Phuket Care-bringing health close to home
Phuket Provincial Administrative Organisation

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Phuket is located in the south of Thailand. It is a popular tourist destination with over 4 million visitors a year. There is a blend of the traditional rural society and the modern on this 543 sq. km. island. The population density is 574 people per sq. km. Hygiene and health remain a major focus for the government. The Phuket population consists of: 311 380 registered Phuket citizens, 124 552 Thai citizens registered elsewhere (Department of Justice figures) and 4 726 693 tourists (Tourism Authority of Thailand. Southern Region 4, Phuket) For the same period there were 23 638 elderly, 259 chronically ill and 2312 people with a disability in Phuket. The overall population is increasing and the proportion of the elderly is rising. The cost of private hospitals in Phuket is high, (30,000 baht per day) and is beyond many citizens. There was massive congestion in Phuket state hospitals and the cost was 3,000 baht per day. Within the state system there was a total of 629 hospital beds across the three state hospitals. The ratio of doctors to the population is 1:1470, dentists 1: 5855, pharmacists 1:14954 and registered nurses 1: 364 which is inadequate to cope with the demand for services. This resulted in the most vulnerable not having access to the care they needed. The burden then falls on the patients and their relatives who in general lack knowledge of best health care practices. This was particularly true for the most vulnerable, the poor, the elderly, the chronically ill and the disabled. Many of whom are confined to bed with heart disease, high blood pressure and diabetes which can result in disease complications such as infection and pressure sores and often they cannot get to one of Phuket’s three state hospitals. With the existing high demand for services and the difficulty or inability of the vulnerable to travel there was a significant problem. The target group is therefore the poor, the elderly, the chronically ill and the disabled. The aim was to bring basic services to them, free of charge, allowing them to live independently in their communities. This involves integrating the shared policies of services between Government agencies, private organizations, local administrations and the involvement of civic and community groups. The patients are cared for by a team of doctors, nurses, health workers and village health volunteers. The research report on “Community Information Phuket 2009” also identified that the three public hospitals in Muang Phuket, Thalang and Kathu were overcrowded. Travelling to the hospital for appointments was quite expensive or difficult for the poorest, the elderly, the chronically ill and disabled people. Indeed, many of these patients are unable to travel and cannot help themselves. The purpose of the Phuket Provincial Administration Organization is to make Phuket region a "livable city and with high ethical standards". They found the situation unacceptable and implemented the project of “Phuket Care – bringing health close to home" from the year 2009 onwards.

B. Strategic Approach

 2. What was the solution?
The Phuket Provincial Administrative Organization works through state hospitals, local clinics and volunteer health workers to provide free home health care to patients. The project provides treatment at home, at a local community clinic and in district hospitals where necessary. Treatment of emergency cases and chronic patients are facilitated by the local clinic and the reception/transportation of the patient is arranged by them, providing a better quality of life.

 3. How did the initiative solve the problem and improve people’s lives?
The Phuket Care Project has operated continuously since 2009. The multidisciplinary team consisting of a network of health/mental health volunteers and the agency's main hospital, Phuket Provincial Administration Organization have worked together to bring greatly improved health care to the most vulnerable in Phuket. The implementation of the project for access to free health services in their communities for the state's seniors, chronically ill, poor and disabled in Phuket supports their right to get effective health care. Within the local community there are volunteer medical workers. These people receive training every six months, for a 3 to 5 day period, and then provide front line support for patients in their local community. When a registered patient is ill they are first seen by the health volunteer who will provide care and advice for minor issues but will take them to a local clinic for a better diagnosis if required. The local clinic will either arrange for a doctor or nurse to visit the patient in their own home or arrange for an ambulance to take them to the hospital if necessary. Any hospital visit is coordinated by the local clinic and the patient is seen in a timely fashion. With trained local volunteers in the community a medical emergency can either be treated at the scene before the emergency patients are transferred to hospital, or a mobile team can come to them. An advantage of having the community volunteer as the front line care provider is that they know the patients and can build a relationship with them. Some rural people are suspicious of modern medicine and the local volunteer can help overcome this so that the proper care can be provided. Some families are concerned that they will become totally responsible for the health care of their family so having the support available is reassuring for them. The Phuket Care project coordinates a charity to provide support for medical devices such as Fowler beds, air mattresses and orthotics. Consumables such as incontinence pads, diaper hygiene and materials for wound care are also provided. The implementation of the PPAO project is a holistic program that integrates the medical, psychological and social components of a patients and the communities’ life. The health care system by the community for the community provides a comprehensive solution, not only for illness but also for the prevention of illness. The system is based upon five key characteristics. 1 Understanding – understanding the social and cultural community. 2 Pay attention – notice the suffering of real people. 3 Peace of mind – the staff are well trained with a reliable referral system. 4 Pride - all parties are proud of their work. The health professionals, the volunteers and the communities take pride in their work. 5 Cooperation – all parties must work closely together.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The problem was one of scale. The number of patients greatly exceeded the numbers the well-trained medical staff and well-equipped hospital s could deal with. Long waiting times, lack of continuity of treatment and a distrust of modern medicine for some of the rural elderly saw that the system was failing the most vulnerable. Working within the financial constraints of the situation, the PPAO devised an innovative approach in the following ways. • Harnessing the private, public and local resources to empower communities to self-manage their health needs. • Making the care free and available in their homes and villages by providing local care and mobile medical units. • Strengthening community networks and building trust in modern medicine at the local level. • Training and using volunteers to connect with individual patients and bring harmony between local wisdom and modern medicine. • Educating the local community about health and emphasizing the importance of public service to the population. • The cost per day of treating a person in hospital is US$80 and with an annual budget of US$164 the program has not only been a success by supporting the health of its citizens and their communities but has also been financial and sustainable success.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The project began planning in 2007 and was implemented in 2009 by the Phuket Provincial Administrative Organization. It continues to be administered by the PPAO in consultation with its local partners. Such is the success of the project there has been an increasing number of participants each year. Currently there are about 1,465 people participating and as a result, the most vulnerable people of Phuket can receive adequate health services and an improved quality of life within their community.
 6. How was the strategy implemented and what resources were mobilized?
After identifying the issue and evaluating the available resources - economic, physical and human; the PPAO adopted the following strategy to improve the health and lives of its most vulnerable citizens. 1. Established a Division of Health Promotion and Disease Control. This is the primary agency for supporting the medical staff and provides technical specialist advice. 2. Analyzed the health problems of elderly, poor, chronically ill and disabled in the community. 3. Design an action plan to tackle the health of the community to achieve sustainability within the community. The Phuket Provincial Administration Organization conducted joint planning sessions with the Phuket Provincial Health Office. 4. Local governments in the region were consulted to facilitate the establishment of the local networks to build acceptance of and sustainability of the project within the community. 5. A joint operation between the Ministry of Health in Phuket and the PPAO to identify, recruit and train community volunteers. 6. Advertising and promoting the project to the people. This was done via newspapers, local newsletters, The Journal News, local TV, radio and through community networks. 7. Continual monitoring and evaluation of the project has taken place with external Universities engaged to conduct research projects. The volunteers are the heart of the project. Thai people believe in a holistic approach to health with spiritual well-being essential. Being well does not only mean an absence of disease. The mental health of the patient is equally important. Modern medicine, especially in an overcrowded system where there is no opportunity to build a relationship between the patient and medical professional, can be seen as cold and mechanical, lacking a human heart. The volunteers provide the link between the professional health services and an understanding of the local people. At the initial training session there were 239 volunteers and many more have come forward during the project. Currently there are 214 fully trained, active volunteers.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The project was initiated in 2007 by the Phuket Provincial Administrative Organization and Phuket Provincial Health Office. This was a response to a Community forum with patients and relatives. The forum highlighted the lack of access for the vulnerable and the feeling that the government did not care. Some of the disadvantaged ethnic groups and fishing villages felt their unique cultures were being abandoned and they we being left at home alone without care. After consultation with other Government agencies including Social Development and Human Security, local government and community leaders research was undertaken and the project was implemented in 2009. The number of program participants increase every year with The Institute of Child Develoment Rajanagarindra National Health Security Office (NHSO) and the Rotary Club of Sino Phuket provides material, equipment and medical supplies. The Phuket Provincial Administration Organization was responsible for: • The initial identification of the need. • Supplying the mobile medical teams. Cooperated with local Government and external bodies such as Rotary to fund the materials and ambulance service. • Developing the Primary Health Inspection Service to provide advice and knowledge about health. • Created a display at their 3 monthly exhibitions to advertise the project to people. • Coordinating local governments to facilitate the transport of patients • Support the travelling medical teams • Assess patients and provide care The Phuket Provincial Health Office was responsible for: • Arranging the meeting to clarify the guidelines • Run workshops for volunteers • Run activities for the most vulnerable • Provide volunteers to advise and support patients

 8. What were the most successful outputs and why was the initiative effective?
The implementation of the project has resulted resulting in Phuket’s most vulnerable people having equal access to public health services. No longer does your health care depend upon your income, sex, religion or education standard and this contributes to a strong community that is self-reliant. The following examples showcase some of the achievements and strategies. • Relatives do the daily care, ensuring healthy eating and basic exercises. • Local volunteers visit the vulnerable for health checks keeping a record of vital signs and basic hygiene and advise relatives on how to care for the patient. The volunteer will provide basic care such as massage, cleaning and dressing wounds, where necessary they liaise with the local health center or district hospital for further treatment. • The volunteers arrange for ongoing records on each patient to be maintained. • Since the volunteers are local there is respect for traditional medicine and the use of medicinal plants. • Local government provides ambulances to transport patients where necessary. • The district hospital admits patients for emergency care or rehabilitation that cannot be done in the local settings. In addition there have been other very important but less measurable outcomes. • Increased awareness and education in local areas about health matters. • An increase in the acceptance of the role of modern medicine in good health. • With currently 214 trained volunteers the idea of community service has been reinforced and valued. The blueprint for this project has been used to reproduce this program in three other provinces in Thailand. This testifies both to the success of the project and the high regard it is held in by the Thai people. The project has been successful because it utilizes volunteers as the primary health givers. This is cost effective but also has a number of benefits beyond economic. • Building knowledge of health issues in the community • Providing a human element to the modern medical process • Allowing patients to be more self-sufficient and allowing them to spend more time in their community and not become disconnected from it.

 9. What were the main obstacles encountered and how were they overcome?
The main obstacles faced by the project were not enough trained medical staff, insufficient beds at the hospitals and the resultant overwhelming pressure on the system. The Phuket Care Program reduced the reliance on the hospital for primary medical care whilst at the same time empowering local communities and increasing the awareness of health issues at the local level. For patients unable to attend the hospital, even in emergency situations, a mobile team was established to go to the patient. Some of the practical issues to overcome were: • The initial training of the volunteers. With 239 volunteers at the beginning of the program they were given only a basic training but this is updated and extended every six months. Volunteers are required to provide a written report on every visit and this helps with maintaining quality control over service delivery. • Some families were resistant to taking on the care of their family members as they felt this may be too difficult for them. The volunteers worked closely with these families to demonstrate the level of support they would receive. • The provision of specialized equipment and consumables such as pulleys, bandages, and beds. • The administration of the program was undertaken by PPAO and its experience with administrative procedures was invaluable as new processes needed to be created for this project.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
The project has directly improved the quality of lives of 104 villages. The benefits have been explained fully under other criteria but in summary. • The lack of affordable health care for the most vulnerable of Phuket’s citizens has been addressed by creating a local outreach network from the hospital. This has involved training 400 volunteers so far to provide the frontline health care for patients who may otherwise not have been able to get this care. • Providing a free health care system in your own home or locality with the possibility of transport to a pre-arranged visit to the district hospital has eased the financial and time pressures on patients and their families. • By spending more time in the community patients have an improved quality of life and a greater sense of self-worth. • With the understanding that health is more than just an absence of disease there is some mistrust of modern medicine which lacks the spiritual/human element. The volunteer provides the bridge to allow the best possible care. • Spreading the knowledge about health through the community has empowered local communities to take the responsibility for care from the hospital, always aware that emergency and specialized care is available as needed. • Local communities have been strengthened as people can stay in their communities as active members without travelling to hospital. • At present there are over 1600 patients registered with the program, many of whom would not have received treatment otherwise due to the difficulty or affordability of travel. • Women are receiving maternal care during and after pregnancy. Children are automatically followed up regularly by the volunteers to identify any problems. • There is transportation, an ambulance, available to take emergency and chronic cases to the district hospital where they will be expected and not need to wait for long periods. • Giving people the opportunity to volunteer and be respected for the work they do promotes a strong sense of service within the community and is a good example for the future generation. • This project has been copied in three other provinces so far and is proving to be a model that others can utilize to solve similar issues in their own province. • The project is running to budget of $164 USD per patient annually, which makes it both affordable and sustainable. Indirectly there has been an easing of the pressure on the current hospital system which has resulted in better health care for all with shorter waiting times than would otherwise have been possible.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Although this criterion is not applicable to this application, it is worth reporting that steps have been taken to ensure that all processes are transparent and open to inspection. The budget is managed electronically and undergoes regular audits. Patients can only register through their local clinics and must provide ID cards and family books. All volunteers are required to provide written reports of each visit they make. The project is evaluated annually by external parties to ensure it is meeting its goals.

 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)
Although the project is responding to the health needs of all the people within the target groups, this has been particularly effective in dealing with women’s health through prenatal and perinatal care. The volunteers educate and advise women on childbirth, support women giving birth prematurely and assist children born with disabilities form birth. Many rural women were reluctant or unable to travel to hospital for the check-ups during pregnancy and the care within their community is valuable. The availability of care locally also greatly increased the number of visits to a health care worker for children. With the care available within their community patient’s quality of life improved.

Contact Information

Institution Name:   Phuket Provincial Administrative Organisation
Institution Type:   Local Government  
Contact Person:   Penjit Parichatnon
Title:   Supply Officer  
Telephone/ Fax:   076354820
Institution's / Project's Website:  
Address:   5 Narisorn Road, Talad Yai
Postal Code:   83000
City:   Phuket
State/Province:   PHUKET

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