Abstract
Congestion in large public hospitals resulting in long waiting times to receive services is a chronic problem in Thai health system. This affects the quality of service and patient satisfaction. In 2017, the Ministry of Public Health (MoPH) announced a policy to reduce congestion in large hospitals by using 3 strategies, namely, reducing people's illness, increasing service efficiency, and strengthening capacities of health facilities. One of the measures is to reduce waiting time for medicines at hospitals by allowing patients to bring their prescriptions and receive their medicines at drugstores. This initiative was designed because drugstores are the first point of contact that distribute in different areas allowing better access than public hospitals. In addition, pharmacists in drugstores can apply the knowledge of pharmaceutical care and expand their role in caring for patients. In October 2019, in response to the MoPH, the National Health Security Office (NHSO) initiated a pilot program to allow patients receiving care at hospitals to receive their medicines at community drugstores to reduce congestion in hospitals. In the early phase, the program aimed to develop service systems by piloting in 50 public hospitals and a network of 500 quality drugstores nationwide. Emphasis is placed on dispensing medications to patients with 4 disease groups, namely diabetes, high blood pressure, psychiatric disorders, asthma and other chronic diseases that is not complicated to care for. The NHSO also assigned Health System Research Institute (HSRI) to develop system to monitor and evaluate the pilot program. The monitoring points should cover the assessment of service quality, benefits of the program to patients, service providers and society, and reasonable reimbursement rate for both the drugstores and the hospitals as well as provide recommendations for reducing congestion in hospitals in the next phase. The HSRI has appointed and provided funding to HITAP research team for this work. The objectives are to evaluate the pilot program and develop policy recommendations for the expansion of the pilot program in the future. This study used a program evaluation framework known as the CIPP model, which comprises four groups of assessment issues: assessing project context, inputs, process and the outcomes. The outcomes were divided into three aspects according to the ECHO Framework: economic outcomes, clinical outcomes, and humanistic outcomes, measuring across patients, hospitals and drugstores. In addition, the unit cost analysis of services was performed for both the hospitals and the drugstores. This research is a cross sectional study from October 2019 to September 2020, which collected data using both quantitative and qualitative methods. The quantitative method covered the analysis of unit cost of services, secondary data analysis of NHSO database and hospital database, as well as a survey of patients' satisfaction. The qualitative study consisted of document review and in-depth interviews with key stakeholders. This study collected data in participating hospitals located in 13 health regions by choosing one hospital in each region, except Bangkok, where 3 hospitals participated in the study. The study found that the main objective of the policy was to reduce hospital congestion, which was not yet observed by this study. However, some stakeholders suggested that this policy should focus on improving the quality of drug counseling and pharmaceutical care. The study results showed that the pilot program had some successes such as a joint service model between hospitals and drugstores was developed, collaboration was initiated to provide good care for patients and pharmacists in drugstores expanded their roles in providing pharmaceutical care. Success factors include 1) policy support from hospital-level policy makers 2) knowledge and operational experiences of the program operators both hospitals and drugstores 3) readiness of infrastructure especially the information system 4) the number and distribution of drugstores. In addition, the study demonstrates that patients who received medicines at hospitals had an average waiting time of 41.9 minutes, which was 6 times longer than a waiting time at the drugstore, which was an average of 6.2 minutes. Patients who received their medicines at the drugstore had twice as much consulting time as those who received them at the hospital (7.3 minutes vs. 3.4 minutes). The cost of travel and food for visiting hospitals was significantly higher than that for the drugstores. If patients travelled from home to receive medicines at the drugstores, they could save 41-50 baht on average, or 42-52%, and if the patient went to drugstores, food costs could be saved 54-58 baht, accounting for 81-83 percent. Patients were statistically significantly more satisfied with medicine reception at the drugstores than at hospitals. The issues that were found to be very different were the short waiting time, short travel time and the convenience of travelling to drugstores. In addition, pharmacists were enthusiastic and attentive. Pharmacists used proper speech and manners and the pharmacist explains the drug use information until patients understood. Challenges of the program were 1) The number of patients receiving medicines at drugstores is very low compared to the total number of patients receiving services in hospitals. When considering the overall picture of the country, the coverage of hospitals that patients received medicines at drugstores is low. Only some hospitals have a large number of patients participating in the program. This is caused by many reasons, including a lack of publicity for the project, doctors did not refer patients to drugstores and patients refused to take part in the program. 2) Participating in the pilot program with the current model increased hospital’s workload in screening and inviting patients to participate in the program, coordination and preparation of information to transfer to drugstores, and the logistic of medicines from hospitals to drugstores 3) Information systems in 2020 did not support the transfer of information between hospitals and drugstores 4) reimbursement rate did not reflect actual costs 5) Monitoring and evaluation systems was limited and should be continually developed.
