primary healthcare management paper

8/9/2019 primary healthcare management paper

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How Does Primary Care Move? An Analytical Evidence of Management for

Accessibility and Equity, Thailand

Siranee Intaranongpai1 , Somporn Pothinam2 ,Songkramchai Leethongdee3 , Pramote

Tongkrajai4Nenavath Sreenu5

1Faculty of Nursing , 2,4Faculty of Medicine, Faculty of Public Health ,

Mahasarakham University , Thailand , 5School of Management Studies, University of

Hyderabad, India

Background: New paradigm of national health service development focusing on

improving primary healthcare equity had been experimented in Thailand

Objective: the main assessment of the study to evaluate primary healthcare

management for accessibility and equity in Thailand

Methods: This study has been developed based on literature review of research as

well as in-depth interview, participation observation, and policy ethnography

approach in primary healthcare management. To improve the performance healthcare

delivery services process and major step find the problems identification and

formation the planning implementation

Result: Themes Shifting of Tasks, Management for remote area to

accessibility, Shortage of staff management, Stakeholder management,

Formulate plans, Flexible and appropriate technologies were emerged. The

proposed model can be implemented in primary healthcare management services in

order to improve primary healthcare performance. It may also be applied to other

services.

Conclusion: The study suggests the adoption of an approach of management

practices in dealing with Thailand healthcare services system problems and providesthe quality healthcare service at primary healthcare level

Keywords: primary care, management, accessibility, equity, policy ethnography

Introduction

Primary Care as well as Primary health Care(WHO, 2008) is essential health

care based on practical, scientifically sound, and socially acceptable methods

and technology made universally accessible to individual and families in thecommunity by means acceptable to them and at a cost that the community


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and the country can afford to maintain at every stage of their development in

a spirit of self-reliance and self-determination. (WHO, 1978). Characterteristics

define primary health, care : it is general, accountable, available,

comprehensive, accessible, integrated, affordable, continuous, holistic,

coordinated, community involvement, confidential, appropriated technologies,

approach to delivery, and plays an advocacy role. (Wendy Rogers, 2003;

Wonca Europe, 2002).

The original ideal of primary health care has become known as comprehensive PHC.

This is in contrast to selective primary health care which is more medically focused

with a reliance upon medical interventions and doctors for provision of and control

over health services. Despite significant philosophical differences, comprehensive

and selective primary health care may appear to offer similar services. Population

health shares many principles with comprehensive primary health care, in particular

the focus upon equity, community participation, integration, intersectoral

collaboration, multi-disciplinary teams and health promotion. (Prince Mahidol

Award Conference, 2008) World Health Report 2008 in conference of

Primary Health Care now more than ever focus that primary care should be

corporate primary health care. Destination at last are including 1)

transformation and regulation of existing health system: aiming for universal

access and social health protection; 2) dealing with the health of everyone in

the community ; 3) a comprehensive response to people s expectations and

needs, spanning the range of risks and illness; 4) promotion of healthier

lifestyle and migration of the health effects of social and environment hazards;

5) teams of health workers facilitating access to and appropriate use of

technology and medicines 6) institutionalized participation of civil society in policy dialogue and accountability mechanism; 7) pluralistic health system

operating in a globalized context; 8) guiding the growth of resources for health

towards universal coverage; 9) global solidality and joint learning; 10) primary

care as coordinator of a comprehensive response at all level; 11) PHC is not

cheap : it requires considerable investment, but it provides better value for

money than its alternatives (WHO. 2008)


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Thailand has a long history of primary health care (PHC). Primary Care has been

the key agenda for the recent Thai Health Care Reform. It was expect to

improve health of the population as well as to reduce health care cost.

(Pongpirul. 2008) TheNational PHC program was implemented nation-wide as

part of the Fourth National Health Development Plan (19771981) focusing on the

training management of grass-root PHC workers consisting of village health

communicators and village health volunteers. Since then PHC has evolved through

many innovativehealth activities: community organization, community self-financing

and management, the restructuring of the health system and multisectoral co-

ordination. (Andy Haines, Richard Horton and Zulfiqar Bhutta . 2007)

Current Health Care System in Thailand

The Thai health care system has undergone several reforms. In 1952, the area of

responsibility for the Ministry of Public Health was extended by adding the health-

care infrastructure and the development of human resources to provide health-care

services throughout the country. Various health policies were on the agenda of

national development plans, beginning with the First National Economic

Development Plan of 1961, and notably the successive National Economic and Social

Development Plans, since 1971, and their implementation. Health care is organized

and provided by the public and private sectors. The Ministry of Public Health

(MOPH) is the principal agency responsible for promoting, supporting, controlling,

and coordinating all health service activities. In addition, there are several other

agencies playing significant roles in medical and health development programs such

as the Ministry of Education, the Ministry of Interior, the Ministry of Defense, the

Bangkok Metropolitan Administration, state enterprises, and private-sector

enterprises. They operate health facilities including hospitals that provide primary,

secondary and tertiary medical services. During the last ten years, private hospitalsand clinics have been expanding rapidly in Bangkok and provincial cities. In 2003,

public-sector and private-sector health care facilities were categorized as follows:

In Bangkok, there were five medical-school hospitals, 29 general hospitals, 19

specialized hospitals and institutions, as well as 61 health centres and 82 health centre

branches. Throughout the country, beyond the city of Bangkok, public health facilities

included four regional-level medical-school hospitals, 25 regional-level hospitals, 40

specialized hospitals, 70 provincial-level general hospitals under the auspices of theMOPH, and 56 hospitals operated by the Ministry of Defense. These medical facilities


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were underpinned by 725 community hospitals at district level as well as 214

municipal health centres. At the sub-district (tambon) level, there were 9,765 health

centres as well as 66,223 rural and 2,470 urban primary health care centres. The last

two types of health facilities were managed by village health volunteers (close to

800,000 in 2004) under the supervision of health workers of sub-district health

centres. The private sector has also played a significant role in providing curative

care. In 2003, there were one private medical school in Bangkok, 346 private

hospitals (100 in Bangkok and 246 in other provinces), 11,853 clinics, 12,878

drugstores (1st and 2nd class) and 2,106 traditional medicine drugstores. In 2002, the

overall ratio of hospital beds to population was 1:206 in Bangkok, compared to the

ratio of 1:462 in all other provinces. The ratio of physician to population was 1:3,295

for the whole country, ranging from 1:767 for Bangkok and 1:7,251 for the

Northeastern Region.

Health Care Financing

Thailands health care system reflects the entrepreneurial market-driven nature of its

economy. It is a cross-over system of public-sector and private-sector interfacing in

both health-care financing and provision. Overall, the resources allocated to health

care have markedly increased recently. The total health expenditure has increased

gradually, at a faster rate than the growth of the gross domestic product (GDP). In

2003, the total health expenditure equaled 3.3% of the GDP, of which a higher

proportion (61.6%) was covered By the public sector than by the private sector

(38.4%).(Suvaj Siasiriwattana, 2006)

Primary healthcare elements

The following list of key elements1 of primary health care were drafted to follow

the principle statements and to provide a checklist of the critical features a

primary health care organization should have in order to meet the vision andprinciples.

1. Community involvement uses appropriate resources for meaningful

community involvement and develops the capacity of the community to

address health issues

2. Accessible services are provided as close to the client as possible and

community members can access the service and/or provider of choice easily

3. Available primary health care services are available based on therequirements of the community being served


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4. Comprehensive - a full range of services is provided with an emphasis on

disease/injury prevention and health promotion. Clients are involved in

discussion of broader health needs

5. Integrated and coordinated - involves a wide range of multidisciplinary service

providers, use of community staff, and coordinated services to avoid

duplication and make the best use of available resources

6. Approach to delivery considers the broader determinants of health Appropriate

technologies cooperates to develop and use the most appropriate tools,

techniques and information technology.

7. Quality helps local providers to deliver a high quality of service by

rewarding continuous quality improvement and using evaluation research

findings to develop the most effective services and linkages between service

providers

8. Accountable addresses the needs of individual communities, adheres to

provincial government policy, and contributes to ongoing improvement of

services; the system answers the questions of accountability of whom, for

what, and to whom

9. Affordable provides services within the limits of the communitys resources

10. Ongoing evaluation uses information and ongoing evaluation to improve

quality, delivery and outcomes (Wendy Rogers, 2003)

Challenges for the future of primary health care in Thailand

National governments and the international community are renewing their efforts to

expand access to PHC and they have committed a lot of money for this purpose. But

there have been many major changes in these last three decades that pose big

challenges for the future of PHC. The drafters of the Alma Ata Declaration drew

largely on the experiences of those post-revolutionary and post-colonial regimes,which were rapidly overcoming a lack of health facilities, health workers and drugs.

Whilst some remote areas still lack health services many settings have both trained

and untrained people, providing health care and selling drugs. The boundary between

public and private sectors is blurred and government health workers frequently ask for

informal payments or see patients privately. Many of these activities occur outside an

organised, regulated framework of health care provision. Potential users are much

more likely to live near a health facility or some kind of provider than 30 years ago,


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but now they face major challenges in paying for care and finding competent

providers and effective and appropriate drugs.

PHC was designed to deal with prevention/health promotion and with infectious

diseases associated with poverty, poor sanitation and certain insect vectors. Although

these illnesses persist, there is growing pressure on health systems to address other

problems. One dramatic change has been the transformation of HIV infection into a

chronic and progressive disease for which people can claim entitlement to treatment.

People are also affected by other chronic conditions, associated with ageing and

lifestyle changes. This raises difficult questions about which treatments are

appropriate, who should pay for them and how health systems should be organised to

help people manage long-term conditions. Concern is growing about the potential

threat of epidemics of new diseases or organisms resistant to the available drugs.

Recent examples are SARS, multi-drug resistant tuberculosis and a possible influenza

pandemic. Government responses rely heavily on convincing people to report

suspicious outbreaks and cooperate with public health measures they may perceive to

be against their short-term interest. This requires high levels of trust between the

population and their health system.

More actors are involved in health systems than thirty years ago, including a variety

of private providers of health-related goods and services, national and international

NGOs, citizen advocacy groups and political parties (where competitive electoral

politics have been introduced). Governments are seeking new ways to influence

health systems with their powers to allocate money, enact and enforce laws and

publish information. This sometimes involves new types of partnership for service

delivery and regulation. Finally, there have been dramatic developments of new

technologies for diagnosis and treatment of disease, which influence the design of

health systems. In addition, the rapid changes in information and communicationtechnologies are having a big impact. Providers and users of health services

increasingly have access to the mass media, mobile telephones and the internet. They

carry health information produced by governments, professions, citizen advocacy

groups and private companies. In contrast to 30 years ago, when health professionals

were the major source of expert knowledge, people have a variety of sources from

which to find information. The anniversary of the Alma Ata Declaration provides a

good opportunity to reaffirm national and international commitments to expand accessto PHC. But, it is important to understand the changed context when formulating


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strategies for achieving this. Many innovations have emerged that involve quite

different roles for governments, markets, civil society and individuals than the

drafters of the Alma Ata Declaration envisaged. We need to find ways to involve all

actors in an intensive process of innovation and learning if the latest statements of

good intentions are to be translated into major improvements for poor people.

(sanguan nitayarumphong. 2008)

Institute of Medicine (2008) suggested that at the macro-level there is a

need understand better how sustainable primary health care-oriented health

system may be developed and how primary health care, through intersectoral

action for health may contribute to address the social determinants of health.

Primary care research should address the assessment of improvements that the

Quality Chasm report is calling for in 6 dimensions of health care

performance: safety, effectiveness, patient-centrednesscenteredness, timeliness,

efficiency and equity. At the meso-level, it need research about models that

bridge the gap between hospital care, primary health care and public health ,

that investigate how professional, civil society organizations and population can

interact to strengthen primary care, and what are the best ways of organizing

the micro systems that deliver care as well as how does management in

primary care. This research aim to evaluate primary care management for

accessibility and equity in Thailand to look at the primary care as a complex

adaptive system.

Research framework

From the in formation gathered in the literature review and the Kalasin

Provincial Hall(2009) a framework was established to form the basis of the

questions for inclusion within the case study as shown below in Table 1


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Table 1 Research framework

Framework questions Literature examples

What defines the primary care carried out in a

Management prospective

Why has management need to use in primary

care delivery

Who and How has corporated improving

health in primary care management

What are the benefits and problems of

management in primary care

Nation

Thai

Equity

Accessibility ect.

Hospital level

Community level

Benefits

Problems

Method

Design

This qualitative study used the policy ethnography approach to investigate the perspectives of actors within a health care system as primary care management

person. Subtle realism points to the imperfect attempts of researcher to reach

practical understandings of primary care management phenomena, and adopting

this approach is the best way to knows of responding to the charge of nave

realism. Guided interviews and participation observation were used with the

director of community hospital, family medical doctor and health care team

management. Participation observation occurred during the interviews and in

neighborhood Home health care team during a typical Home care

management . The study was approved by both the and

Sample

A purposive sample of the director of community hospital, family medical

doctor were choosed. .

Data collection

Participation observation

Data analysis


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Data collection and analysis occur concurrently and are based on constant

comparative analysis that involves comparing primary care service incidents,

participants or segments of data within community staffs and between hospital

staffs in order to generate categories, concepts relevant to primary care

management area. The interview data and field memos were subjected to

thematic analysis independently by the authors and the result were then

compared. Joint analysis continued until consensus between the researchers was

reached. The data from the participant observation were used to provide

context, validation, and refinement.

Result

Themes Shifting of Tasks, Management for remote area to accessibility,

Shortage of staff management, Stakeholder management, Formulate plans,

Flexible and appropriate technologies were emerged.

Shifting of Tasks

the delivery of primary care for disability people is via physical extremely

services, community nurses services, and community volunteers. It works best

where there is a multidisciplinary team approach to care

Apply home care team ; no nutritionist no pharmacist ; no physician

sometimes ; was done to fit of north-east Thailand context where shortage

staffs unlike central area that health providers and medical technologies are

highly concentrated in big cities rather than rural areas

Management for Remote area to Accessibility

Physicians moved outside the hospital setting and there was a shift from

specialist-in-hospital-care to practitioner-in-community-family-care

By decision making of , the most far community health center was set up

to be community medical unit where client easy to use service

home care clients for all disability people enhanced them to manage care

Insufficient of finance to go hospital

By nature of disability in remote area, they have health insurance by policy

but do not follow up at health service setting because of economic burden Shortage of staff management


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different figure western Home Health Care Team, Contracting Unit of

Primary care integrate with stakeholder as community care were set up

very physician shortage, physical extremely as main group and other hospital

staffs were trained to practice Home Health Care under family medicine

concept.

Linkages between home health care hospital team and public health team as

well as stakeholder in community to co-service providers helps local providers to

deliver a high quality of service by rewarding continuous quality improvement and

using knowledge management ; KM (pre-post conference before and after home

care)to develop the most effective services

Stakeholder management

Involves a wide range of multidisciplinary service providers, use of community staff,

and coordinated services to avoid duplication and make the best use of available

resources

New organization, more progressive in embracing the challenges of servicing

primary care director of district hospital think broadly and identify relevant

stakeholder, community health volunteers and local government are main group

that have a stake in the decisions and actions of new organization call

disability association

Formulate plans

primary care service under provincial strategic plan has been controlling by

director of community hospital but to response local health need hospital health

team and community health team with stakeholder do primary care practice

depend on bottom up new formulate plan

Balancing local health need, Insufficient budget and Health indicators under

policy was done by director of community hospitalFlexible and appropriate technologies

The provision of primary care service for disability clients focused on health

facilities at the community level because this level is cost effective and

appropriate for the majority of the client who are facing minor disability

to save cost, home health care team set up equipment for rehabilitation and

palliation disability person by using apply low cost tools based on

understanding the socio-cultural backgrounds of their families and communityhealth volunteers in which Contracting Unit of Primary care are provided


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Literature review

In the UK definition, the delivery of primary care is via GP services, PCT medical

services, and alternative provider (e.g. private health company) medical services, as

well as NHS walk-in centers and other community services outside the hospital

service. It works best where there is a multidisciplinary team approach to care. In

Thailand, until the 1990s, primary health care consist of health centers that

started out as antennas of hospital The focus of the care was on technical

adequacy and clinical decisions, not on patient centeredness and quality of

human relations. Family medicine appeared as a new specialty in Thailand in

1998. The first health center to feature the family practice model was

established in 1991. It was intended as a step in changing the health care

system. (Pongsupap, P. 2007)

Today, family medicine, embedded in primary health care, health policy

explicitly links universal coverage, frrst-line health health service strengthening

and family medicine development. The Ministry of Public Health sees in

family practice the potential to change health care delivery in Thailand. Base

on hope that family practice can bring a new style of relating to patients, with

a new understanding process of health and illness, and a new emphasis on

illness prevention and coordination of care. By family practice, it will lead to

improved access to care, increased emphasis on prevention at the community

level and reduced cost of care. Recent statistics indicate that health centers

and community hospitals are the most popular source of health care although

shortage of human resource, budget, material. Four in five patients used the

out-patient health services at the government health facilities. (Churnrurtai,

K.et.al. 2009 : 10)

In spite of the current volatile political situation of Thailand, several factorsare essential for an alternative community care and have emerged. Community

health fund was decentralization out come of power and budget to local

communities (Kamnuansilpa P, 2003)

*

PHC has been successful in Thailand because of community involvement in health,

collaboration between government and non-governmentorganizations, the integration

of the PHC programme, the decentralization

of planning and management,intersectors collaboration at operational levels, resource allocation in favour of PHC,


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the managementand continuous supervision of the PHC programme from the national

down to the district level, and the horizontal training of villagers to villagers (Andy

Haines, Richard Horton and Zulfiqar Bhutta . 2007)

*

In the Thai primary health care system, the problem of over-use of medicine,

especially expensive antibiotic drug and new medical technologies is not only found

with the Civil Servant Medical Benefit Scheme, but it is also evident in health service

provision of private for profit health care providers. The limited capacity of the

government to regulate private for-profit providers facilitates inefficient use of public

and private health resources. The 10th National Development Plan of Thailand

makes the policy recommendations for improving efficiency in public health resource

use.(Andy Haines, Richard Horton and Zulfiqar Bhutta . 2007)

*

The primary health care management plays a pivotal role in health achievements and

efficiency improvements of the Thai health care system. Contracting the district-level

health providers to provide primary care and close-to-client services for Universal

Coverage beneficiaries is an important means of ensuring efficient and rational use of

services while ensuring proper referral systems. When the majority of Universal

Coverage members who are poor and residing in rural areas can actually exercise their

rights in using a comprehensive range of services provided by the primary health care

network, it results in equity in health service use and efficient use of public resources.

Using fee-for-service reimbursement to pay health care providers of the Civil Servant

Medical Benefit Scheme sends a strong signal to healthcare providers who are

supreme commanders of health resources to provide more diagnostics, medicines, and

probably unnecessary medical treatment. Empirical evidence consistently confirms

Civil Servant Medical Benefit Scheme beneficiaries receive more branded and moreexpensive medicines than beneficiaries in other public health insurance schemes.

Moreover, evidence shows that Civil Servant Medical Benefit Scheme beneficiaries

have higher hospital admission and greater cesarean section rate than other schemes.

It is found that even though Civil Servant Medical Benefit Scheme finances five times

higher per capita, clinical outcome is more or less similar to beneficiaries of the

Universal Coverage scheme. In the Thai primary health care system, the problem of

over-use of medicine, especially expensive antibiotic drug and new medicaltechnologies is not only found with the Civil Servant Medical Benefit Scheme, but it


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is also evident in health service provision of private for profit health care providers.

The limited capacity of the government to regulate private for-profit providers

facilitates inefficient use of public and private health resources. The 10th National

Development Plan of Thailand makes the policy recommendations for improving

efficiency in public health resource use.(Andy Haines, Richard Horton and Zulfiqar

Bhutta . 2007)

achieving intersectoral collaboration and local planning and management of primary

health care services requires an explicit commitment to equity in health care and

strategic planning across all levels of government as well as across traditional

departmental barriers. Possible organisational changes to strengthen primary health

care in Australia include the creation of formal structures to support community and

consumer involvement, the organisation of health care services to decrease

competition between providers, and the creation of primary health care teams as

functional units. (Prince Mahidol Award Conference, 2008)

The first stakeholder management capability calls on the organization to analyze who

the stakeholders are and what they want. Recall that Blair and buesseler (1988:9)

define Stakeholders as any individual, groups, or organizations that have a stake in

the decisions and actions of an organization, and who attempt to influence these

decisions and actions.

Blums (1974:1983) health and well-being paradigms show health resulting from

four forces: environment, genetics, lifestyles, and medical care. A hospital trying to

improve health must now consider new and different types off stakeholders working

with the environment, lifestyles, and genetic composition of the population. The

hospital must analyze who all these stakeholders are, what their stakes are, and how

salient they are. How can the hospital do this? By using Blair and Buesselers (1998)

conceptualization of stakeholders with Blums (1974:1983) model of health, ahospital con think broadly and identify relevant stakelolders.

/Recall that stakeholder salience is a function of perceived legitimacy, power, and

urgency so that, if hospital leaders perceive a stakeholder as having little legitimacy,

power or urgency, then they may view the stakelholder with little salience, /The

characteristics of hospital executives, such as their values and environmental scanning

behavior, will affect their perceptions and thus their perceived salience of

stakeholders (Mitchell, Agle, and Wood, 1997) and so Daake and Anthony (1998)recommend formal assessment of stakeholder power.


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Proencas (1998) community sensing approach advises that front-line employees who

are close to actual patients, residents, and the community, can often related better than

executives to cultures, backgrounds, and traits of non-traditional local stakeholders.

This can help leaders to better discern the salience of unfamiliar community health

stakeholders such as grass roots support groups for unwed teen mothers. Such a

group could be more salient than first thought because it has influence over the people

whom the hospital wants to reach. Some stakeholders that have been viewed as low

salience for acute medical care (e.g., schools) would be more salient for community

health and might not allow a hospitals ecucators to go into classrooms if the hospital

does not treat the schools as salient CH stakeholders.

To start, Freeman (1984) proposes that organizations with high stakeholder capability

will have effective communication processes with stakeholders, will use marketing

techniques and research to segment stakeholders into distinct groups to better

understand them, will support boundary spanners which help bring external

stakeholders into the organizations considerations, will allocate resources for salient

stakeholders, and will have a culture that is proactive toward stakeholders. These are

basic organizational functions of marketing, management, decision-making,

consensus building, interorganizational relationships, internal operations, and so forth.

The hospital that seeks to improve community health is likely to formulate plans, then

implement implement programs and services, and finally evaluate those activities.

Processes by which plans are foumulated-such as strategic planning, goal setting, and

program planning-should include CH stakeholders. A hospitals planning processes

probably do consider the traditional stakeholders (e.g., physicians, payers); it should

now include what the organization will do in order to consider community health

stakeholders and their interests. Importantly, as stated by a Hartford (CN) Hospital

executive and a local citizen, a hospital must plan with local people rather thanplanner them so that a hospitals CH work is not viewed skeptically as a marketing

ploy (Community Health Intersection, 2001).

The stakeholder management process should be modified to stakeholder

collaboration. The same should be done for implementation of programs and services

such as having processes by which to involve community stakeholders and their

stakes that would shape the actual services, their distribution, and so forth. In

economically depressed Camden, NJ, Our Lady of Loureds Hospital collaborated withstakeholders and the diverse under-educated citizens to improve health by involving


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them in planning which CH services to deliver and how to deliver them (Weech-

Maldonado and Merrill, 2000).

The organizational processed by which a hospital has considered its traditional

stakeholders and interests would be a starting point for developing processes also to

consider CH stakeholders and their interests. Acquiring qualitative and quantitative

data, using oral and written input, working with stakeholders on community task

forces and committees, and listening, should all help. So too would a culture that sees

these stakeholders as essential, respects and involves them as valued partners for

community health. The Harford Hospital cited earler realized it had to change its

culture to go from its organizational focus to a neighborhood focus (Community

Health Intersection, 2001).

To really consider CH stakeholders interests, hospitals should use organizational

processes to facilitate communicating, working in groups, making decisions, using

power, allocating rewards, accepting behaviors, styles, and normas of all stakeholders

rather than just those of the hospital and medical care stakeholders. Thus, a hospital

may adapt existing processes to better seek and utilize more qualitative data form

grassroots stories (lbid.). This will take more time and slow the process but will help

overcome the low trust some salient stakeholders feel toward hospitals. These

organizational processes will help to collectively create consensus on mission, goals,

clientele, and services for CH improvement and will decrease stakeholder conflict

while increasing stakeholder support (Mitchell and Shortell, 2000).

Analysis

1. The original ideal of primary health care has become known as comprehensive

PHC. This is in contrast to selective primary health care which is more

medically focused with a reliance upon medical interventions and doctors for

provision of and control over health services.2. Close to 800,000 in 2004) under the supervision of health workers of sub-

district health centres. The private sector has also played a significant role in

providing curative care. In 2003, there were one private medical school in

Bangkok, 346 private hospitals (100 in Bangkok and 246 in other provinces),

11,853 clinics, 12,878 drugstores (1st and 2nd class) and 2,106 traditional

medicine drugstores.

3. The Thai primary health care system, the problem of over-use of medicine,especially expensive antibiotic drug and new medical technologies is not only


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found with the Civil Servant Medical Benefit Scheme, but it is also evident in

health service provision of private for profit health care providers. The limited

capacity of the government to regulate private for-profit providers facilitates

inefficient use of public and private health resources.

4. The boundary between public and private sectors is blurred and government

health workers frequently ask for informal payments or see patients privately.

Many of these activities occur outside an organised, regulated framework of

health care provision.

5. The organizational processed by which a hospital has considered its traditional

stakeholders and interests would be a starting point for developing processes

also to consider CH stakeholders and their interests.

Conclusion

This study ha explained how the stakeholder management approaches that hospitals

often use in the medical care domain can be modified for the community health

domain. The stakeholder management approach has value such as its emphasis on

clearly identifying what the interests of stakeholders are. But community health

should not be managed by hospitals as another line of business but requires a

different way of doing business and a different approach to stakeholders as

explained earlier. Modification of stakeholder management into stakeholders

collaboration is needed for hospitals and other health care organizations to work

effectively in the community health domain with other stakeholders. Research is

needed to study the extent to which executive collaborate with these stakeholders,

especially stakeholders who are not viewed with great salience yet are important in

community health. Future research should also be performed to evaluate the

outcomes of stakeholder collaboration. Important outcome would include stakeholder

commitment and stakeholder satisfaction. Actual community health status shouldalso be studied as an outcome although it might not be easy to measure stakeholder

collaboration as and explanatory variable. These and other advances in CH research

methods and findings will be important to guide future community health efforts by

hospitals and other health care organizations.

References


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