บทคัดย่อ
การเปลี่ยนแปลงทางสังคมและเศรษฐกิจของประเทศ ตลอดจนวิถีชีวิตและความเชื่อของประชาชนส่งผลต่อทันตสุขภาพของประชาชนไทย วิถีชีวิตบางอย่างทำให้ประชาชนมีความเสี่ยงต่อการเกิดโรคในช่องปากมากขึ้น โดยเฉพาะการบริโภคน้ำตาลที่เพิ่มมากขึ้น รวมทั้งการเพิ่มขึ้นของโรคทางระบบ ส่งผลต่อสุขภาพช่องปาก แต่อีกด้านหนึ่งการเปลี่ยนแปลงเป็นสังคมเมือง มีส่วนทำให้คนดูแลสุขภาพช่องปากดีขึ้น นับตั้งแต่ปี 2544 รัฐบาลได้ให้ความสำคัญกับนโยบายสร้างหลักประกันสุขภาพถ้วนหน้าให้แก่ประชาชน ครอบคลุมทั้งการสร้างเสริมสุขภาพ การป้องกันโรค การรักษาพยาบาลและการฟื้นฟูสุขภาพ มีการจัดระบบบริการระดับปฐมภูมิที่มุ่งหวังให้เป็นสถานที่ใกล้บ้านและใกล้ใจ บริการดังกล่าวรวมถึงด้านทันตกรรม อย่างไรก็ตาม การบริการทันตสุขภาพสำหรับประชากรทุกกลุ่มอายุโดยไม่กำหนดกลุ่มเป้าหมายหลัก และใช้งบประมาณรวมอยู่ในการเหมาจ่ายรายหัวประชากร เป็นรูปแบบการจัดบริการที่แตกต่างจากประสบการณ์เดิมของประเทศไทย ทำให้เกิดคำถามจากผู้เกี่ยวข้องว่ารูปแบบการจัดบริการทันตสุขภาพของประเทศไทยภาตใต้นโยบายหลักประกันฯ จะก่อให้เกิดภาระด้านงบประมาณต่อระบบใหญ่หรือไม่ ด้วยเหตุนี้ สถาบันวิจัยระบบสาธารณสุข จึงสนับสนุนให้มีการศึกษาเพื่อหาข้อเสนอในการพัฒนาระบบบริการสุขภาพช่องปาก เพื่อรองรับการปฏิรูประบบบริการสุขภาพไทย
บทคัดย่อ
Dental Health Services Under Universal Health Coverage PolicyThe study of oral health services system to focus “Oral Health Services Under Universal Health Coverage Policy” was conducted during 2001, the first year of the implementation of universal health coverage (UC) policy. Followings are major findings and recommendations:Findings:1. Policy to emphasize on prevention is still far from expected. Almost all of the services delivered by the studied hospitals were pure curative purpose while preventive services accounted for less than 3%.2. There were 26% increasing of clients in dental clinics of the six government hospitals. Most of the increasing number were adults and elderly people. Services for children were comparatively decreased. More than half of the clients had to pay for the service fee. Among the clients 37% were gold card holders under the UC program. The total clients were from 6.5 % of the total population and only 1.5% of the total gold card holders. Most clients visit the dental clinics for only one time and received only one dental service. More than 80% of the services were under a core-package for example dental filling, tooth extraction, tooth scaling, etc. Clients had to be on longer waiting list, particulary for denture services. Preventive activities in the community formerly responsible and carried out by provincial health office were not be able to continue by the regional or general hospitals during the first year.3. Most of the private hospitals, six out of seven, delivered only hospital-based curative services. Almost half of the patients (43.5%) were gold card holders. Administrators of the private hospitals were much worry about the financial problem from providing dental health services. Some administrators closely monitor the expenses and set up additional regulation to prevent financial loss. However, the loss scenario is unlikely happened in the near future because only 4.5 % of gold card holders used the services.4. Many private dental clinics are reluctant to apply and enter the sub-contract system in providing dental health services because the UC policy did not effect their business . In addition, they are afraid of spending time in preparing paper work and uncertainty to have a quick reimbursement of the fund. Anyhow, some clinics which had experience in getting insurance sub-contract from business companies, expressed different opinions. They supported the idea that subcontracting from the UC program will result in a mutual benefit. The private clinics can gain more patients during the low client period of the day and can maximize their current employee staff performance. The idea of subcontract out the dental services for the private hospitals depended on the decision of the contacting unit which dental health service might not be at top of the concern for them. In addition, the idea of subcontract might not be possible in the rural area where dental professional are scare and inadequate. Although private clinics were ready in the aspects of the service unit and technology but the social readiness such as the handle of patient right to know is important. 5. The UC policy can ease the financial constrain of the current system but can not trackle the lack of dental health personnel. Data in 2001, showed 68% of the provinces has under satisfactory ratio of dental health personnel per population. There is a need to readjust current dental health manpower development not only in term of number but also the new required skill. For example, dentists in both public and private sectors should be trained to carry out dental public health work in the community while dental public health nurses should be able to work hand in hand with private sector.6. The first year experience of the dental health service under the UC policy was not fully match the standard set up for the primary care unit especially the coverage and personnel aspects. Several alternatives can be choose to solve the problem: a) government employed more dental health personnel. b) a joint government and private services c) prioritize the most needed service to meet the standard criteria instead of providing all services as currently. In principle, the solution can be a combination of these three alternatives with modification for specific area.7. There are also phenomenon in favor of improving dental health services. Private hospital hired more full time dentist instead of part time and former sub-district health center could start deliver dental health service after transform to be a primary care unit by the primary contacting hospital. Recommendations:1. The goal of a universal coverage for all dental health services can not be achieved in these near future. We recommend the strategy for UC policy to focus primary on coverage of particular age group such as children and also focus the coverage in dental preventive and promotive services. This will yield a high impact to solve dental health problem of the of the population.2. There is an urgent need to set up a shared information and data bank for both public and private sectors at the local and national level. Without common indicators and information, it is difficult to evaluate the success of the UC policy.3. The monitor and inspection body for the implementation of dental health services under the policy is vital. There must be criteria to select the inspection body. If the provincial health office is choosed to serve as the inspection body, the personnel must be trained to enhance their skill and capability. In some countries, the government contracting out the management and implementation of the program to local dental health association.4. One of the major standard criteria for sub-contract the service is the reach out capacity to the population. If the accessibility of the population is not satisfy, the contracted units must expand its network. Detail on how to assess the capacity of the contracted unit and its network must be clearly documented.5. Dental health promotion in a boarder sense should be introduced. The real dental health promotion is not limited to clinic-based services or family visit or screening for preventable conditions but should encompass initiating promoting dental health environment. Further study Carry out this study during the first year implementation of the UC policy pose some limitations in term of the limited number of study hospitals and provinces and the dynamic stage of the implementation. Several problems or issues might have been solved so far. Recognizing this limitation we also recommend further studies in the following area.1. Macro-policy study to provide recommendations for the national health system.2. Additional case study to gain more knowledge in dental health services under the UC policy and context such as: a) Subcontracting joint public and private dental clinics for delivering services to specific age group or conditions. b) Effective management and supervision of the service network. c) Development of key performance indicator and information center for assessing quality of both public and private services. d) Estimation of average cost and expenses in carry out dental health services in different provinces.
