Abstract
This research aimed to 1) extract lessons learned on the management of chronic illness patient health service systems of the sub-district health-promoting hospital under the provincial administration organizations (PAOs). 2) study participation in developing the health service system for chronic illness patients by those related to the sub-district health-promoting hospital under the PAOs. 3) develop a policy proposal to improve the health service system for chronic illness patients at the sub-district level under the PAOs. This research used a mixed-method approach, collecting quantitative and qualitative data from three provinces where the transfer of the sub-district health promoting hospitals to the PAOs was 100%, more than 50% and less than 50%. The total sample size was 1,896 participants, gathered between June and September 2023. The meetings to gather feedback and critique the draft policy proposals were scheduled for November 2023. The data analysis involved descriptive statistics and content analysis. The research findings were summarized as follows: 1. The findings of the study on the lessons learned in managing the health service system for chronic illness patients at sub-district health-promoting hospitals under the PAOs were as follows: 1) Health service delivery mostly follows standard practices, but operational details vary according to the different supporting form the public health provincial and supporting hospitals in each area. In fiscal year 2566, the PAO faced readiness challenges and required assistance from the Ministry of Public Health in managing the health service system for chronic illness patients. Plans were in place for the full development of the chronic illness patient health service system in the fiscal year 2567. 2) The health workforce at sub-district health-promoting hospitals under the PAO lacks sufficient numbers, according to the organizational structure. There are no physicians within the PAO's jurisdiction for supervision of medical services. The personnel necessitating adjustments to accommodate new working systems, and the need for capacity development in general medical services and chronic disease care. 3) Various health information systems such as HosXp, JHCIS, and MyPCU, connected to the Ministry of Public Health's Health Data Center, are in use. There is a lack of agreed-upon quality indicators for chronic patient care. The chronic illness data entry into the system is minimal however, PAOs have plans to develop PAO databases. 4) Access to Essential Medicines: supporting hospitals still support access to essential medicines, but there are changes in operational procedures. The quantity and list of medicines have been reduced. 5) Financing from the Central Unit for Procurement (CUP) is allocated disproportionately between supporting hospitals and subdistrict-promoting hospitals under the PAO. The budget received was lower than the declared amount. 6) The leadership and governance of PAO administrators exhibit leadership and governance qualities but lack experience and perspectives in developing the health service system for chronic patients. Specialized and experienced teams in health and public health management are needed. For the health service system outcomes of sub-district promoting hospitals under the PAOs, the following points were noted: 1) Improving Health: An attempt was made to provide treatment for chronic diseases as closely as possible to the previous transfer. The general population, the risk groups, and individuals with chronic diseases have decreased access to diagnostic examinations and screening for complications, along with activities promoting health behavior modification. 2)Responsiveness: Responsiveness involves following general medical practices for chronic diseases, but there are no apparent plans or guidelines for managing outbreaks and new epidemics or handling emergencies for chronic patients. 3) Social and Financial Risk Reduction: The problems include receiving budgetary support less than what was reported, and unclear and untimely allocation of budgetary support proportions from the National Health Security Office through supporting hospitals. The financial regulations of the Ministry of Interior are not conducive to managing and supporting the chronic patient health service system. The social risk management strategies are also not clearly defined. 4) Improved Efficiency: There is a lack of defined quality indicators for chronic diseases connected to the Ministry of Public Health. Strategies for developing and evaluating the outcomes of the chronic patient health service system aligned with the Primary Health Care System Act of 2019 remain unclear. 2. Participation in developing the health service system for chronic illness patients at sub-district promoting hospitals under the PAOs revealed that all parties involved recognize existing issues in the health service system for chronic patients, varying across different aspects. Therefore, it remains crucial and necessary to expedite the comprehensive development of the health service system, addressing all six components of the core pillars of the six building blocks of the health service system. The most crucial aspect, especially, is ensuring that there is an adequate and well-developed workforce and funding for the effective organization and enhancement of the chronic illness patient healthcare system. 3. The policy proposals for developing the health service system for chronic illness patients at sub-district promoting hospitals under the PAOs. All relevant units involved need to redefine roles and responsibilities to foster public health care collaboration, focusing on mutual support and assisting each other, emphasizing patients with chronic illness as the center. This approach aims to ensure that the chronic illness patient healthcare system operates at a high standard, undergoes continuous development, and aligns with the principles of decentralization. Most importantly, it is crucial to promote the responsibility of every citizen, especially those with chronic illnesses, in taking care of their health without burdening healthcare professionals. Regarding the results, the health service system for patients with chronic disease of sub-district promoting hospitals transferred to the PAO could be developed into a policy proposal. These two characteristics are as follows. 1. Policy proposals for the development of health services for patients with chronic diseases can be divided into two categories: Form 1 In the case of health services for patients with chronic diseases of sub-district promoting hospital under the PAO, must be organized together with the former host hospital or under the network of the Ministry of Public Health. The policy proposals are as follows: 1) The Ministry of Public Health must review or revise relevant laws and regulations to organize health services for patients with chronic diseases in cooperation with the Ministry of the Interior. 2) The Ministry of Public Health and the Ministry of Interior jointly prepare guidelines for the arrangement and development of the hospital's chronic disease health service system in collaboration with existing host hospitals or under the Ministry of Public Health's network. The service is mainly based on service recipients, especially patients with chronic diseases.3) The PAO and provincial public health office should develop strategies, convey indicators, and supervise, monitor, and evaluate the management of care systems for patients with chronic diseases. 4) PAO and provincial public health office jointly develop personnel capacity to have the knowledge and ability to organize the health service system for chronic disease patients of sub-district promoting hospitals transferred to PAO to be modern and meet higher standards. 5) Drive the telehealth/telemedicine system into the health service system for patients with chronic diseases in the sub-district promoting hospitals transferred to the PAO. Form 2: In the case of health services for patients with chronic diseases of sub-district promoting hospitals under the PAO must be organized under the jurisdiction of legal entity authority of PAO accompanied by the principle of decentralization.1) The PAO must undertake organizational restructuring. The manpower rate framework should meet the sub-district promoting hospital's mission. In particular, multidisciplinary team personnel were provided at the hospital. 2) The PAO must have a policy to organize the health service system for patients with chronic diseases in the area of responsibility of the sub-district promoting hospitals transferred to the PAO according to the data on the analysis of the health problem situation that can meet the health indicators as determined for the goal of access to a comprehensive and equitable health service system for patients with chronic diseases, to promote a good quality of life, and to continuously evaluate the health outcomes and impacts of health service customers. 3) Provide systematic health services to patients with chronic diseases to meet quality standards by creating other network partners to participate, including health network leaders at the local level. and 4) capacity development of personnel at all levels, multidisciplinary teams, including executives/practitioners involved in the division of public health and environment, and the sub-district promoting hospital. Gain knowledge in healthcare and develop a health service system for patients with chronic diseases efficiently and promptly. 2. Policy proposals are important for developing health services for patients with chronic diseases. These can be divided into 3 categories: 1) Important policy proposals to be implemented, 2) Policy proposals that should be implemented, and 3) Policy proposals for consideration, as detailed in the policy proposals.
