Abstract
The expansion of benefit package covering patients with chronic kidney diseases (CKD) since 2007
resulted in increased access to care and minimized disparity of access to renal replacement therapy (RRT)
across public health insurance schemes. Nonetheless, growing concerns of financial burden to the public
health programs ensued. This poses a challenge for policy makers in terms of inventing preventive or
mitigation measures for CKD.
Recently (2016) Ministry of Public Health promulgated upscaling of Klong Klung Model (KKM) as a
prototype for such measures after the findings of effectiveness of the model. Given complexity of the
health care systems, the upscaling might not be straightforward. There is still need for clarification of
what and how building blocks of the model were developed under specific circumstance of Klong Klung
District in Khampang Phet Province, a lower northern province.
Using comparative cross-case analysis, this report gathered data from focus-group discussions,
direct observation and documentary review relevant to development of CKD care models in Klong Klung
District and its comparator in Kong Rha District, Phattalung Province in the South. It was found that KKM, with a focus on prevention and mitigation of CKD, was developed based on
randomized controlled trial to test a standardized protocol jointly determined by Klong Klung Hospital
and the Kidney Disease Institute of Thailand. To the contrary, the care model at Kong Rha District covered
a spectrum of care ranging from prevention to RRT. Kong Rha adopted a trial and error approach in
applying existing knowledge acquired by the local team in close collaboration with a multidisciplinary
team of Phattalung Hospital (the referral center of the province) led by an internist with training in kidney
dialysis. Given such differences, both models shared a common feature of leadership: sustained leading
role of a senior nurse head for Kong Rha and of the hospital director for Klong Klung. Both leaders was
found to perform in a remarkably autonomous status based on patient-centric principle. Under this leadership
style, multidisciplinary team members interacted on an equal ground rendering ongoing learning
and adaptation.
In term of generating knowledge on the effectiveness, KKM was found to be much more systematic
in data management and analysis reflecting a significant technical contribution from academic experts of
the institute. In contrast, Kong Rha faced with limited capacity in terms of manpower and technical
expertise in making use of the data. This resulted as expected in more ambiguous findings to prove the
effectiveness of the model. In effect, the limitations of Kong Rha reflect widespread phenomenon of sluggish
development of the capacity to make use of existing health information systems in the country despite
substantial investment in the hardware.
Finally, we did not find “vulnerable population” as a common language among the study areas. This
does not mean that the health professionals play down the importance of ensuring access to care of the
poor or the disadvantaged. To the opposite, they have made substantial attempts to do so. For instance,
community resources were mobilized to reconstruct a sufficient hygienic space for home-based peritoneal
dialysis in Kong Rha. Under KKM frequent home visits to all the patients especially the poor enabled
better understanding of limited food choices contributing to difficulty in sodium reduction. This led to
modification of dietary education to be more suitable to the poor patients’ situation.
