MPH/HSMP 2007-2008 : Central assignment: Imbalance of health care workers in Tak Province, Thailand


This is the detail of problem that I presented on the last Monday at Auditorium, ITM

                  There are 19 regional health areas with all 77 provinces in Thailand now, Each area has 4-10 provinces. Ministry of Public Health (MOPH) is responsibility to authorize all of areas and Provincial Health Office is responsibility to authorize all public health services.

               Tak province is in 2nd regional health area. It has the second largest area in Northern of Thailand. There are hills, mountains and a longest Thai-Myanmar boarder for 560 kms in length. There are 500,000 Thai people with a lot of hill-tribe people. There are 200,000 migrants, both legal and illegal. There are 3 temporary shelters for 100,000 displaced persons. Tak is divided to 2 different areas by geographical features, 4 districts in East, 5 districts in West along to Thai-Myanmar border.            

               Health care services, There are 2 general hospitals, 310 beds with 26 doctors in Muang district, 320 beds with 34 doctors in Maesot district and 6 community hospitals, 2 sixty beds hospitals with 5 doctors in each hospital , 4 thirty beds hospitals with 4,4,55 doctors in each hospital. In Sub-district level, There are 9 District Health Offices authorizing 115 health centers. NHSO provides budget by Universal program per capita especially registered population.

               Tak provincial Health System: There are two line of command overlap in provincial health system, directly command by provincial governor of  Ministry of Interior and indirectly by he permanent secretary of MOPH. Almost resources support by MOPH.            

               The top manager of provincial health system is Chief Medical Provincial health officer. There are two groups of health care facility in the district, one is hospital, another one is district health office that is directly  responsibility of health centers  and sub-health center. So it’s difficult to integrate health care in the districts.

               There are two top managers in the districts, hospital directors and Chief District health officers. They all belong to the staff of MOPH, but for administrative line, District health officers are directly commanded by the Chief District house officer whom is the staff of Ministry of Interior. It’s  very complexity.There are two general hospitals, 6 community or district hospitals, 115 health centers and 35 sub-health centers.           

               By the geographic difference, There are divided  into two referral network, Maesot general hospital network in the west area and Somdejprajaotaksinmaharaj general hospital network in the east area.            

               Human resource in Tak Province in 2006, There are 86 doctors with 57 specialist and 29 general practitioners. There are 807 nurses with 32 technical nurses and 774 registered nurses. There are 466 medical officers that almost of them work in health centers or sub-health centers. The nurses act as midwife, too.            

               There are at least  one health center in each sub-district. There are vary between 1,500-7,000 population in catchment area of health centers.            

                There are three times of number of population in the west area more than in the East area. There are 524,897 Thai people whom are registered by government and approximate 190,685 Non Thai whom are hill tribe people stayed along border that aren’t registered or legal and illegal migrants come from neighbor country.            

                 There are three temporary shelters for approximate 100,000 displaced persons who take care by NGOs, but they quite freely leave to go to another place and make many health problems. When you see the last slide about human resources in Tak. It isn’t predominantly difference between the East and West. This slide show that the ratio use us to compare more difference than the absolute numbers.           

                 After the health care reform and the universal coverage programs were implemented in 1997, MOPH adapted the WHO Model of Health Service Delivery Design and use it to be guideline for heath resources distribution. The standard of doctor/population ratio in primary and secondary care is 1:10,000 and proportion between specialist and general practitioner is 50:50. The ratio of nurse, medical officer per population is 1: 1,000 and 1: 1,500.           

                 The National situation of doctor in Thailand, doctor per population in all country is average 1: 3,500, in Bangkok is 1:950 and in other area is 1: 5000. It show that there is very poor distribution of doctor in Thailand.            

                 It is quite well in Tak, better than the standard ratio, but worse than the average. When we compare only in province, the west area is predominantly poorer than in East province, it is relative difference. There are the same figures of nurses and medical officers.           

                There are not only less in number of staffs, there are high turn over rate, short length of service of staff in the west area, too. The health care workers in the West area proposed to move away themselves to the East area, that make a problem in human resources management in Tak Province and make high tension to hospital directors and Chief District health officers every year.

                 When I analyze in depth of the situation. I found that the imbalance of health care worker has the effects to decrease the quality of care in Tak Province and effects to poor health outcomes. I show you the problem root cause analysis in this slide.           

                 Imbalance of Health care worker is composed of lack of stability and insufficiency of staff in the West area where are many health problems and diversity of population.           

                     The antecedence root causes come from two factors, contextual and personal factors. For the contextual factors, there are two main causes, environment and work factors. The personal factor is motivation factor both monetary and non-monetary factors.

                 Environment factors, it’s more than 100 kilometers far from the central of Tak vary in each districts and more than 690 kilometers far from Bangkok. There are 560 kilometers of Thai-Myanmar Border that make the health care workers insecurity with Karen-Myanmar war, crime or illegal drugs trade. It’s difficult to work because of high mountainous areas, difference in culture or language. There is limit of transportation, taking 3-6 hours by car, no bus or train and high risk with multiple curved, narrow, rough street along to border.           

                Work factors, there are high workload, insufficient, low and old equipments, limit some essential drugs and materials, prone to infectious diseases. There are 1 or 2 times of supervision by Provincial heath office, insufficient consultant or coaching and difficult to consult them because of the limit of information technology.            

                Monetary factors, they get low salary with the same rate with whom work in urban area and spend more money in transportation or communication , low overtime compensation, no extra-money on top for medical officers that  it make more difference between professional.            

                   Non-monetary factors, 80 percent of health care workers came from urban area in the central of Tak, so they have to go back  home to stay with their family every week. There are not good school for their children, no entertainment, no shopping centers. There are low opportunity in continuous training because of lacking staff in their workplaces. There are low recognition from population and administrators. There is low carrier path for staff who work in health centers and community hospitals with maximum at level 7 from 11 positional classification, which related to their salaries.These causes effect to quality of care.

                   I apply the concepts of School of Antwerp as reference framework to glass this problem. It effects to the three levels, care, service and system.

              The quality of care, patient centered care was found by holistic care, continuous care and integrated care.The quality of integrated health service was found by acceptability, accessibility and affordability.

               The quality of integrated health system was found by no overlapping,  no deficiency, delegation of task, accessibility to useful tier and information accompany with patient. From reference framework, there are poor quality in three levels. With less staff but high workload, they take care of patients only disease curative care or physical dimension, so there are poor holistic care . The continuous care is neglected with poor follow up, poor referral system. They don’t concentrate in patient’s autonomy or community participation.           

                The low utilization rate  and low coverage of preventive care show that the accessibility is poor. Even though, Thai people don’t have to pay for services because of The Universal coverage scheme, but many people couldn’t go to health centers or hospitals because they were not enough money for transportation, their family accommodation or food during treatment.           

                    There are poor quality of integrated health  system in every criteria, there are overlapping between hospitals and health centers, such as ANC, immunization, chronic care with functional deficiency in health centers. People cannot access some useful tier, no information accompanying with patient. Doctor don’t delegate some technical tasks that can do by medical officers or nurses, so many people with uncomplicated disease have to wait too long for a short consultation and take long time to transport from their houses.

คำสำคัญ (Tags): #mph#health workforce#imbalance#stability
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