Clinic crisis prompts primary care reform for better access, quality
 
The primary health care system under the universal coverage scheme (UCS) in Bangkok has been thrown into chaos after about 190 privately-owned clinics serving as primary care units under the scheme in the city were excluded from the health care network over fraud allegations.
 
As a result, the existing UCS health care facilities are being flooded with patients who used to receive services at the banned clinics and forced to extend office hours to cope with a surge in a number of new patients.
 
Many of them are complaining about the inconvenience and long queues at new health care units.
 
In response to this crisis, the National Health Security System (NHSO) is racing against time to lessen the impact of the problem on both patients and health care units while at the same time attempting to reform Bangkok’s primary care system under the UHC scheme.
Redesign of the primary care system
 
A new structure of Bangkok’s primary care system has already been designed to improve quality and accountability of contracted health care units, while new clinics are being recruited into the redesigned primary care system, said Dr Jadej Thammatacharee, Deputy Secretary-General of the NHSO.
 
By Nov 1 the NHSO expects to include at least 500 new clinics into Bangkok’s primary care network under the UCS and patients will then be allowed to choose and register their desired new primary care units through various channels including by phone, smartphone application, and contact any of these primary care units in person, he said.
 
“We expect the new system to run smoothly in about two months from now,” he said.
The new primary care network in each health area of the city will consist of three components, namely a primary care unit, a regular care unit and a referral unit.
 
The primary care unit is a privately-owned clinic while the regular health care unit could be either a Bangkok Metropolitan Administration (BMA) public health service centre or a hospital, which could be either a state-run hospital or privately-owned one, he said.
The referral unit is a hospital capable of handling referral by admitting a patient to it for treatment or transferring him or her to a larger hospital if necessary, he said, adding that the referral unit will in the future possibly be developed into a cluster of hospitals, not necessarily a single hospital any more, to provide more choices to patients.
The new role of regular health care unit
 
Although the budget will be allocated directly to all of these health care units, as usual, the regular health care unit will also have a new role in helping the NHSO with controlling the quality of health care services offered by clinics in the same primary care network, he said.
 
Dr Panrudee Manomaipibul, director of Department of Health of Bangkok Metropolitan Administration, said all 69 public health centres under the department will take an important role in assisting the NHSO to ensure service quality of these privately-owned clinics, which is part of the ongoing primary care system reform.
 
So far 47 out of these 69 centres are offering services in extra office hours until 8 pm daily, to cope with a surge in demand following the exclusion of the 190 clinics, she said, adding that more centres will manage to extend their office hours too as the BMA will have to take up more of the more than 2 million people who previously registered with the excluded clinics.
Dr Jadej also stressed the need to build up trust in the importance and quality of the primary care system, a key element in a sustainable health security system.
 
An indicator of the primary care system development being successful is that patients are receiving care at health care units closet to their homes and hospitals are no longer crowded, he said.
 
Freedom of choice
 
From Jan 1 next year onwards, patients will be allowed to change their primary care units more freely and immediately and without having to wait for 15 days as in the past system, and can change 4 times/per year for easier to access the health services for their health need, he said.
 
Sometimes, they may want to change to a new primary health care unit closer to their workplaces rather than their homes, said Dr Panrudee.
 
Bhumibol Adulyadej Hospital, a tertiary hospital in the northern part of Bangkok that is seen as an excellent model of successful primary care network development, is also being affected by the clinic exclusion crisis.
 
The hospital is now struggling to handle an overwhelming number of patients seeking treatment for a common health condition such as a common cold and stomach pain at its outpatient ward again, said AVM Dr Thaweepong Pajareya, director of the hospital.
 
Despite its remarkable success in cutting the number of hospital visits by 80% with the help of a highly effective primary health care network, which serves around 300,000 people in four districts, the hospital was abruptly back to square one again when the clinics in its network were suddenly excluded following the fraud scandal.
 
Never lose faith in the primary care system
 
After all, the hospital director strongly believes a good primary health care network is the solution to this problem, learning from the hospital’s past experience and success.
He also is seeing this reform of the NHSO’s primary health care system as a good opportunity to push for all other primary health care networks in Bangkok to adopt e-Referral, an information technology-based referral system the hospital has developed and been using.
 
With e-Referral, about 90% of the referral data is processed electronically, which is something AVM Dr Thaweepong now hopes to see in all other parts of Bangkok as well.
 
“We should really be thankful for this crisis (the abrupt exclusion of 190 clinics) which has led to the reform of the primary care system and hopefully will eventually make the ambition to bring quality health care closer to home become true,” said Sujin Rungsawang, a member of a sub-committee on health security in Health Region 13 of Bangkok.
 
When good quality health care services are available in every community, people will save a lot of money and time they now spend on travelling to the hospital, said Ms Sujin who is also the president of a coordination centre for informal workers.
 
“We have to admit that the promise to bring quality health care closer to our home has not really happened just yet, so we still have to travel all the way to the hospital,” she said.