Journal of Health Systems Research

Oral Health Status and Self-Report Dental Service Utilization Experience among Homeless People in Thailand: A Cross-Sectional Study in Members of Work from Homeless Project

Wararat Jaichuen — 2024-09-29

This special article provides the first empirical evidence on the oral health conditions and dental service experiences among homeless people in Thailand, based on information from the volunteer spirit activities on medical and dental services to members of the social enterprise project “Work from Homeless”. On May 20, 2023, a total of 140 project members were most older persons, 130 voluntarily joined the interview, 122 had oral examination, 115 were in dental treatment needs (not including dentures). A total of 90 people received simple dental services as needed on the day of the activity, 24 refused treatment, and 1 person received no dental treatment due to uncontrolled diabetes. Only 98 people who agreed to be interviewed and examined were presented. The results confirm severe dental problems and higher unmet dental service needs among these homeless people than the general population, despite this list of unmet dental services has already been included in the benefit packages of all three health insurance systems. Not being aware of their health rights is likely to be a major barrier for homeless people in accessing to dental services. Creating awareness among homeless people of their rights should therefore be the first strategy to be implemented. Additional patient perspectives on barriers and enablers to dental care access are required for future planning of the dental service system to ensure that no one is left behind.

Assessment of Thailand’s Health System Performance in 2022-2023

Pongsadhorn Pokpermdee — 2024-09-29

Background: The assessment of Thailand’s health system performance from 2022 to 2023 aims to analyze health outcomes in comparison to the OECD (Organisation for Economic Co-operation and Development) and ASEAN (Association of Southeast Asian Nations) countries. The study aimed to examine and synthesize the relationships between health expenditures and key indicators, and to prioritize the health indicators that Thailand urgently needed to achieve from among the 193 OECD health indicators. The goal was to formulate policy and strategic recommendations that enhance the sustainability and international competitiveness of Thailand’s health system.

Methodology: This study used a mixed methods approach to analyze both the quantitative and qualitative aspects of health system outcomes. It explored the relationship between health expenditures and key indicators by comparing Thailand’s data with that of OECD and ASEAN countries. The study also incorporated a two-round modified Delphi survey, gathering anonymous expert opinions online to frame top priority indicator groups with final policy recommendations.

Results: Thailand data covered 158 indicators and lacked 35 indicators. Of those available, 112 indicators were comparable with the OECD countries, while 46 non-comparable indicators were those with trends, proportions, or qualitative data. Main findings were: 1) out of 5 dimensions of the comparable indicators, there were 51 indicators that Thailand health system outperformed the OECD average and 61 indicators that lagged behind the OECD average. (1) Within the health status dimension, 17 indicators were identified as challenges, with 8 indicators requiring immediate attention. The top three indicators in need of urgent development were the maternal mortality ratio, infant mortality rate, and the prevalence of type 1 and type 2 diabetes in adults. (2) Under the health risk factor dimension, 12 indicators were challenges while top three were the premature birth rate, the smoking rate among children aged 13-15 by gender, and the smoking rate among the population aged 15 and over by gender. (3) Under the service access dimension, 12 indicators were challenges and top three were the ratio of doctors per 1,000 population by region, the proportion of household expenditure on health, and the proportion of patients waiting for cataract surgery over three months. (4) Under the patient care quality dimension, 11 indicators were challenges, with 16 indicators in need of urgent development, while top three were the percentage of the population aged 65 received influenza vaccine, the proportion of antimicrobial resistance in long-term care, and the suicide rate among inpatients with psychiatric illnesses. (5) Under the health resource dimension, 9 indicators were challenges, 18 required urgent attention, and top three priorities were the number of critical care beds, the number of nursing graduates, and the number of nurses per 1,000 population. 2) From the prioritization of the 61 indicators needed urgent development, the top five indicators deemed most critical by experts were: the number of critical care beds, the production of nursing graduates, and three indicators tied for the third place were the maternal mortality ratio, the rate of foreign body left after procedure, and the number of nurses per 1,000 population. The fourth priority was the percentage of the population aged 65 and over received influenza vaccine. The fifth priority included the proportion of antimicrobial resistance in long-term care; government expenditure on health as a percentage of total government expenditure; and the number of physicians per 1,000 population. 3) The correlation study between health expenditure and health outcomes showed that Thailand and other ASEAN countries with low per capita health spending–mostly developing nations–had poorer health outcomes compared to more developed OECD countries. Despite relatively low health expenditure, these countries often achieve good accessibility, quality of care, and coverage of essential health services. Thailand’s per capita health expenditure was 25,472 baht (730.5 USD PPP), lower than the OECD average. Nevertheless, Thai population benefited from universal access to core health services. 4) The results of policy and strategic proposals for driving and developing the capacity of Thailand health system sustainably were divided into proposals for managing the development of 5 dimensions of health system outcomes: focusing on creating health literacy; developing health care system for older persons; developing the service system, especially the primary care system, reorienting medical services to the community; by planning the management and distribution of resources comprehensively; and creating a development plan to achieve health outcomes according to the OECD targets in terms of management of critical patient beds and nurse production.

Conclusion: Thailand’s health system performance showed improvement and ranked high in ASEAN, however, the health outcomes fell short when compared to developed countries. Therefore, it is essential for Thailand to further enhance the efficiency of its health system to achieve better quality health outcomes for its population.

The Transfer of Sub-District Health Promoting Hospitals to Local Government Organizations: Progress and Challenges

Sonvanee Uansri — 2024-09-29

This qualitative research reviewed documents to investigate the progress of health facility decentralization according to sequential plans, decrees following revisions of the Decentralization Plan Act. Specifically, this research examined the criteria and procedures of transferring the Chaloem Phra Kiat 60 Years Nawamintrachini Health Centers and sub-district health promoting hospitals to local government organizations in 2021. The results reveal continuous improvements in the clarity and flexibility of the transfer criteria and conditions. Notably, the transfer criteria have been segmented into stages to evaluate the readiness and potential of local government organizations for the expected responsibilities. However, significant challenges persist, particularly regarding the laws and regulations governing the operations of medical and health professionals, including all other categories of human resources, and budgetary management by the National Health Security Office related to primary health care function of the transferred facilities. These challenges were compounded by a lack of continuity in decentralization and operational plans, budgetary constraints, legal issues encountered in the transfer of human resources, and an unclear division of duties between related units. The study offers policy proposals as follows: 1) review and amend the Ministry of Interior’s regulations regarding the operations of transferred health facilities to enhance efficient management and service delivery. 2) Amend regulations to increase workforce flexibility of transferred health facilities to local government organizations taking account of local contexts, issues, and limitations within the personnel budget framework. 3) Allocate budgets according to the responsibilities of transferred health facilities to ensure stable income to attain self-managed revenues for effective health service delivery.

Primary Care Service Standards and Readiness of Sub-District Health Promoting Hospitals Transferring to the Provincial Administration Organizations

Daravan Rongmuang — 2024-09-29

Background and Rationale: The Decentralization Act B.E. 2542 mandates the transfer of health responsibilities to local government organizations (LGOs). This research aimed to investigate the standards and readiness for service provision of sub-district health promoting hospitals (SHPHs) that wanted to be transferred to the provincial administrative organizations (PAOs).

Methodology: This mixed-methods qualitative research included in-depth interviews and focus group discussions with policymakers (n = 6), public health representatives (n = 28), PAO representatives (n = 16), and public sector representatives (n = 24) selected purposively. For the quantitative research, the sample consisted of SHPH directors or representatives (n=430), selected through random sampling and by size of PAOs. Research instruments included a semi-structured interview guide and a questionnaire on primary care capacity standards and readiness. Content analysis was used for qualitative data, while descriptive statistics and chi-squared test were used for quantitative data.

Results: 1. SHPHs reported adequate or high structural service readiness; however, staffing levels particularly health professionals and supporting finance/account personnel were inadequate. 2. Most SHPHs anticipated maintaining or even increasing service quantity post-transfer to the PAOs, except in dental care where reductions were expected. 3. Recommendations from SHPHs to enhance the transfer of health responsibilities included ensuring that health services to the public maintaining the pre-transfer level, especially the provision of chronic disease treatments such as diabetes, hypertension, and dental care, should continue status-quo health service networks.

Conclusion: PAOs and the provincial health offices should develop local health plans, recruit both health professionals and supporting personnel, and sign agreements to maintain existing service models during the transition period. They should also prepare to promote, support, oversee, and evaluate operations according to professional standards and facilitate community-driven initiatives.

Capability, Community Participation and Factors Associated with the Abilities of Village Health Volunteers’ Community Health Management of Devolved Sub-District Health Promoting Hospitals of Provincial Administrative Organizations

Chaweewan Sridawruang — 2024-09-29

This cross-sectional analytical study aimed to investigate the capability, community participation and factors associated with the abilities of village health volunteers (VHVs) in community health management of devolved sub-district health promoting hospitals of provincial administrative organizations (PAOs). The questionnaire survey included 3 dimensions: first, the capabilities of VHVs measured in 3 domains; knowledge, attitudes, and behavioral skills in community health management. Second, the participation and third, the capabilities of VHVs in community health management; all were measured based on self-assessed questionnaire. The content validity verified by three experts was of 0.85, 0.92, 0.95, 0.92, and 0.94, respectively. The study was conducted between March 2023 and February 2024. Sample selection employed a multi-stage random sampling method. This study recruited 482 VHVs from across 10 provinces of 4 regions. Data were analyzed using a computer program. Multiple logistic regression was used to analyze the data. Adjusted odds ratios (Adj.OR), 95% confidence intervals (95% CI), and p-values were reported. Results: Most of the participants were VHVs of medium-sized health promoting hospitals (52.9%), were female (82.0%), with age range of 50-59 years (38.6%). The average duration of being a VHV was 16.38 ± 9.64 years, and 87.3% had training experience. Capacity of VHVs in community health management comprised knowledge, attitudes, and behavioral skills in managing community health in five areas: health planning, leadership and budget management, organizing health promotion activities and disease prevention in the community, evaluating community health management, and information technology for managing community health. The findings showed that most VHVs had a high level of knowledge, attitude, and behavior in community health management. Specifically, VHVs demonstrated a high level of knowledge (mean 28.16, SD=1.79). They also showed a positive attitude (mean 4.37, SD=0.49). The highest average was found in organizing health promotion activities. The lowest was the evaluation of community health management. There was a high level of community health management behavior (mean 4.31, SD=0.50). The highest mean was found in information technology for community health management. The lowest were in organizing health promotion activities and controlling them, prevent disease in the community. The community participation of VHVs in community health management was at a high level (91.9%, mean 4.27, SD=0.57). A multiple logistic regression analysis was conducted to identify factors associated with VHVs’ ability to manage community health at a high level. The analysis revealed five significant factors: 1. skill potential, 2. participation, 3. age group, 4. the duration of being VHV, 5. occupation.

Diabetes and Hypertension Screening Platform for Sub-District Health Promoting Hospital to Track Community Health

Anas Tawalbeh — 2024-09-29

Background and Rationale: This subproject aimed to develop a digital platform for diabetes and hypertension screening for sub-district health promoting hospital (SHPH) to tract community health to align with efficient community development of the big project.

Methodology: This participatory action research involved 3 target areas of 3 SHPHs (Khaotum, Yarang, and Ma’mawi) and 3 sub-district administrative organizations (SAOs: Yarang, Pakoo, and Sakhobon) in Pattani province. The research process began with community survey to analyze the problems of executives in using data for decision-making. The big project offered platforms to executives for monitoring and decision-making. The platform of diabetes and hypertension screening to monitor community health was developed for the present study. Executives were able to access health data for planning and decision-making. The research recruited 39 samples representing 4 groups of stakeholders: 6 SAO executives and employees, 9 executives and nurses of SHPHs, 9 village health volunteers (VHVs), and 15 patients/relatives. The samples were selected purposively (from SOAs and SHPHs) and randomly (VHVs and patients). Questionnaires and interviews were tools for evaluating satisfaction and the platform uses.

Results: The development of the digital platform solved data problems with convenient use and high satisfaction to users through serial trainings. Evaluation using questionnaires and interviews found that: 1) the change of community health screening from a manual (paper) based to digital based delivered accurate, fast, convenient, and systematically stored database for real time use. This helped future planning operations on tracking community health. 2) SHPH and SOA could see trends of community health problems at real time and plan to mitigate problems with precision, clarity, and accuracy. 3) The platform served as communication and collaboration medium between SOA, SHPH, VHVs, and target groups. 4) It could facilitate the basic health screening, make an appointment for treatment and follow-up for people in need. Post-training evaluation of platform use skill was at high score.

Suggestions: Responsible officers in monitoring community health and service users should receive comprehensive, clear and easy-to-understand training on the use of this new platform.

A Meta-Analysis and Consensus Conference on Updating a List of Medicines for Out-of-Hospital Cardiac Arrests in the Emergency Care System

Piyawat Dilokthornsakul — 2024-09-29

Background and Rationale: Having a list of essential emergency medicines and management guidelines requires clear evidence approach. Based on the hospital’s potential, this study intended to update a list of essential medicines for managing out-of-hospital cardiac arrest (OHCA) patients for appropriate cadres of emergency responders in the emergency care system (ECS) Chiang Mai case study.

Methodology: The study was divided into two parts. The meta-analysis started from literature search then data extraction by two independent researchers. The PICO (patient, intervention, comparison, outcome) keyword search for full-text studies published in English between 1990 and 2021 in electronic databases such as PubMed, Medline, Embase, Cochrane, including references was undertaken. The search yielded 2,096 papers, 866 duplicate articles were eliminated, as well as 1,199 papers with unrelated titles and abstracts. Thirty-one papers were good for meta-analysis and reached recommendations on an essential emergency medicine list for OHCA patients. The second step was a consensus conclusion based on evidence gathered from in-depth interviews with 12 academic professionals and 12 emergency medical practitioners.

Results and Conclusion: The list of drugs for OHCA patients was developed through a thorough analysis and the inputs from experts. Dopamine, norepinephrine, and epinephrine injections are three items required at the advanced life support (ALS) level. OHCA patients who received epinephrine within ten minutes of calling the ECS had a high survival rate and clinical prognosis. The emergency and pharmacy departments should have the emergency medicine kits handy. After the ECS dispatch, pharmacists should monitor the use of and refill the emergency drugs ensuring preparedness of the kit for next emergency incident.

Lessons Learned from the Management for Public Health Emergencies of Healthcare System during COVID-19 Pandemic in Southern Border Provinces, Thailand

Suthat Siammai — 2024-09-29

The COVID-19 pandemic challenged the management of public health emergencies of health systems. This qualitative research aimed: 1) to study the situation, lessons learned, and challenges in preparedness, prevention, and response to the COVID-19 emergency; and 2) to evaluate the outcomes of emergency management systems during the COVID-19 crisis of the southern border provinces. The participants consisted of 115 policy key informants and 139 practitioners purposively selected. Data collection methods included in-depth interviews, focus group discussions, and brainstorming sessions. The transcribed data were analyzed using content analysis. Results revealed that the preparedness, prevention, and responses to the COVID-19 emergency by the tertiary, secondary, and primary healthcare systems in the five southern border provinces were inadequate. Challenges included limitations in establishing emergency operation centers and incident command systems, lack of preparedness drills according to operational guidelines. Team members did not fully understand their roles and responsibilities within the mission framework (situation assessment, operations, risk communication, case management, medical supplies and logistics, and legal aspects). Additionally, insufficient personnel and budget for proper management of COVID-19 patients and the deceased according to scientific protocols and lifestyle/religious beliefs posed obstacles to disease prevention and control efforts. The evaluation of public health emergency management system revealed that all provinces lacked efficiency in preventing and controlling COVID-19. The Ministry of Public Health should establish policies and allocate necessary resources to enable continuous preparedness drills for national epidemic response plans, emergency operation centers, and incident command systems at the provincial and district levels. Collaborations with special agencies such as the Provincial Islamic Committee Office, Islamic religious leaders, and religious teachers should be fostered to address future epidemics.