Questions/Answers

Overcrowding in an outpatient department is a major problem in public hospitals. Thailand achieved “Universal Health Coverage” (UHC) in 2002 under the three public insurance schemes: Civil Servant Medical Benefit Scheme (CSMBS); Social Security scheme (SSS); and Universal Coverage Scheme (UCS). All Thais can access a comprehensive package of health services; however, in Bangkok, there were only 88 public health service providers to serve ten million dwellers who are living and working here. National Health Security Office Region 13 Bangkok (NHSOBKK) is responsible for developing a service system to be easily accessible. NHSOBKK initiated the project to solve overcrowding in big public hospitals in 2005 under a cooperation of all healthcare stakeholders in both public and private sectors. This project strengthens a function of primary care unit under healthcare network cross the different affiliation healthcare providers with the core principle of “patient center and close to home”. This project can increase accessibility of the vulnerable groups such as the elderly, the chronic-sickness patients, children and low-income people, and ensure quality of standard treatment.

To relieve overcrowding in hospitals and ensure quality of healthcare services are the two main operations so that people can access to the health service with the confidence especially the elderly, the chronic-sickness patients and the low-income groups. The initiative closely collaborated between local organization, public and private sector agencies, called “Public Private Partnership” (PPP). NHSO BKK play a role as a facilitator to organize and develop the healthcare service network and the relationship between agencies, especially private clinics. This system will be a prototype of a mega city in the future.

Although Thailand achieved UHC in 2002, a coverage capability shall be enhanced, for example, equal accessibility of healthcare; healthcare expenditure reduction; measures to prevent poverty from healthcare expenditure. The disparity is moderate, reflecting its Gini Coefficient is about 0.4 - 0.5 and is likely to decrease from the past. Improvement of healthcare accessibility will be kept good health, reduced inequality and financial protection for all, especially the vulnerable group.

To solve overcrowding in the big public hospitals responsible for more than 100,000 UCS people by the collaboration with private clinics to provide primary healthcare services close to home before referring to the hospital if it exceeds the potential. The primary healthcare units and the hospitals have been strengthened by the healthcare network system called “Primary Care Trust” (PCT). This trust means credibility between the private clinics and the hospitals in the standard medical treatment with the quality and continuous healthcare for the patient who has been referred. Capacity building of Primary Care Trust has been supported by NHSOBKK. Moreover, NHSOBKK developed the e-Referral system to share patient’s medical records to both Physicians of clinics and hospitals. This electronic medical data transfer system ensures that patients will get the same standard treatment from different level of healthcare providers. Public Private Partnership, Primary care Trust and e-Referral system can solve the overcrowding in the healthcare system and ensuring the quality of healthcare to all Thai citizens.

PCT is applied with a concept of Public Private Partnership, including four strategies to work together with various healthcare providers in the urban area. 1. Remodeling interoperability of healthcare network to be host-clients system, called PCT as the hospital is a host and the private clinics are clients. 2. Strengthening of healthcare network. The regular academic meeting between hosted and clients improved standard healthcare, referral system and continuous care. 3. Developing participation of all stakeholders as well as the community. 4. Innovating electronic referral data with e-Referral system that collaborates with The National Electronics and Computer Technology Center (NECTEC).

Our PCT is adapted from PCTs in England that acts as a healthcare purchaser from private clinics and quality regulators. PCTs have a similar healthcare network area in Bangkok, such as the amount of population, the several agencies of private providers. In Bangkok, PCT is the only developing system of healthcare network. NHSOBKK is a purchaser for UCS. The key success factor of Bangkok’s PCT is human touch relationship between host hospital and private clinics.

PCT shared the lesson learned in many conferences such as Prince Mahidol Award Conference, and a field study of Universal Health Coverage in the megacity. Healthcare personnel from oversea, Japan, Indonesia, the Philippines, Cambodia, and other countries have an interest in the issue of healthcare organized under variety of providers in urban area. The Minister of Public Health has a policy to extend PCT and e-Referral systems to another city in Thailand. The governor of Bangkok Metropolitan also has a same policy to extend PCT and e-Referral systems to all Bangkok Metropolitan Administrator‘s hospital and primary health center.

NHSOBKK provided financial resources to the PCT’s host hospitals. The amount of budget depends on the amount of primary care units in PCT, at least 30,000 – 100.000 THB/unit/year. The hospital is a host for capacity building of PCT. The primary care units were strengthened by the host hospital. The hospital must develop its information system linking the e-Referral system with the primary care units. The community within the PCT’s service areas communicated with the people in the area allowing accessibility of the healthcare services.

The collaboration with several public and private healthcare providers in Bangkok created easier accessibility of all people who live in this megacity, especially the vulnerable group, the elderly, the children, the chronic-sickness patients, the people with disabilities and the poor. Several providers include hospitals and private clinics with an interest to join PCT. In 2019, PCT is one of NHSOBKK strategies to extend all service networks in Bangkok similar to the BMA’s governor policy to extend primary care to all areas in Bangkok, too. Moreover, National Health Security Office strategic plan 2017 – 2021, Ministry of Public Health strategic plan 2016 – 2020, and the Constitution of the Kingdom of Thailand B.E.2560 section 258, established a primary health care system in which there are family physicians to care for the people in an appropriate proportion. Thailand has become a site for learning by international countries on various topics and issues having to do with the implementation of UHC, such as strategic purchase, the functioning of primary health care, and healthcare accreditation. We can work together to achieve Sustainable Development Goals target 3.8 “Good Health and Well Being”

Yes

This project is evaluated every year from the National Health Security Office Regional Board and the strategic and Cluster of strategic and evaluation of NHSOBKK. The action research evaluation techniques (Plan, Act, Observe, Reflect) have been done from the individual record data from all level healthcare providers in the Universal Coverage Scheme in Bangkok. The customer service complaints and voices from stakeholders also have been assessed.

The key performance indicators include as follows: i. The number of complaints ii. The referral proportions iii. The outpatient service in host hospitals iv. The proportion of healthcare service for registered in PCT v. The utilization rates of all citizens under UCS vi. The utilization rates of vulnerable group vii. The rates of ambulatory care sensitive condition (ACSC)

The results were found as follows: i. Healthcare services assurance: higher referral ratio and decrease patient complaints. ii. Quality improvement: The rate of ACSC admission in the PCT network was lower than others. This shows that the host hospital could build the quality standard to the primary care units within the network. The chronic-sickness patients would be not admitted in the hospital if not necessary. iii. Solving overcrowding; The outpatients decreased in the host hospital because they can go to the primary care units near their home. iv. Increase accessibility; Increase utilization rate of UCS and vulnerable groups in PCT.

The principle of the initiative is to establish collaboration from all sectors. Regarding initiative procedure, NHSOBKK is working with the primary care development working group under National Health Security Office Reginal Board. This working group consists of agents from all healthcare stakeholders in Bangkok. It was found that the team from Bhumibol Adulyadej effectively implemented the initiative so that the overcrowding problem was resolved. The Bangkok Metropolitan Administration, who is the local governor and owner of public health centers, played a significant role with the cooperation. The Ministry of Public Health likewise has a cooperative policy to work with private sectors. The primary care units, public health centers and private clinics, and public sector are the key role to implement in the PCT area. The private clinics and the host hospitals are working together. NHSOBKK is a facilitator to establish collaboration of all stakeholders and evaluated in order to create sustainable development.

The formation of healthcare services in big cities with several public and private is applied with a principle of PPP. The principle will have a facilitator who will organize service systems, stakeholders, to take care people effectively, continuously with quality of care. Capacity building is an important aspect to strengthen PCT network. Electronic medical record has been shared with e-Referral system. This linkage impacts the accessibility of people to be easier and more convenient as well as to reduce indirect cost and improve the quality of care. It gets better results toward Bangkok’s citizens especially the vulnerable group.