Questions/Answers

Kidney failure is among the most deadly and costly diseases faced by patients and modern society. According to database of Health Data Center; HDC, Ministry of Public Health, new patients diagnosed with chronic kidney disease, caused by diabetes and high blood pressure tend to increase for the last 5 years (from 2014 – 2018; 9,700, 10,241, 11,128, 10,688, and 18,278 cases, respectively). From the numbers, there were 352, 649, 958, 1,116, and 935 patients who had the kidney disease stage 3-4. This finding has triggered us to get ready for the worst even though we still hope for the best that no one has ever needed the hemodialysis. The Chaiyaphum Hemodialysis center is established as the most appropriate and possible choice which most patients could afford. Working in Healthcare Service Center, we under Division of Public Health and Environment, Chaiyaphum Municipality, have learnt about the disease from our patients and acknowledged the problems in the social perspective from our community networks. After several meetings among all stakeholders, we have come up with the initiative which is intended … 1. To provide an affordable hemodialysis service for all patients as the alternative choice besides going to hospitals. 2. To work closely with community networks in order to maintain both before and after service monitoring and evaluating. 3. To educate and train people about the health literacy model in order to promote proper health behaviors which help decrease Non-Communicable Diseases(NCDs), especially high blood pressure and diabetic which caused the chronic kidney disease.

According to category 1 delivering inclusive and equitable services for all, the hemodialysis center is established to help the poor in needed of happy and healthy life without illness. With helps from communities and other stakeholders, the governing body of the municipality could use these networks of collaboration as the innovative way to deliver inclusive and equitable health services to all people.

According to Goal 3 of SDGs, the initiative is intended to provide healthy lives and promote well-being to all members in the Chaiyaphum communities by collaborating with their leaders through community networks with several targets. Target 3.4 By 2030 reduce by one-third premature mortality from NCDs through prevention and treatment and promote mental health and well-being to all members in Chaiyaphum communities. Through village health volunteers, the initiative can screen all 35-year-old people or older in every community for NCDs, Non-Communicable Diseases; diabetes and high blood pressure which are the main risk factors for developing kidney disease. Then, the risk and patients alike are taught and trained about health literacy model to create better living condition and more healthy ways of being Moreover, the patients mostly in stage 3 to 4 of the chronic kidney disease will be scheduled to have the GFR test, Creatinine Clearance, and Microalbuminuria at least once a year at any of our 3 service centers nearby their houses. Trying to meet target 3.8, we plan for universal health coverage, take out patients’ travelling expense by transporting them from home to the center and vice versa, let them access easily to quality essential health-care services.

In social term, to ensure sustainability of the initiative, the Chaiyaphum Municipality has signed the memorandum of agreement on healthcare term with several institutions such as Chaiyaphum Hospital, National Health Security office , Khon Kaen University, Nephrology Society of Thailand, and other private organizations. In economic term, the Chaiyaphum municipality has been working through its community networks to reduce patient’s medical fee both directly and indirectly, increase income of patient’s family. In environmental term, the village health volunteers trained by the center have advised people in the communities about the health literacy model for improving their living condition.

After signing memorandum agreement with Chaiyaphum hospital, the Chaiyaphum hemodialysis center is referred as the place for patients who have the Chronic Kidney Disease. This lets the hospital focus on more serious CKD patients while the normal CKD patients could save time and money by going to any of our 3 municipality health centers nearby.

Data collected from Sept. 3rd, 2018 to Sept. 30th, 2019 has shown that 188 patients have received the hemodialysis for 12,704 times at the center all together. From the number of patients, there are 93 females and 95 males which consist of a monk, a prisoner, two boy and 91 men. The initiative has served everyone equally and randomly according to their syndromes not gender or else.

As the name dictates, the Chaiyaphum Hemodialysis Center has been established in order to serve people who have or risk having the CKD at any stages preventively and protectively by collaborating with community networks in Chaiyaphum Municipality. With this in mind, the center has targeted on people at risk of having diabetic and high blood pressure, the two main causes of the chronic kidney disease, who are 35 years or older. Then, after trained by physicians and nurses from the center, the community health volunteers are provided with the target names as well as their addresses and asked to measure their blood pressures, weights, heights, and fasting blood sugar. Next, the nurses or physicians can analyze data and categorize the targets into groups; normal, at risk, and NCDs group. Finally, treatment procedures would be appropriately applied to each and everyone in the groups.

After physicians have categorized target people into groups, the initiative was implemented. From 15,332 persons, we can reach and measure only 12,113 (89.24%). From the number, we, then, categorized them into 3 groups as following: 1. The normal group of 5,969 people who are not at risk having CKD will have to undergo the blood pressures, weights, heights, and fasting blood sugar annually. 2. The at-risk group of 5,755 people is trained and asked adjusting their eating habit, living clean, etc., to prevent the NCDs by the family care team besides teaching about the health literacy at home to adjust and improve their health and living environment. 3. The NCD group of 389 people are periodically monitored and tests to evaluate their condition and plan for proper treatment. From all 15332 people, even though there aren’t any patients in needed of the hemodialysis other than referred from the Chaiyaphum hospital, the initiative is quite successful in term of preventing and building awareness to the communities. Members of communities have learned about the disease and known what to eat, how to live, etc.

1.The center requires high investment which Chaiyaphum municipality couldn’t afford. The division has to sign memorandum agreement in order to arrange for dialysis machine installing at the centers. 2.The center hasn’t had its own Nephrologists. Thus, having signed the memorandum with the Chaiyaphum hospital, the center gets its specialists while referred and referring patients to the hospital. 3.Restricted from the law about monitoring outside patients, the center has signed memorandum with other 142 Local Administrative Organizations, establishing collaboration among communities to provide patients with transportation from and to the center and monitoring the patients in all aspects.

The “searching for patients” initiative is innovative in the context of my region in the co-operative way. From the beginning, a particular 35-year-old or older might relax at home. Then, village health volunteers come and ask him/her to do some measures and tests. Later that day, there may be a family health team coming to check on her or him thoroughly. In the next day, there may be a van together with her/his head of village picking her/him up to see a specialist or nephrologists and so on.

Inspired by the successful initiative of Khaophragnam Sub-district Municipality called Excellent Happy Home Ward by using its community networks, Mayor of Chaiyaphum municipality and director of public health and environment division have set up the mission to improve health care and well-being for all people who live in municipality area.

N/A

Any contexts within the municipality governing can have and will have benefits over the community networks since they are local political strongholds. Heads or leaders of the community respond directly to their villagers well being. Transferring or adapting the initiative to any other contexts in communities has great potential.

1.The municipality has allocated a budget of 2,159,000 baht in 2013 to improve the building and allow us to use its community strongholds in order to Implementing 2.The center will receive 1,500 ฿ from National Health Security Office. 3.Our nurses can monitor patients by using application “CKD RuxTai” from Khon Kaen University 4.From Chaiyaphum hospital, the patients are referred to the center and vice versa besides providing nephrologists. 5.The center is filled with equipments and specialists from private sectors. 6.All 142 LGO help transport patients from their homes to the center and vice versa.

Since its starting date at September 3rd, 2018 till now, the center has served about 188 patients with 12704 times of hemodialysis. The center has earned enough income to prolong operational and institutional expenses in the aspect of monitoring, evaluating and transporting patients between their houses from and to the centers.

Yes

Internally, the hemodialysis center conducted self-evaluation, employing the 9-item Thai Health status Assessment Instrument (9-THAI) to evaluate the quality of life (QoL) of patients. Externally, the initiative is evaluated by Prime Minister’s Office according to Good Governance (GG) framework. There are three steps evaluations; primary evaluation, basic information verification, and the final evaluating by the special committee. Then, there are the interviews and surveys conducted by Suan Dusit University to evaluate quality and quantity wise.

Internally, the 9-THAI is a short-form containing only 9 items calculating and interpreting outcome scores by percentage method. After evaluating, the CKD patients have shown the level of quality of life. Externally, Prime Minister’s Office has used the good governance concept to evaluate the initiative. The concept of good governance in Thailand consists of 5 indicators; Legitimacy, Transparency, Accountability, Efficiency and Effectiveness, and Participation of all institutions. Moreover, The CIPP Model of Stufflebeam are employed by Suan Dusit University to evaluate the initiative management success such as Context Evaluation, Input Evaluation,Process Evaluation, and Product Evaluation.

Internally, the main findings of the evaluation by 9-Thai model suggested that patients have scored 88% on moderate to high quality of life in the physical aspect and scored 87.1% on moderate to high quality of life in the metal aspect. Externally, the initiative was recognized as the honorable mention from the good governance model by Prime Minister’s Office in 2019 fiscal year. After evaluating 5 categories in CIPP model by Suan Dusit University, the average score of Product evaluation is 90.80%. The least score is 86.60% on the matter of building service networks to serve patients continuously and sustainably. Despite the high average score over all, the building network score suggested that the center has more works to do in building service networks to serve patients.

1.Chaiyaphum municipality by the governor and Healthcare Service Center of Chaiyaphum Municipality provide the service locations. 2.Members of Village Health Volunteer Networks, VHV Networks, Head of Villages or Leaders of Communities are assigned and trained in order to monitor and evaluate patients who live in their communities. 3.Provided by the Mayor of Chaiyaphum province, 142 Local Government Organizations, LGO, have signed memorandum agreement with Chaiyaphum Municipality to provide inclusive first aid and transporting patients from and to the center. 4.Chaiyaphum hospital has been supporting the initiative with its physician and referring the hemodialysis patients to the center back and forth. 5.Chaiyaphum Health Provincial Office provides us education materials, helps establishing our Chaiyaphum hemodialysis center, and annually evaluates the center performance. 6.The Nephrology Society of Thailand evaluates hemodialysis performance of the center. 7.From the memorandum which the center has signed with Khon Kaen University, our nurses can use KKU’s application called “CKD RuxTai” for monitoring patients. 8.National Health Security Office funds 1,500 ฿ per case of hemodialysis at the Chaiyaphum Municipality Hemodialysis Center.

Designing Stage: Four key stakeholders who are the National Health Security Office, the Chaiyaphum municipality, Chaiyaphum Hospital and Chaiyaphum health provincial office, had held several meeting to establish the hemodialysis center, to plane out the procedure, to implement the operation, to gather information, and to evaluate the outcomes. Implementing Stage: Five institutions; the Chaiyaphum municipality, the Chaiyaphum Hospital, the Village Health Volunteers, all 142 Local Government Organizations and private sectors, have been working hard, dedicating their time, resources and man powers, and etc., in order to implement the initiative for all people in the communities. Evaluating Stage: The Prime Minister’s Office and Suan Dusit University help us evaluate and find the results and downfalls of the project for future development planes.

-Too much too often, patients are getting into more and more passive mode since all institutions are willing to serve and doing hard work for them. Later on, we, institutions, may have to back out a little bit and let them act of moving around by themselves more while we only stand by for helping. -Consequently, the passive behavior is in turn making the patients ignorant to preventive practices that our volunteers have trained and taught them and having no interest of changing bad habits. “More frequently” seems to be the only way out off this obstacle. “Time after time” or “time and time again” sounds boring but what else can we do! -There is an overlap schedule between the public health center and the hemodialysis center. The public health center office hour is 8:30 to 16:30 while the hemodialysis center starts hemodialysis clinic at 5:00 a.m. Patients have to wait for us to pick them up and wait in the longer queue than they usually are. The center are talking about over-time wage for the driver or recruiting more drivers for 3 shifts taking turn.