Abstract
Health care reform in Thailand is still in the process of development and planning. This study emphasized primary health care in Amphur Bangsai, Phra Nakhon Si Ayuthaya. The participatory action research was utilized and aims to analyze and synthesize the primary health care system in Amphur Bangsai, Phra Nakhon Si Ayuthaya including planning, organizing, staffing, directing, controlling, tools, and what should be the minimum health care service package for people in all age groups. Since the participatory action research was utilized; some traditional research methods were still needed such as documentary review, in-depth interviews, focus group interviews, brain storming, and reflection. The quantitative and qualitative analyses were included within this study as well. The Bangsai’s situation analysis was done during January 2002 until December 2002. The action plan was developed and some critical points of primary health care systems including instruction for action, and was implemented during January 2003 until March 2003.The results were as followas:Since health insurance policy for all Thais and the “All For Health and Health For All” policy were utilized, Amphur Bangsai, Phra Nakhon Si Ayuthaya built up the transitional primary health care system by organizing and registering the previous structures into two primary care units (PCU). PCU 1 includes three northern primary health care centers, and PCU 2 includes three southern primary health care centers. Bangsai Hospital is the only public hospital (10 bed-admissions) in this area that functions as a contraction unit for primary care (CUP).The study has shown that staffing in Bangsai health care organization still has some positions available especially in the six primary health care centers as stated. As a result, in both quality and quantity of health care service for these people in this area remains unsatisfactory.Based on the long-term effects of not having enough quantity and qualified workers in each position, causes the services to deteriorate. Bangsai Hospital (CUP) designed to provide mobile clinics consisting of doctors, nurses, pharmacists from the hospital and the workers from the health care centers. At the beginning, there was a need to provide services that would emphasize a cure for chronic illnesses. The health care center workers need to come together with their customer service ability, including teamwork as a whole. Whether they are a secretary, health care worker, nurse, or doctor in the clinic, they need to learn to perform some common procedures to take care of the people. Even though they may not be a qualified doctor or nurse, they need to be willing to work as a team and get the job done. All workers in the primary health care unit need to be able to get suggestions from other colleagues if their people are sick. Since the mobile units have been constructed, each care worker in the PCU clinics has improved their ability and has become more efficient in terms of investigation, diagnosis, and treatments. In this study, we found that most workers lack health promotion and prevention foundation in service quality. For example, health care workers would provide the person and family preventive service (such as home visit as their schedule posted) when they had enough time, which never was the case. As a result, the equity and continuous service was not achieved. We found that in some severe illnesses, there was a need to refer to another hospital but the referral system was not appropriate. In most cases, it did not serve the quality of care. In terms of community participation, most people in Amphur Bangsai participated to create good health practices such as seeking good nutrition habits, self-care, and building a good environment. In addition, alternative medicine was also being used in Bangsai, which has proven not to be risky in medical science point of view, and in some cases, it saved money and improved the quality of health. However, some villages still have little awareness to solve their own health problems. The community institute in Amphur Bangsai has a lack of concern in health care if we compare to other communities due to the budget being arranged for visible stuff instead of health promotion and prevention. In terms of directing, the executive team in Amphur Bangsai had the most experience, since they had worked and solved many community problems in the past. Some good strategies have been used which emphasized making a serious situation into a positive learning atmosphere. Some things were ignored from the executive team if they felt they could not change the situation at this time. The Bangsai’s workers preferred not to point fingers at each other, instead wanting us to move on in a positive attitude. This attitude made Amphur Bangsai progressed in a positive way by having good teamwork with good intention to develop Bangsai community. In terms of using tools in primary health care system in Amphur Bangsai, the Komart’s 7-tool was modified based on the concepts of anthropology being used. The workers stated that the tool was effective to study the community. The tool also helped to understand the people at Amphur Bangsai. They continue to use this tool to work with the community.Within the short term of this study, the minimum health care service package for people in all age groups resulted in showing most people lack the knowledge to know what they need for health care services. They trust health care workers as their representative to direct their health care. However, the minimum health care service package for people in all age groups including promotion, prevention, curing and rehabilitation still need to be researched in each health care problem, especially dealing with chronic illnesses such as diabetes or hypertension. In Bangsai’s view, most people in Amphur Bangsai were not satisfied in the transitional primary health care system because of the following reasons: Not enough health care workers in both quantity and quality.No trust from the people since the health care center has no technology in both technical service and instruments.No effective referral system for severe cases.Since the Bangsai’ situation analysis has been completed, the solution of the action plan was, “We want to develop the referral system to the one which is effective so we can earn trust and credibility from the people in Amphur Bangsai.” The action plan had been done during January 2003 to March 2003. The team decided to increase the potential of writing the health project to develop the community in Amphur Bangsai. Therefore, those health care workers can learn to write the project to develop their community. Two research proposals were as follows:1. Hypertension and Diabetes screening and health education in people with the age 40 or higher in Amphur Bangsai.2. Health promotion of exercise related to need of the people in Amphur Bangsai.After the implementation of the referral system in Amphur Bangsai, all objectives have been met in both quality and quantity. We received instruction for the referral system so that they could refer patients between the health care centers in Amphur Bangsai, Phra Nakhon Si Ayuthaya with more effective and high quality. During the implementation, we met the most important challenge, which was to increase the potential of the health care workers in Amphur Bangsai. All health care workers in the projects said that their ability improved in terms of working as a team, learning how to turn problems into challenges. Every worker had a chance to take turns in the leadership role within each team. We all learned how to complete the process of monitoring and evaluating with positive thoughts. We learned how to utilize resources in the most effective way. We all agree that it is useful for further development of primary health care reform research to meet the health community and governments goal “All For Health and Health For All.” There are some suggestions in terms of plan and policy to make it better next time and they are as follows: 1. Continuing development of health care workers in terms of role and functional fit in their positions with the highest potential. Utilize especially in terms of transitional primary care unit system. We need to make job descriptions for each position.2. Retrospective study of man-power and job from both ministries (Publichealth Ministry and Interior Ministry, and “All For Health and Health For All” policy), man- power is all right for all requirements. Workload needs to be done for the PCU.Encourage health care workers to further their studies by supporting community’s scholarships and having them utilize their existing potential. Sign contract in joint programs with academic institutes such as Ramathibodi School of Nursing to produce graduate nursing students to work in the community. For the open positions, they need to recruit people for the position that are vacant such as a dentist. Executive team should continue strategies to encourage health care workers to have unconditional love for their community and be proud to work with their community to make them meet the over all goal “All For Health and Health For All”Due to earning very little money working with the government, we should support health care workers whenever we can by rewards or presents to create more happiness.Planning and management should be continuous such as workload or budgets.Personnel training in specific courses have to be appropriate in timing frequency, so that they would be able to utilize what they have learned in their community. Emphasize work quality more than quantity including service and educatingpeople in the community.Coordinating planning and development between Ministry of public healthand Ministry of the interior in terms of underlying what kind of jobs need to be done by health care workers in the community.In terms of development in researchers, we discovered and applied improved primary health care mechanisms and strategies into Bangsai Primary health care system research. We mobilized actions and initiated collaboration to continue, articulate and promote new health care teams to promote a future vision for all in Bangsai community. We had a chance to take a positive role in policy development. Finally, we maintain that the researchers’ team and Bangsai have developed a healthy relationship with strong communication that leads to future projects working together.
