primary care policy & systems 2014.12.17
TRANSCRIPT
Primary Care: Policies and Systems
Asst. Prof. Borwornsom Leerapan, MD PhD
The 15th ACMET: The Holistic Medical Education in 21st Century Phayao University, Phayao, Thailand
December 17, 2014
Pix source: ra.mahidol.ac.th
Presentation Outline
Pix source: online.wsj.com
What we already known about PHC
in Thailand?
What we already know about
education of PHC in Thailand?
What policies and systems are needed
for the future of PHC in Thailand?
Myths and Facts About Primary Healthcare in Thailand
Pix source: online.wsj.com
“Primary” & “General”
Primary General Primary School
Primary Data
Primary Election
Primary Tumor
Primary Stage [of projects, etc]
Director-General
Attorney-General
Surgeon-General
General Hospital
General [Prayuth Chan-ocha]
Ø How do you feel about the “Primaries” and “Generals” listed above”?
Ø How’s about “Primary Healthcare” and “General Practitioner”?
What Do You Mean by “Primary Care”?
1. Basic medical services
2. Self-care, and health for all
3. First-contact, continuous, coordinated, and comprehensive care
4. Health promotion practices, and actions on social determinants of health
(=What a layman usually thinks of primary care)
(The Declaration of Alma-Ata 1978)!
(Starfield 1992, 1998)
(Ottawa Charter 1986, The 66th World Health Assembly 2013)
Source: http://www.who.int/publications/almaata_declaration_en.pdf
Source: www.rdic.cdd.go.th/E-book/book_city.pdf
Source: http://www.who.int/social_determinants/B_132_14-en.pdf?ua=1
Source: Stange KC. Barbara Starfield: Passage of the Pathfinder of Primary Care. The Annals of Family Medicine. 2011 July 1, 2011;9(4):292-6; Pix source: prac%ceimprovement.com.au;
Action on Social Determinants of Health
(การสร้างเสริมสุขภาพ).
Community-based Primary Healthcare
(การสาธารณสุขมูลฐาน).
Primary Care Medicine, Family Medicine
(เวชศาสตร์ปฐมภูมิ, เวชศาสตร์ครอบครัว).
Basic Medical Care (บริการการแพทย์ระดับพ้ืนฐาน).
• Health promotion practice at the population health level .
• “Health in All Policies”
• Self-care.• Community health worker • Community health volunteer • “Health for All”.
• First-contact care • Continuous care • Coordinated care • Comprehensive Care
• Health center (สอ./รพ.สต.).• OPD, physician office • Mobile medical units
What Do You Mean by “Primary Care”?
Community-based Primary Healthcare
Clinical Practices at Primary Care
Level
“The Doughnut Hole” of Primary Care
• Primary care services in developed countries
• Medical facilities in urban settings • Medical facilities in private-sector
(without public health functions)
• Primary care services in developing countries
• Medical facilities in rural settings • Medical facilities in public-sector
(with public health functions)
Ø What exactly policies & systems are we talking about?
Level of Healthcare Systems
[“Medical Care?”] [“Medical Services?”]
[“Health Care?”] [“Health Services?”]
[“Supra-tertiary care?”] [“Quaternary care?”]
Major Issues in Thai Healthcare Systems
• Thailand 1970s – Rural Health (“PHC") • Thailand 2010s – ??
“Transformative education creates change agents.”
“But change agents create what?”
Rural vs. Urban
18,972,330 (31.1%)
29,133,829 (44.2%)
41,944,111 (68.9%)
36,847,830 (55.8%)
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
100%
2543 2553
ประชากรในเขตเทศบาล ประชากรนอกเขตเทศบาล
Source: สำมะโนประชากรและเคหะ สำนักงานสถิติแห่งชาต,ิ accessed from http://service.nso.go.th/nso/nsopublish/service/servstat.html
Poor vs. Middle-class
Source: สำมะโนประชากรและเคหะ สำนักงานสถิติแห่งชาต,ิ accessed from http://service.nso.go.th/nso/nsopublish/service/servstat.html
Thai vs. Global Citizens
Source: http://news.bbc.co.uk
Urban Lifestyle?
Source: http://www.chaophya.com/index_th.php
Middle-class Lifestyle?
Source: http://www.facebook.com/www.jantrai
Educational System for Primary Healthcare in Thailand
Pix source: online.wsj.com
“System”
Source: Scheerens and Bosker 1997; Pix source: system humanrevod.wordpress.com
Simple Logic Model
“Health System”
Pix source: WHO’s framework for action. (2007)
“Health System”
Source: WHO (2012); de Savigny & Adam (2009)
• The WHO Six Building Blocks” of health (services) systems are derived from “systems thinking”.
Pix source: Don de Savigny and Taghreed Adam (2009).
Features of Current Medical Education & Primary Healthcare Systems
Focus Medicine Public Health
Setting Rural
Urban
Professional Perception
Generalist Specialist
Public Perception
Second-tier Doctors (“basic”)
Top-tier Doctors (“personal & exclusive”)
System Design
Moving Assembly Lines
Customized Services Systems
Community-based Primary Healthcare
Clinical Practices at Primary Care
Level
• To master clinical skills in primary care settings
• To be “clinical leaders” in patient care teams
• To mastery health promotion practices in community-based primary care settings
• To be “health promoters” • To be “healthcare managers”
(+/- public health functions)
Ø Primary healthcare systems
What and How Medical Students Should Be Taught Transformed?
Recommended Policies & Systems
Pix source: online.wsj.com
Delivery of PHC Services
Pix source: www.free-ed.net/free-ed/HealthCare/Physiology/default.asp
Structure & Organizations of primary care services • Patient Care Teams • PCUs/Clinics • Systems/Networks • Governance policies
Four Cardinal Functions of primary care services • First Contact/Access • Continuity • Coordination • Comprehensiveness
“Anatomy of Primary Care” “Physiology of Primary Care”
“If we have good PHC systems”
• PHC referrals to specialists have three functions: 1. Short-term consultation for diagnosis or
management 2. Referral for long-term management of specific
illnesses 3. Recurrent consultation for periodic management
Source: Starfield B, Shi L, Macink J. Contribution of Primary Care to Health Systems and Health. Milbank Q 2005;83(3):457–502.
“If we have good PHC systems”
Ø Using a systematic review approach and adjusting for socio-economic status, researchers can conclude that “the accessibility to PHC” is inversely associated with “the risk of hospitalization for ambulatory care sensitive conditions (ACSCs)”.
Source: Rosano A, Loha CA, Falvo R, van der Zee J, Ricciardi W, Guasticchi G, et al. The relationship between avoidable hospitalization and accessibility to primary care: a systematic review. The European Journal of Public Health. 2013 June 1, 2013;23(3):356-60.
First Contact/Access
Continuity Coordination Comprehensiveness
• Cost sharing • Distance to PC
practice • Distribution of
PC physicians • List size • Home visits in
PC • Electronic access
• Computerization of the practice
• Patient habits with first contact visits/referrals
• Endurance of patient–provider relationship
• PC practice management
• Collaboration among practitioners
• Referral system • Shared care
arrangements
• Premises, equipment
• Medical procedures
• Preventive, rehabilitative, educational activities
• Disease management
• Community links • Technical skills
Desirable PHC Functions
Source: WHO/Europe (2010)
Ø Selected proxy measures from WHO/Europe’s Primary Care Evaluation Tool (PCET)
Structure of Urban Health Services (City of Chanthaburi)
Pix source: สำนักงานวิจัยและพัฒนาระบบสุขภาพชุมชน (2555)!
Structure of Urban Health Services (City of Chanthaburi)
Pix source: Office of Community Based Health Care Research and Development (2012)
Telecare Clinic (Bangkok General Hospital)
Pix source: http://www.bangkokhospital.com/
Complexity in Healthcare Systems (UnitedHealth Group, US)
Pix source: Lewis G. Sandy (2010). AcademyHealth 2010 Annual Research Meeting June 29, 2010
Care Coordination Innovations (UnitedHealth Group, US)
Pix source: Lewis G. Sandy (2010). AcademyHealth 2010 Annual Research Meeting June 29, 2010
Traditional Work Flow in Clinics (Cambridge Health Alliance, US)
Pix source: Southcentral Foundation & Institute of Healthcare Improvement (2010)!
Redesign: Parallel Work Flow in Clinics (Cambridge Health Alliance, US)
Pix source: Southcentral Foundation & Institute of Healthcare Improvement (2010)!
Pre-visit Work in Geriatric Care
Pix source: Harvard Vanguard Medical Associates & Institute of Healthcare Improvement (2010)!
Care Coordination: EMR
Pix source: Bates et al. (2003). A Proposal for Electronic Medical Records in U.S. Primary Care
Supplies Demands
“What Bangkokians Want?”
Pix source: healthyfoodstar.com, en.wikipedia.org
Ø How do they “survive” the current PHC services in BKK?
Source: Macagba, R. L. (1985). Hospitals and Primary Health Care: An International Study from the International Hospital Federation. In M. Hardie (Ed.), World-wide survey on the Role of Hospitals in Primary Health Care. London: International Hospital Federation.
Ø “Chaordic Design Process”: 4Ps – Purpose
• Develop a Statement of Purpose
– Principle • Define a Set of Principles
– Participant • Identify All Participants
– Practice • Create a New Organizational Concept • Write a Constitution • Foster Innovative Practices
Design of PHC Services
Source: www.chaordic.org
Design of Urban PHC Services
Purpose
Principle
Participant
Practice
• What is the primary focus at the moment? (increasing utilization, improving access, quality, or efficiency?)
• Desirable primary care from whose perspective?
• Individual health vs. Population health?
• Integration vs. Competition?
• Incremental change vs. Radical change?
• UC, SSS, CSMBS?
• Public, private sectors?
• Hospitals, clinics, pharmacies?
• Team leaders: GP, FP, NP, Internist, Pediatrician?
• Team members: NP, P&P specialists, administrators?
• Proposing 3 Policy options:
1) Incremental approach, focus on UC/the underserved
2) Competition approach, focus on individual health
3) Integration approach, focus on population health
Source: Leerapan (2012). Primary Care Services in Urban Settings: Lessons from International Experiences.
Building Blocks of PHC Systems: Research Needed
Pix source: WHO’s framework for action. (2007)
New financing? • OOP? • Co-payment? • Membership fee?
New informatics? • Mobile app? • Personal health
data portal? • Disadvantaged
population’s data
New organizational model? • Team based providers? • Linkage with hospital care?
New kinds of providers? • MDs vs. non-MDs • Professional Manager? • Career path? • Linkage with academia?
New kinds of products? • Life-style modifications? • Preventive medicine? • Outlets of hospital ‘s
labs & pharmacy?
New governance? • Focus on personal services
vs. on public health services • Market vs. Central-planning
• Clinical outcomes of population-health-integrated PCUs vs. individual-health-oriented PCUs
• Satisfaction of patients receiving care from PCUs located in urban community vs. from PCUs attached to hospitals
• Satisfaction of primary care providers working in differently organized PCUs
• Comparison of comprehensiveness of care delivered in differently organized PCUs
• Financial risks of differently organized PCUs • Appropriateness of office hours of urban PCUs • Effectiveness of P&P programs in urban communities
Considerations for Further Study
Source: Leerapan (2012). Primary Care Services in Urban Settings: Lessons from International Experiences.
New Health Research Mapping?
Source: Hoffman et al. (2012).
New Health Research Mapping?
Source: Hoffman et al. (2012).
Different kinds of knowledge are needed
Source: alumni.harvard.edu (2010).
Food-for-Thought
Pix source: online.wsj.com
“If I had asked people what they wanted, they would have said faster horses.”
--Henry Ford