formulate the systematic process of both outreached services and efficient referral system to the hospital have been implemented. Hopefully, the efficient access to health services could serve as the basic human right and promote their quality of life. This could, in turn, prepare them to be a healthy person back to the society.

B. Strategic Approach

 2. What was the solution?
At first, the proven identification of all inmates to be eligible for three main health insurance schemes is extremely necessary in order that the health services reimbursement would be done in the right track. The systematic service delivery both outreached services and those at the facility covering health promotion, preventive measures, treatment, and rehabilitation has been established in line with the mutual and closed collaboration between Songkhla Hospital and the Correctional Institutions involved. The referral system from 3 institutions to the centre of outreached facility which was set up at one institution and from the outreached one to the hospital was needed to be well prepared and organized.

 3. How did the initiative solve the problem and improve people’s lives?
Prior to 2014, 4 Correctional Institutions located in Muang District, Songkhla Province had faced troublesome circumstances due to lack of medical staff at the health station. In each correctional institution with over 2,000 inmates, only 1-2 correctional nurses have practiced. It was very seldom that medical doctors paid a visit to these institutions. On a daily basis, nurses could only provide basic treatment and some emergency care. Severe or critical patients must be referred directly to Songkhla Hospital (SKH). However, there was no preparation for those sick inmates in the hospital in particular. As the Universal Coverage Scheme (UCS), the main health insurance scheme, allocates budget mainly according to the number of beneficiaries registered at the contracting unit for primary care (CUP) in a district area in terms of capitation per head, all inmates have to be identified and transferred from the previous CUP to SKH which is supposed to be the new CUP in the area where correctional institutions are located. However, in the past, less than 60% of inmates could be identified. The main obstacles were the cooperation of inmates and their relatives to disclose the ID number. Hence, SKH could get the capitation per head much less than actual expenses of patients to be taken care. Correctional institutions realized and put more effort to seek the ID number. Recently, the number of inmates with ID has been increasing dramatically up to nearly 90% in 2016. The UCS budget of SkH has eventually increased and was a big driven for outreached services. In order to provide outreached at the health station in the correctional institutions properly, the system must be developed including renovation of health station; health care team formulation; periodical timetable; and the referral system. The decision of only one station as a centre was made due to limited staff. The other three institutions will transfer patients to the centre. The multidisciplinary team from the hospital comprises a medical doctor, nurses, a pharmacist, and an IT staff. They practice along with 2-3 prison nurses and well-trained inmates as auxiliaries. The outreached services have been operated every Thursday morning. On average, 80 patients are treated as compared to only limited number of 20 that would be transferred to the hospital due to the correctional rule of one sick inmate to two wardens. The medical record has been developed using the same electronic programed as SkH. The connection of medical history between the health station and the hospital has been done to accommodate the provision and monitoring procedure of health care properly. In case patients need to get consultation from specialist(s), the appointment will be promptly done. Moreover, minor surgeries such as incision, debridement could be proceeded. Recently, chronic disease patients such as diabetes and hypertension that have good compliance and effective disease control could have refilled medicines at the health station. Moreover, the complication screening procedures for those chronic disease patients are initiated. All of them are periodically investigated. Anyone who is diagnosed with definite indications will be referred to specialists for prompt treatment. Health promotion and prevention activities are operated. Health education has been implemented at inmate wings at least once a year. Vaccination; health screening; HIV and tuberculosis screening and prompt treatment have also been undertaken. As a result, systematic health care service provision for sick inmates has dramatically been improved. As a gate keeper, multidisciplinary team could provide all basic care. Only severe and critical patients will be referred to the hospital. It’s convinced that social disparity of this vulnerable group is much lessened. Stigma whenever they have to visit the hospital is obviously relieved.

C. Execution and Implementation

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

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

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

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

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

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Better quality of life is the key benefit by means of sufficient and qualified treatment; healthy environment; disease protection and controls; and immunization. Delayed treatment was solved. Sanitation in cells and wings has been improved. Inmates with chronic diseases have been periodically examined and referred as needed. On the inmate perspective, stigmatization has been improved. No fetter is apparent during the health service inside the correction institutions. Waiting areas for inmates at the hospital are being renovated. Fast track for them is set aside. In the near future, 2 inpatient wards with 2 beds each could be available.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Inmate is one of the vulnerable groups that Thailand currently gives a high priority to tackle problems and to improve the quality of life. Due to the limitation to reach health services in the past, the government is convinced that any vulnerable group has the equal right to get public services including health care services. “No one is left behind” is a national campaign to bring about the opportunity of vulnerable groups to get their met needs. This project apparently aims at the equitable health service provision for one of the most vulnerable groups in Thailand. Moreover, the quality of their life is seriously considered. Regardless of freedom, seeking healthy conditions is unforbidden. Even if the resources are scarce, the health team has to adjust and manage limited time, personnel and medical devices for the minimum standard. Rotational management of services was proved to spend much more time. The hub was, then, set aside. This enormously reduced time spent effectively. The weekly outreached services could be possible, In turn, it is evident that the number of patients in a year of implementation is four times more than that of the previous period of time.

 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)
This project "Healthcare service for Inmates in the “Songkhla special treatment for Correctional” ensures that disadvantaged inmates, no matter men or women, could get access to health services .All prisons and correctional institutions for both males and females can referred their sick inmates to the health station for health care. All promotion activities are also provided to all. The outputs in the past year stated that the number of inmates who received services at the hospital has decreased from 2015 to 2016 (2,958 to 1,847, respectively).On the other hand, the services in the correctional institution has been dramatically increasing up to 2,555 cases.

Contact Information

Institution Name:   SONGKHLA HOSPITAL
Institution Type:   Academia  
Contact Person:   wasana Chungtragoon
Title:   Head of Primary Care Unit  
Telephone/ Fax:   +(66) 7 433 0181
Institution's / Project's Website:  
E-mail:   wasanatan@hotmail.com  
Address:   666 Songkhla-Kohyo Rd. Tambon Pawong
Postal Code:   90100
City:   Muang
State/Province:   Songkhla

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