Questions/Answers

Cardiovascular disease is the leading cause of death and disability worldwide. In 2015, ischemic heart disease was the fourth leading cause of death in Thailand which translated into two deaths every hour. While deaths due to cardiovascular disease take a heavy toll, the number of people living under the burden of heart disease is on the rise. The number of patients waiting for cardiac surgery in Thailand is growing each year. Many of these patients seek care from government hospitals, as the majority cannot afford private services. As the number of people awaiting cardiac surgery grows, patients suffer worsening symptoms due to treatment delays. Providing prompt surgical treatment is crucial for preventing the progression of cardiac disease and, ultimately, untimely death for these patients. The Joint Partnership to Ensure Timely Access to Cardiac Surgery in Thailand by Somdechprapinklao Hospital (henceforth, the “Joint Partnership”) is an innovative project established in 2015 to provide equitable access to urgently needed cardiac surgery in Thailand. It is a model of collaborative engagement amongst state-supported hospitals, with a vision of providing high-quality cardiac surgery care to all patients in need. In particular, the Joint Partnership aims to prevent low-income patients from facing inequitable waiting times for cardiac surgery. The collaborative model of the Joint Partnership enhances patient outcomes directly by improving access to surgical care, while also strengthening the publicly-funded health system in Thailand. Ultimately, the goal of the Joint Partnership programme is to expand the network of partnering public hospitals so that low-income cardiac patients throughout Thailand can equitably access effective surgical therapies in a timely manner, while ensuring that standards for cardiovascular surgery achieve a uniformly high level of excellence throughout all regions of the country.

The Joint Partnership’s primary aim is to provide timely, high-quality cardiac surgical services for disadvantaged populations through a collaboration between government hospitals. Specific objectives to achieve this aim include: Adapt referral systems and increase surgical volumes at partnering hospitals to better match existing surgical capacity to patient demand Decrease patient waiting time for surgery from 6 to 2-3 months, reducing symptom burden and preventable deaths Maintain and, where necessary, improve standards of cardiac surgical care to ensure high-quality outcomes across participating hospitals The need for a rapid expansion of cardiac surgical capacity is great, as evidenced by the experience of the participating sites. These include Siriraj Hospital, a tertiary care hospital in Bangkok overwhelmed with high volumes of cardiac surgical referrals from across the country, resulting in a waiting list of 500-600 cases annually. Charoenkrungpracharak Hospital hosts a cardiac catheterization lab but has no surgical team available onsite to provide care. At Ananthamahidol Hospital, located in a remote area, patients are unable to access timely surgical care due to lack of trained cardiac surgical staff locally. Each of these challenges uniquely contributes to the backlog of patients awaiting surgery and is addressed through the Joint Partnership.

We submit this application under the category of “Reaching the poorest and most vulnerable through inclusive services and partnerships.” The Joint Partnership project explicitly aims to decrease the burden of disability and death due to cardiac disease amongst Thai patients who face multiple barriers to timely surgical care, including issues of economic and geographic access. This is an issue of not only national but also global significance: non-communicable diseases, and cardiovascular disease in particular, account for a disproportionate share of early mortality in low- and middle-income settings, a disparity in health outcomes that is gaining increasing attention internationally. The Joint Partnership collaborative model amongst government hospitals exemplifies a partnership focused on providing inclusive services to promote equitable health outcomes. By strengthening health system processes, the Joint Partnership has had direct positive impacts on health, as evidenced by reduced waiting times for needed cardiac surgeries and, thus, preventable complications and deaths due to cardiovascular disease. It is also expected to have a downstream impact on the patients served by other government hospitals, by raising standards of care and improving healthcare access at these sites as well.

The 2030 Agenda seeks to improve lives by responding to people’s needs and rights while realizing the Sustainable Development Goals. In line with the 2030 Agenda’s focus on ending poverty and creating healthy environments, the Joint Partnership seeks to ensure healthy lives for Thai patients living with cardiovascular disease through equitable access to surgery. As outlined above, the number of patients awaiting heart surgery in Thailand is very high. The majority of these patients are from low socioeconomic backgrounds. Without financial recourse to privately paid alternatives, symptoms progress, sometimes to the point of death, while awaiting surgical therapies through the public sector. Rectifying this problem will help to achieve SDG 3.4, focused on reducing premature mortality from non-communicable diseases. The Joint Partnership project has demonstrated the effectiveness of strategies to improve delivery of surgical services to disadvantaged populations through more efficient management of existing resources: by creating a responsive referral network and better aligning patient demand with available human and technological resources, the project successfully reduced waiting times by more than 50%. This was accomplished without sacrificing quality, with surgical outcomes judged as excellent per criteria set by the Society of Thoracic Surgeons of Thailand.

The Joint Partnership initiative addresses a significant issue of public health concern – cardiac disease and appropriate management – by improving timely access to high-quality cardiac surgery for a predominantly low-income and/or rural population of patients. This improvement in service delivery has been accomplished through a series of quality improvement initiatives at participating hospitals. Siriraj Hospital receives very high volumes of patient referrals for surgery from across the country. When the number of referrals exceeds the hospital’s capacity to provide timely cardiac surgery, patients previously referred to Siriraj are referred to Somdechprapinklao Hospital for expedited surgical procedures. At Charoenkrungpracharak Hospital, scheduling surgeries outside of operating hours allows cardiac surgical teams from Somdechprapinklao Hospital to perform surgeries for patients. Ananthamahidol Hospital has expanded both temporal and geographic access for underserved communities by bringing in a surgical team from Somdechprapinklao to manage patients in this remote rural area. The positive impacts of more timely access to surgical care for vulnerable populations are not only temporal: by obtaining needed surgery months earlier, patients are able to return to their productive lives more quickly and avoid undue expenses while awaiting care, both for themselves and families

The Joint Partnership initiative was born out of the painful realization that many Thai patients were dying while awaiting cardiac surgery at government hospitals, as they had inadequate resources to seek care more rapidly through the private system. This prompted a group of cardiac surgeons at Somdechprapinklao Hospital to develop an innovative service delivery mechanism to enhance equitable access to cardiac surgery for low-income patients. Somdechprapinklao Hospital is uniquely situated to assist a large population in need: the hospital serves not only Royal Thai Navy staff and their families, but also the general public and patients referred from other hospitals nearby. Surgeons at Somdechprapinklao Hospital work cooperatively with Siriraj Hospital, where many referred patients from around the country endure long waiting periods prior to receiving surgical treatment. When these patients are referred to Somdechprapinklao Hospital for expedited care, they benefit directly from prompt surgical management. Similarly, patients living in the vicinity of Charoenkrungpracharak Hospital have benefited from shorter waiting times due to extended surgical operating hours, and low-income rural patients living near Ananthamahidol Hospital Lopburi benefit from prompt, high-quality surgery performed close to their homes, provided through the Joint Partnership’s rural outreach program.

The Joint Partnership initiative to reduce waiting times for cardiac surgery represents a new approach to reducing premature death and disability from cardiac disease within the Thai context. First and foremost, the Joint Partnership achieved significant reductions in waiting time for cardiac surgery by developing a unique demand-based referral and care delivery system between a number of public hospitals administered by different government agencies: Somdechprapinklao Hospital is under the supervision of the Royal Thai Navy, Siriraj Hospital resides under the Ministry of University Affairs, Charoenkrungpracharak Hospital is under the Bangkok Metropolitan Administration, and Ananthamahidol Hospital Lopburi is under the Royal Thai Army. Successfully uniting these various hospitals administered under a range of government agencies to effectively improve service delivery is a milestone in the history of the Thai health system. The Joint Partnership pilot is the first such effort in Thailand, and will hopefully serve as a model for excellence in service delivery and collaboration for other health initiatives across the country – particularly those aimed at better serving the poor and underprivileged patients of Thailand through the government healthcare system.

The collaborative network of public hospitals developed by the Joint Partnership to create a more responsive and efficient system for cardiac surgery delivery is an original idea and model of cooperative work amongst Thai government hospitals. This collaboration has yielded marked improvement in the national health care service delivery system by ensuring underprivileged patients equitable access to cardiac surgery, despite being unable to pay for private care. It is hoped that this innovative framework for collaborative service delivery improvement amongst Thai government hospitals could potentially become a model for enhanced, equitable service delivery for other health problems in the future.

The main human resources required to implement the initiative were surgical teams at the participating facilities (Somdechprapinklao Hospital, Siriraj Hospital, Charoenkrungpracharak Hospital, and Ananthamahidol Hospital Lopburi). In terms of financial resources, cardiac surgeries offered through the initiative were provided free of charge for participating patients, through site-specific mechanisms: At Somdechprapinklao Hospital, patients referred from Siriraj Hospital are provided with a doctor’s referral letter. This entitles them to coverage for the medical expenses incurred for their surgeries. At Charoenkrungpracharak Hospital, patients may be eligible to receive direct disbursement, depending on their medical insurance coverage. To receive direct disbursement, patients are advised to review their rights to cost-free medical treatment at the hospital. At Ananthamahidol Hospital Lopburi, heart surgery costs are covered by the Ananda Mahidol Hospital Foundation. Patients are eligible for direct disbursement according to government policy.

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The initiative has been transferred to other contexts. The Joint Partnership initiative received national attention upon being commended for excellence in national public service in 2017. The Joint Partnership program, which is ongoing, has received a number of requests for participation from other state hospitals, with plans for expansion to additional sites in the future. Additionally, the principles and practices of the project have already been applied by other departments within the Thai public health system. For instance, a cardiac catheterization laboratory project has been set up in accordance with the Joint Partnership’s guidelines on collaborative referral and treatment structures amongst government hospitals. Adopting these guidelines has enabled the cardiac catheterization laboratory to provide enhanced emergency and elective care for cardiac patients, from both the local vicinity and around the country.

The key strength of the Joint Partnership initiative is the cooperative nature of the work amongst the participating state hospitals and the strong partnerships that have thus been developed. Building on this foundation, there are several specific characteristics that make this initiative sustainable. Social sustainability: This project provides assistance to low-income patients who are suffering while waiting for needed heart surgery in state hospitals. The impressive declines in waiting time since the initiative’s roll-out, and the associated declines in cardiac death rates and symptom burden, have garnered popular support for continuing the program. Economic sustainability: The project provides a foundation for long-term economic development by reducing the medical expenses of nursing care and medications for both in- and out-patients, costs that are often high and recurring. Earlier surgical treatment results in faster improvements in symptoms and complications of heart disease, reducing hospitalization time and costs, and enabling patients (and their supporting families) to return more quickly to healthy, productive lives. From an institutional perspective, the initiative is supported financially by government funding as previously described. Contextual/systemic sustainability: One of the main philosophical motivations driving the initiative is the desire to benefit disadvantaged patient populations in urgent need of cardiac care. Achieving this aim has proved motivating to healthcare staff involved in the initiative, promoting long-term sustainability. Participation in the initiative, particularly amongst smaller and/or rural facilities, supports the expansion of medical knowledge and reinforces cooperative work between public hospitals. Finally, the initiative aims to develop human resources for health by building teams of cardiac surgeons across the country.

Temporal sustainability: One of the explicit goals of the Joint Partnership project is to become a model for cooperation between public hospitals in order to strengthen cardiac care services for patients across the country. The project’s initial successes, including the expedited patient referral service and creative deployment of surgical teams to remote and/or understaffed facilities, demonstrates the excellent service delivery that an innovative team of heart surgeons can provide. The Joint Partnership plans to expand this collaborative model further, by piloting a training and research institute for surgeons specialised in cardiac procedures. This next phase was conceived in recognition of the fact that expansion of surgical operations at Charoenkrungpracharak Hospital and Ananthamahidol Hospital Lopburi will require specialized training for operating nurses, to be conducted by a cardiac surgical team from Somdechprapinklao Hospital. This train-the-trainers model is anticipated to yield important benefits in terms of both human resources and temporal sustainability of the project. Ultimately, the step-wise training of additional cardiac surgical teams to staff sites across the country in the future will greatly expand access to timely cardiac surgeries for patients throughout Thailand, and provide enormous benefit to the country in the long run.

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The programme has been evaluated by several relevant Thai government agencies, as follows: 1. The programme is a cooperation of four state hospitals and supported by the relevant management teams from each hospital. All participating hospitals have been evaluated by relevant health-related Thai government agencies, such as the National Health Security Office. Key aspects assessed included the availability of medical equipment and adequacy of human resources (i.e. the existence of an appropriately trained surgical team). Standard surgical treatment processes were also evaluated, to ensure patient safety. 2. Relevant treatment records with identifying indicators were sent back to the home office of each medical institution, to enable evaluation of treatment outcomes. The names of these medical institutions are as follows: the Medical Service Department of Siriraj Hospital, the Medical Service Department of Charoenkrungpracharak Hospital, the Naval Medical Department, and the Royal Thai Army Medical Department. 3. Programme implementation and surgical team performance were assessed on-site by the Office of the Public Sector Development Partnership.

1. Medical equipment and human resources assessment: All participating hospitals successfully achieved accreditation for treatment and care by the National Health Security Office. This accreditation process enabled all participating hospitals to provide high-quality medical care services to all patients and to establish appropriate health standards. 2. Medical record review: This process improved quality of the project implementation by ensuring prompt feedback on surgical outcomes. It also supported knowledge exchange between medical personnel, including information about treatment outcomes across state hospitals. This contributed to sustained improvement in nursing care of cardiac patients at the participating sites.

The indicators for evaluating project implementation are divided into two groups: quantitative indicators (output indicators) and categorical indicators (outcome / performance indicators). 7. 3.1 The primary output indicator is the number of patients undergoing cardiac surgery per year from each participating hospital: Somdechprapinklao Hospital, where 30 patients from Siriraj Hospital are referred for cardiac surgery Charoenkrungpracharak Hospital, where 55 patients have access to cardiac surgery outside of routine operating hours Ananthamahidol Hospital Lopburi, where 12 patients awaiting cardiac surgery undergo expedited procedures performed by a team from Somdechprapinklao Hospital 7.3.2 The primary outcome indicator is whether the target annual mortality rate has been met at each participating hospital (yes/no), where the target mortality rate is defined as less than 5% of the total number of patients referred to other designated hospitals for cardiac surgery per year. To date, this target has been met by all hospitals.

The Joint Partnership is a cooperative program supported by a network of state hospitals. It is committed to helping society and improving the quality of services for vulnerable populations, particularly poor people in rural areas. Patients are provided with equitable, high-quality essential healthcare services, which is the primary motivation behind and great strength of the implementation plan. The surgical team at Somdechprapinklao Hospital, working to its full potential by coordinating care for patients awaiting cardiac surgery through a network of government hospitals, has successfully reduced waiting times for cardiac surgery from 6 months down to 2-3 months. To achieve this, the cardiac team developed a referral network to ensure that governments with high volumes of patients awaiting surgery, such as Siriraj Hospital, can transfer patients to Somdechprapinklao Hospital for more timely surgery. Charoenkrungpracharak Hospital also participates in this initiative, through an alternate mechanism: this well-equipped medical facility has extended its typical hours for surgical operations outside of routine office hours, allowing patients within its catchment area to be treated by a mobile team of heart surgeons from Somdechprapinklao Hospital. This model has been further extended to serve hospitals in remote areas. Ananthamahidol Hospital Lopburi, for example, joined the project in order to be able to operate its own services with the support of mobile surgical teams. This enables rural populations to access to healthcare services more easily. Through each of these innovative partnerships, patients receive expedited surgical services close to their homes. The project implementation will be evaluated based on specific indicators as outlined above, i.e. total number of patients receiving cardiac surgery annually through the initiative, and postoperative mortality rates. Processes will be monitored and evaluated by other participating hospitals.

The initiative was motivated by the recognition that the most vulnerable patients lacked prompt access to cardiac surgery. In response to this need, the Joint Partnership’s collaborative program of expedited referral and mobile surgical teams has enabled patients from disadvantaged communities to access efficient, equitable surgical services and gain better quality of life. Several key lessons have been learned from this initiative: First, in order to achieve the impressive reductions in waiting times demonstrated by the Joint Partnership’s programs, efficient resource management and maximization of existing staff potential are crucial factors for success. A second key element for success was the far-reaching vision of the management team, and the great dedication of the operating staff to achieve this vision. Throughout the process of implementing the initiative, relevant knowledge and practical experiences were exchanged amongst staff, augmenting the workforce capacity despite limited resource management personnel. Recommendations: (1) Increase the number of healthcare workers and creatively utilize the skills of existing healthcare staff and (2) carefully analyze and address systemic challenges to ensure efficient resource management. Our experience has taught us that thoughtfully addressing these factors enables patients to access needed treatment in a timely manner.