Questions/Answers

From correcting physical defect to recovering of well-being, quality of life in cleft lip cleft palate (CLCP) patients is improved. Access to healthcare services for the underprivileged is best achieved through cooperation among relevant agencies in a given community. The main objective of this ongoing “Network of Equity of Access to Health care for Better Quality of Life ” initiative has been not only to correct physical defect to achieve functional recovery but also to obtain life-long improved quality of life in such patients. The initiative demands time and effort, and managing knowledge in the process of resource sharing in order to provide access to healthcare services for patients. Services normally available to patients in metropolitan area have been made available to CLCP patients in rural areas from northern highlands of Thailand and Myanmar migrant population. The initiative aimed at solving physical disability, managing patient’s household issues and promoting quality of life; this resulted in improved quality of the community and the society as a whole. Knowledge obtained from care delivery activities in the initiative has been used to form a service delivery model. Such model could conceptually be applied to other disease/disability groups. The result will be an improved quality of life of individuals, patients and healthcare professionals alike. Managing patients with CLCP requires experts in various fields generally available at advanced tertiary care centers, and usually requires long-term care plan. Optimal outcomes are also determined by non-medical factors such as care provider attitude, cost of patient’s traveling and patient’s adherence to care plan. This initiative has paved a way towards an improved public health resource management in providing access to healthcare for the poor and the underprivileged. This equity of access model could potentially be expanded to cover other regions and eventually the whole country.

The main objective of the initiative, “Network of Equity of Access to healthcare for Better Quality of Life in CLCP Patients”, or NETWORK, was to provide equity of access to medical care for CLCP patients from remote rural areas, marginalized population and migrants. Patients and their families were informed of standardized care proven effective for CLCP and its related medical problems. Patients and families, with assistance from healthcare professionals, made an informed decision whether to receive such a medical care. A network of stakeholders was established to provide supports to patients in need. Patient-related information was recorded and made available electronically through the internet to all participating care providers. Patients were to visit a nearby community hospital first and referral to more advanced facility, and eventually to the most advanced facility in the network if needed, would be made available. This network of healthcare services was expected to optimally utilize existing public health resources and to improve access to effective medical care for CLCP patients.

The NETWORK is an integrated network of public healthcare providers using multidisciplinary approach. In order to provide a medical care to a CLCP patient, professionals in relevant fields usually work together and in cooperation with civil society and patient’s family. One unique feature of this initiative is an active participation of the patient’s family. Most CLCP patients are from low-income families. These include migrant patients along Thailand-Myanmar border. These patients with poor healthcare access are provided by this initiative with a medical care alternative that offers outcomes of international standard. This seamlessly integrated access of healthcare is an innovative approach for the underprivileged who live in the remote areas in highlands and along the border of Thailand. This network of medical care for CLCP patients who live in highlands and along the Thailand-Myanmar border also improves their quality of life, besides providing them with equity of access to healthcare. The patient’s family, the smallest unit of a society, can enjoy life, physically and psychologically, of equal opportunities.

One problem in public healthcare services in Thailand concerns with patient information sharing. As electronic medical record system of one hospital is practically isolated; information sharing among healthcare providers practically does not exist. As CLCP patients need to be assessed by healthcare professionals from different care facilities. A lack of information sharing hinders a collaborative service. Many patients initially visit a community hospital and later a tertiary care center on their own. Patient health information at the local community hospital is not available to the tertiary care hospital and vice versa. Due to lack of proper information sharing, patients may have to suffer unnecessary traveling during the entire course of treatment plan, some may be as long as 20 years. This hardship is even more pronounced for those who live in remote highlands or along the border. This integrated network of healthcare offers centralized coordinating functions between and among patients and providers, community hospitals, tertiary care centers and the university hospital involved. Patient information is always available to the origin hospital and the destination hospital involved in referral. This central administrative body can also help facilitate any referral-related problems and issues.

According to the current organization of the public health system, there are 3 tiers of healthcare providers: primary care center, secondary care center and tertiary care center. University hospitals are more advanced tertiary care centers and manage patients referred from tertiary care centers. Managing CLCP patients requires multidisciplinary approach to achieve optimal outcomes. In general, all patients are referred to a university hospital in a given region once diagnosis is obtained. This is the model practiced in most developed countries and it has been adopted to modern Thai medicine. If this practice goes on, public health system will continue to experience the following. 1. Long-term treatment plan for CLCP patients cannot be carried out to cover most patients in remote rural areas. 2. Healthcare facilities most accessible to patients in rural areas, e.g., community hospitals, cannot provide care the patients need as they are not properly equipped and staffed. And all patients must be referred to centralized facility, i.e., university hospital, only in order to receive care needed. Furthermore, capability of primary care facilities will never be developed.

Patients and their families who live in remote rural areas, along the Thailand-Myanmar border as well as migrants and migrant workers, including people of ethnic minority, can gain access to healthcare needed. This model of facility care networking can be implemented in other parts of Thailand to cover people who live in areas bordering other countries, i.e., Laos, Cambodia and Malaysia. Thus, the poor and the underprivileged may gain better access to healthcare needed. Healthcare personnel of facilities participating in this initiative enjoy improved work processes, i.e., better quality of life. In the process of patient referral, availability of centralized patient information allows coordinating with other facilities more effective and less time consuming. Implementing something similar to this initiative conceptually could improve quality of life of healthcare professionals in other disease groups.

The NETWORK is an innovative public health service. It employs collaborative community networking. This results in a seamlessly integrated teamwork of multidisciplinary professionals from public health hospitals and a university hospital. The university hospital serves as a coaching agent to strengthen service capability of other hospitals in the network, as evidenced by improvement in care delivery and management. The university hospital also serves as central administrative body that also monitors network activities to ensure that it works seamlessly to maximize healthcare access and delivery. Information on patient and patient care processes is collected and shared over the internet using a centralized information system. Patients in the system are monitored to ensure that problems and issues are managed accordingly. One innovative aspect of this initiative is body of knowledge obtained from information on delivery of care process. Knowledge is shared and made available to all participating hospitals. Information is used by hospitals according to individual facility specifics and as deemed appropriate. As delivery activities change, new information is generated leading to a new body of knowledge that can be used by network members. Basically, as cycles of continuous quality improvement repeat, the body of knowledge expands.

This innovative service system is an adaptation of existing healthcare service system in Thailand. Current public health policy advocates healthcare delivery through primary care center and referral to more advanced care facility (secondary and tertiary care centers) is made when deemed necessary. University hospitals, under the Ministry of Education, help manage cases referred to them from tertiary care centers under the Ministry of Public Health. These university hospitals also play active role in generating new knowledge. However, healthcare delivery to migrants and populations along the border (between Thailand and neighboring countries) is carried out by hospitals in the area. For these populations, direct access to a tertiary care center or a university hospital is not practical if feasible. Thus, access to care for complex medical conditions and multidisciplinary professionals is not readily available to them.

1. Plastic surgery. For a given patient, surgeons from Chiang Mai University Hospital (Maharaj Nakorn Chiang Mai Hospital) and Nakorn Ping Hospital examine, provide consultation and create long-term care plan. 2. Nursing team,Craniofacial center Faculty of medicine Chiang Mai University , serves as a central administrative team. It coordinates, interfaces and communicates with and among care teams, community hospitals, secondary and tertiary care centers, and the university hospital in the network. 3. Public Health Information and Knowledge Center, Chiang Mai University. It manages IT facility to ensure information security and protection against malware. It develops and maintains applications required for delivery of healthcare services in the initiative. 4. Chiang Mai Provincial Health Office and Area-1 National Health Security Office provided funds to support training and transportation. 5. Operation Smile Thailand, a non-profit organization, provided a grant. 6. Faculty of Medicine, Chiang Mai University, provides basic facilities to run the initiative. 7. Community Service Unit, Chiang Mai University, provided consulting services. 8. Management teams from all participating hospitals.

Yes

This ongoing initiative started in 2014 in Chiang Mai, Thailand, involving 4 hospitals: Chiang Mai University Hospital, Fang Hospital, Chai Prakarn Hospital and Mae Ai Hospital. The operation has run effectively and has been further expanded. More hospitals in Northern Thailand have been participating: From Chiang Mai Province: Chom Thong Hospital (secondary care center), Nakorn Ping Hospital (tertiary care center). From Mae Hong Son Province: All nine public hospitals have participated in the network (Sri Sangwan Hospital, Mae Sa Riang Hospital, Sob Moei Hospital, Khun Yuam Hospital, Pai Hospital, Pang Ma Pa Hospital, Mae La Noi Hospital). Mae Hong Son Province borders Myanmar and there is no tertiary care center. The nearest tertiary care center in Chiang Mai Province is at least 6 hours by car from any of these hospitals. Phitsanulok Province: Naresuan University Hospital has adopted this network model to its operation to provide services in its catchment area in the lower part of Northern Thailand. Patient information is made available to all providers in the network. This centralized information approach is now being considered by care providers for other chronic diseases. Implementing this method in managing other disease groups could potential benefit majority of Thai population.

The network is developed using community participation approach. The concept is to obtain a sustainable community health development. It is community-based and takes culture, life style and local requirement into consideration. Textbook knowledge is applied according to local contexts. For example, rice harvesting season requires all adults in the family to work in the field. As a hospital visit requires family members to accompany a pediatric patient, the patient and their family members will not show up at appointment made during such season. Therefore, making an appointment for a follow-up visit must take into consideration the way of life of people in the community. This will ensure the outcome of healthcare as patient adherence to the treatment plan is maximized. As the way of life is minimally affected, treatment plan is optimally accepted. Good outcome of long-term standard care, 20 years in general, is promising. As the healthcare network takes way of life into consideration, its integration with the community is sustainable. The network is basically a seamlessly integrated network of cooperation among relevant stakeholders to offer solutions if problem occurs. Debt may incur if the family cannot afford for long-distance traveling to get the patient to a hospital; in this case transportation cost is provided. Patient’s family determines when the hospital visit will take place. For example, elective surgery appointment may be postponed in order to accommodate adults who have to work in the field during harvesting season. This way, treatment plan does not negative affect income generating activity of the family. As the service takes financial status of the family into consideration, the family has minimal concern about the negative impact. The patient adherence to long-term treatment plan, lasting some 20 years, is promising.

The ongoing NETWORK is the result of a modification of existing Thailand public healthcare system. It is more practical and efficient, befitting local context of individual healthcare facility. It does not require rebuilding a new system of healthcare facility. The network employs existing infrastructure and it works in parallel with the current Thailand public health development roadmap. The healthcare provided by the network requires community awareness and participation. The community identifies the problem and determines a solution with emphasis on community health development approach. Thus, the civil society is strengthened. The community manages and improves the quality of public health services resulting in a sustainable network system befitting a given community. Sense of ownership takes place as community members actively participate. Therefore, the network is upheld and maintained. Factors contributing to the network’s sustainability also include a centralized information system that enables data collection and sharing among providers. Lessons learned and knowledge obtained from the system are applied to continuing quality improvement processes in a sustainable manner. One other success factor deals with management issues. Data on problems and issues on healthcare delivery processes have been collected and processed. The information obtained from gap analysis of public healthcare services serves as a feedback to the Ministry of Public Health. The feedback offers real-life situations in the system useful for public health management processes such as budget allocation, resource distribution and knowledge management. The goal is to strengthen public healthcare professionals and to empower them to use multidisciplinary approach in order to optimize the quality of public healthcare services.

Yes

1. In 2017, an internal evaluation of the initiative was carried out. The results were shown in 7b, 7c. 2. The NETWORK received an award in 2017 from the Office of the Public Sector Development, an agency under the Office of the Prime Minister, in the category of Innovative Services. 3. Part of the initiative was presented at International Conference on P2P, Parallel, Grid, Cloud and Internet Computing, in November 2017, Spain. The conference was about IT application in public health development. The title of the presentation was “A Conceptual Framework for Developing an Information Retrieval for Healthcare Service. 4. This initiative was presented, by invitation, at the 13th International Conference on Thai Studies: Globalized Thailand? Connectivity, Conflict and Conundrums of Thai Studies, 15-18 July 2017, Chiang Mai University, Thailand. Only projects deemed beneficial to the public at the national level and above were invited.(detail will be shown on supporting documents)

1. Outcomes of the evaluation 1.1 improved patient delivery to higher care center or university hospital. 1.2 Increased number of patients receiving speech therapy after cleft palate surgery 1.3 Decreased time spent on traveling to higher care center or university hospital 1.4 Saving on traveling cost 2. An award from Office of the Public Sector Development Commission has created a social acceptance. The initiative originally operating as a network of 4 hospitals in 2014 has expanded as more hospitals have applied to participate. It is currently a network of 13 hospitals, as of December 2017. 3. Presentation on the initiative at the International Conference on P2P, Parallel, Grid, Cloud and Internet Computing, in November 2017, Spain, has led to an increased awareness among IT personnel in healthcare industry. An increased awareness should prompt IT personnel to pay more attention on improving information sharing. 4. Presentation of this initiative, by invitation, at the 13th International Conference on Thai Studies: Globalized Thailand? Connectivity, Conflict and Conundrums of Thai Studies, 15-18 July 2017, Chiang Mai University, Thailand, has gained interests from University Management regarding how to solve problems using multidisciplinary approach involving.

Performance indicators in this initiative are: 1.1 Number of patients receiving treatment at the university hospital increased from 106 in 2014 to 800 in 2017. 1.2 Number of patients receiving speech therapy after cleft palate surgery increased from 15 in 2014 to 70 in 2017. 1.3 Time saving from patient traveling over 3 years = 1,095 travel days per year 1.4 Cost saving from reduced traveling: 23-25 million Baht in 2017 1.5 Number of participating hospitals: 4 in 2014 to 13 in 2017 1.6 Number of participating hospitals with improved service delivery capability: 6 hospitals

This ongoing initiative has involved the following agencies: 1. Craniofacial Center, Faculty of Medicine, Chiang Mai University. The CENTER coaches and coordinates multidisciplinary professionals and relevant parties in the network including participating hospitals, patients’ families, funding agencies and non-financial supporting agencies. The Center is responsible for developing and maintaining the information system in this initiative. Project oversight is also carried out by the Center. 2. Public health hospitals. They are primary care providers working in cooperation with the CENTER. Under self-improving approach, they play active roles in patient care. Patient education necessary for long-term care and visits is also carried out by these hospitals. They also coordinate and cooperate with local health stations, village health volunteers and village heads to monitor patient’s physical development. 3. Field operating units. These include local health stations, village health volunteers and village heads. They coordinate with patients and their families to ensure quality care outcome. They also serve as communication channels with the CENTER. 4. Patient’s family. This is the basic unit closest to the patient and most critical for the success of network operation. Well informed patient and family promises good outcome. The family is the main information provider regarding patient’s physical development, any relevant medical problems and feedbacks. 5. Non-profit organizations and other third-party agencies. They play an active role in building social awareness of the initiative. They also provide funding and assistance to maximize project feasibility. 6. Other agencies including Faculty of Engineering and College of Media and Arts, Community Service Unit from Chiang Mai University, and Smile Operation Thailand Foundation.

Lessons learned could likely be applicable to other areas of healthcare services in Thailand and overseas. - Field work experience allows healthcare personnel to appreciate the real-life situations. Collective effort by network members empowers them to obtain optimal outcome. Interaction among group members leads to sense of belonging and mutual support, resulting in a more sustainable network. - Strengthening a working network requires support from individual network members, public and private sectors alike. Public sector includes all participating hospitals. Private sector also includes various foundations and non-profit organizations. Significant contributions come from civil society and the patients and their families. Contribution from private sector eliminates unnecessary mobile operating units. Private sector also enables and empowers patients to seek assistance needed, e.g. transportation fund, baby-sitting, house watch. These allow a patient to live with minimal or no social stigma. - Networking approach allows optimal utilization of existing public health resources. Continuous quality improvement sustains the best possible treatment outcome. - Knowledge obtained from patient information enables better care provision. - Centralized management team is vital in monitoring problems and issues. Public education and public relations are best handled by this team.