Understanding the Role of Thai Community Hospital Directors in Implementing the Universal Health Coverage Policy in Relation to Primary Health Care

Abstract

In 2001, Thailand adopted the Universal Health Coverage (UHC) policy. This policy focuses on Primary Health Care (PHC), with the aim of reforming the Thai health system to provide health services to all, regardless of a person's ability to pay. The Community Hospital Director (CHD), as the middle manager of the provincial health system and the leader of the district health system of Thailand, is a catalyst for communication up and down the organisational structure, and between executives and front-line services implementing this policy for the rural poor. The role of the CHD is influenced by structural interests, professional sub-cultures, the organisational context and the relationship between the Community Hospital and the communities. For Thai health reform the greatest hope for improving efficiency lies with changes in the provision of primary health services at the community level and this entails understanding the role of the CHD. This study presents a qualitative study of eight CHDs and 35 stakeholders involved in the implementation of rural health care reform (the UHC policy and PHC) in order to understand the structural and institutional factors affecting the Thai CHDs in implementing the UHC policy in relation to PHC, and the complex real life context for primary health care delivery and implementation in rural Thailand. The research design is mixed methods with in-depth interviewing preceeding and informing a focus group. The data analysis technique used in this study is thematic analysis. The results show that the sustainability of PHC services provision under the administration of community hospitals to meet the needs of rural poor may be problematic. Many barriers at the policy and operational levels limit the role of the CHD, who is the lynchpin of the Ministry of Public Health at district level. These barriers include structural interests, understanding of PHC as Primary Medical Care (PMC), Thai bureaucratic management style, and the difference in professional sub-cultures. Moreover, there is no structural and operational support for the CHD's management role. These factors concentrate the consequences of the dual role of the CHD as clinician and manager. These consequences also seem to be linked to the CHDs' primary training in biomedical science. In response to the barriers, the CHDs act according to a 'medical mindset', focusing on their interests, professional autonomy and their hospitals, rather than on the broader health needs of the community. The goal of the UHC policy in providing equity of access to PHC to all citizens may not be achieved, unless the role of CHDs, as both 'professional manager' and 'community developer', is encouraged through training in health management and PHC and is supported by the government. The concept of comprehensive PHC should be acknowledged and put into practice by all stakeholders, both within and outside the health sector. In addition, the government needs to clarify the roles and responsibilities of all stakeholders in district health services management.