Self-assessment of attitudes towards conditions to provide safe abortion among new medical graduates in Thailand, 2018: an application of cross-sectional survey with factor analysis.

BACKGROUND: Unsafe abortion is one of the major public health problems in Thailand. Although the penal code of Thailand and the Thai Medical Council permit doctors to perform safe abortion in certain conditions, little is known about the attitudes that new medical doctors have towards abortion. The objectives of this article are to explore the attitudes towards abortion in certain conditions among new medical graduates and to identify factors related to those attitudes. METHODS: A cross-sectional survey was conducted in 2018 among 2017 medical graduates who attended the annual workplace selection forum. The participants came from the two main tracks of admission to Thai medical schools: normal track and special track physicians, namely, the Collaborative Project to Increase Production of Rural Doctors (CPIRD). Of these 2017 graduates, 926 returned the questionnaire with complete information. Descriptive analysis, factor analysis, and multi-variable regression analysis were performed. RESULTS: We found that most physicians agreed to perform abortions in the context of life-threatening conditions for mothers and children, but not under conditions directly related to physical health (such as pregnancy with socioeconomic problems or pregnancy in adolescents). CPIRD doctors were less amenable than normal track doctors in providing abortions if the reason for the termination of pregnancy was related to socioeconomic problems. CONCLUSION: The study suggests that a proactive campaign for new medical graduates to raise awareness and mutual understanding of abortion services should be exercised. The CPIRD curricula relating to safe abortion should enhance the capacity of medical graduates to deal with pregnant women who face not only a physical health-related problem, but also socioeconomic difficulties and well-being as a whole.

Developing a Thai national critical care allocation guideline during the COVID-19 pandemic: a rapid review and stakeholder consultation.

BACKGROUND: At the height of the COVID-19 pandemic, Thailand had almost depleted its critical care resources, particularly intensive care unit (ICU) beds and ventilators. This prompted the necessity to develop a national guideline for resource allocation. This paper describes the development process of a national guideline for critical resource allocation in Thailand during the COVID-19 pandemic. METHODS: The guideline development process consisted of three steps: (1) rapid review of existing rationing guidelines and literature; (2) interviews of Thai clinicians experienced in caring for COVID-19 cases; and (3) multi-stakeholder consultations. At steps 1 and 2, data was synthesized and categorized using a thematic and content analysis approach, and this guided the formulation of the draft guideline. Within step 3, the draft Thai critical care allocation guideline was debated and finalized before entering the policy-decision stage. RESULTS: Three-order prioritization criteria consisting of (1) clinical prognosis using four tools (Charlson Comorbidity Index, Sequential Organ Failure Assessment, frailty assessment and cognitive impairment assessment), (2) number of life-years saved and (3) social usefulness were proposed by the research team based on literature reviews and interviews. At consultations, stakeholders rejected using life-years as a criterion due to potential age and gender discrimination, as well as social utility due to a concern it would foster public distrust, as this judgement can be arbitrary. It was agreed that the attending physician is required to be the decision-maker in the Thai medico-legal context, while a patient review committee would play an advisory role. Allocation decisions are to be documented for transparency, and no appealing mechanism is to be applied. This guideline will be triggered only when demand exceeds supply after the utmost efforts to mobilize surge capacity. Once implemented, it is applicable to all patients, COVID-19 and non-COVID-19, requiring critical care resources prior to ICU admission and during ICU stay. CONCLUSIONS: The guideline development process for the allocation of critical care resources in the context of the COVID-19 outbreak in Thailand was informed by scientific evidence, medico-legal context, existing norms and societal values to reduce risk of public distrust given the sensitive nature of the issue and ethical dilemmas of the guiding principle, though it was conducted at record speed. Our lessons can provide an insight for the development of similar prioritization guidelines, especially in other low- and middle-income countries.

Primary health care and sustainable development goals.

We examine the potential and limitations of primary health care in contributing to the achievement of the health-related sustainable development goals (SDGs), and recommend policies to enable a functioning primary health-care system. Governments have recently reaffirmed their commitment to the SDGs through the 2018 Declaration of Astana, which redefines the three functions of primary health care as: service provision, multisectoral actions and the empowerment of citizens. In other words, the health-related SDGs cannot be achieved by the provision of health-care services alone. Some health issues are related to environment, necessitating joint efforts between local, national and international partners; other issues require public awareness (health literacy) of preventable illnesses. However, the provision of primary health care, and hence achievement of the SDGs, is hampered by several issues. First, inadequate government spending on health is exacerbated by the small proportions allocated to primary health care. Second, the shortage and maldistribution of the health workforce, and chronic absenteeism in some countries, has led to a situation in which staffing levels are inversely related to poverty and need. Third, the health workforce is not trained in multisectoral actions, and already experiences workloads of an overwhelming nature. Finally, health illiteracy is common among the population, even in developed countries. We recommend that governments increase spending on health and primary health care, implement interventions to retain the rural health workforce, and update the pre-service training curricula of personnel to include skills in multisectoral collaboration and enhanced community engagement.

Dans le présent document, nous étudions le potentiel et les limites des soins de santé primaires en matière de réalisation des objectifs de développement durable (ODD) liés à la santé. Nous formulons également des recommandations politiques pour l'instauration d'un système de soins de santé primaires efficace. Les gouvernements ont récemment réaffirmé leur engagement envers les ODD en 2018 par le biais de la Déclaration d'Astana, qui redéfinit les trois fonctions des soins de santé primaires comme suit: fourniture de services, actions multidisciplinaires et implication des citoyens. En d'autres termes, les ODD liés à la santé ne peuvent être atteints uniquement en proposant des services médicaux. Certains problèmes de santé sont inhérents à l'environnement et requièrent les efforts conjoints des partenaires locaux, nationaux et internationaux; d'autres nécessitent de sensibiliser le public (médecine préventive) aux maladies évitables. Cependant, la fourniture de soins de santé primaires, et par conséquent la réalisation des ODD, rencontre de nombreux obstacles. Tout d'abord, les dépenses inadéquates des gouvernements en matière de santé sont aggravées par le faible pourcentage octroyé aux soins de santé primaires. Ensuite, la pénurie et les inégalités de répartition des professionnels de la santé ainsi que l'absentéisme chronique dans certains pays ont débouché sur une situation où le niveau des effectifs est inversement proportionnel au niveau de pauvreté et aux besoins. Par ailleurs, le personnel soignant n'est pas formé aux actions multidisciplinaires et subit déjà une charge de travail écrasante. Et enfin, la méconnaissance des bases sanitaires est fréquente au sein de la population, même dans les pays développés. Nous conseillons aux gouvernements d'accroître leurs dépenses en soins de santé et soins de santé primaires, d'intervenir pour encourager les soignants à rester dans les régions rurales, et de mettre à jour les programmes de formation initiale du personnel pour y inclure des compétences en collaboration multidisciplinaire et en amélioration de l'engagement communautaire.

Se analizan las posibilidades y las limitaciones de la atención primaria de salud para contribuir al logro de los objetivos de desarrollo sostenible (los ODS) relacionados con la salud, y se recomiendan políticas que permitan el funcionamiento del sistema de atención primaria de salud. Recientemente, los gobiernos reiteraron su compromiso con los ODS en la Declaración de Astaná de 2018, en la que se redefinen las tres funciones de la atención primaria de salud, a saber: la prestación de servicios, las medidas multisectoriales y una mayor participación de los ciudadanos. Es decir, los ODS relacionados con la salud no se pueden cumplir tan solo con la prestación de servicios de atención de la salud. Algunos temas de salud están relacionados con el medio ambiente, lo que requiere esfuerzos conjuntos entre los asociados locales, nacionales e internacionales; otros temas requieren la concienciación del público (conocimientos sobre la salud) acerca de las enfermedades que se pueden evitar. Sin embargo, la prestación de atención primaria de salud, y por consiguiente el logro de los ODS, presenta diversas dificultades. En primer lugar, el gasto público inadecuado en salud empeora debido a los porcentajes tan reducidos que se asignan a la atención primaria de salud. En segundo lugar, la escasez y la mala distribución del personal sanitario, así como el absentismo crónico en algunos países, han creado una situación en la que los niveles de personal están relacionados de manera inversa con la pobreza y la necesidad. En tercer lugar, el personal sanitario no está capacitado para emprender medidas multisectoriales, además de que ya tiene una carga de trabajo abrumadora. Por último, la falta de conocimientos sobre salud es común entre la población, incluso en los países desarrollados. Se recomienda a los gobiernos que aumenten el gasto en salud y en atención primaria de la salud, que implementen intervenciones para fidelizar al personal sanitario de las zonas rurales y que actualicen los programas de capacitación del personal previa a la prestación de servicios para integrar las habilidades en la colaboración multisectorial y el aumento de la participación de la comunidad.

Performance of Thailand's universal health coverage scheme: Evaluating the effectiveness of annual public hearings.

BACKGROUND: Legislative provisions in Thailand's National Health Security Act 2002 mandate annual public hearings for providers, beneficiaries and other stakeholders in order to improve the performance of the Universal Health Coverage Scheme (UCS). OBJECTIVE: This study aims to explore the annual public hearing process, evaluate its effectiveness and propose recommendations for improvement. METHOD: In-depth interviews were conducted with 29 key informants from various stakeholder groups involved in annual public hearings. RESULTS: The evaluation showed that the public hearings fully met the criteria of influence over policy decision and partially met the criteria of appropriate participation approach and social learning. However, there are rooms for improvement on public hearing's inclusiveness and representativeness of participants, adequacy of information and transparency. CONCLUSIONS: Three recommendations were proposed a) informing stakeholders in advance of the agenda and hearing process to enable their active participation; b) identifying experienced facilitators to navigate the discussions across stakeholders with different or conflicting interests, in order to reach consensus and prioritize recommendations; and c) communicating policy and management responses as a result of public hearings to all stakeholders in a timely manner.

Prioritizing critical-care resources in response to COVID-19: lessons from the development of Thailand's Triage protocol.

As COVID-19 ravages the world, many countries are faced with the grim reality of not having enough critical-care resources to go around. Knowing what could be in store, the Thai Ministry of Public Health called for the creation of an explicit protocol to determine how these resources are to be rationed in the situation of demand exceeding supply. This paper shares the experience of developing triage criteria and a mechanism for prioritizing intensive care unit resources in a middle-income country with the potential to be applied to other low- and middle-income countries (LMICs) faced with a similar (if not more of a) challenge when responding to the global pandemic. To the best of our knowledge, this locally developed guideline would be among the first of its kind from an LMIC setting. In summary, the experience from the Thai protocol development highlights three important lessons. First, stakeholder consultation and public engagement are crucial steps to ensure the protocol reflects the priorities of society and to maintain public trust in the health system. Second, all bodies and actions proposed in the protocol must not conflict with existing laws to ensure smooth implementation and adherence by professionals. Last, all components of the protocol must be compatible with the local context including medical culture, physician-patient relationship, and religious and societal norms.

Contracting the private health sector in Thailand's Universal Health Coverage.

Private sector plays an import role in health service provision, therefore the engagement of private health facilities is important for ensuring access to health services. In Thailand, two of the three public health insurance schemes, Universal Coverage Scheme and Social Health Insurance, contract with private health facilities to fill gaps of public providers for the provision of health services under Universal Health Coverage. The National Health Security Office (NHSO) and Social Security Office (SSO), which manage the schemes respectively, have designed their own contractual agreements for private facilities. We aim to understand the current situation of contracting private health facilities within UHC of the two purchasing agencies. This qualitative descriptive case study was conducted through document review and in-depth interviews with key informants to understand how they contract private primary care facilities, service types, duration of contract, standard and quality requirement and renewal and termination of contracts. Private providers make a small contribution to the service provision in Thailand as a whole but they are important actors in Bangkok. The current approaches used by two purchasers are not adequate in engaging private sector to fill the gap of public provision in urban cities. One important reason is that large private hospitals do not find public contracts financially attractive. NHSO classifies contracts into 3 categories: main contracting units, primary care units, and referral units; while SSO only contracts main contracting units. Both allows subcontracting by the main contractors. Contractual agreements are effective in ensuring mandatory infrastructure and quality standards. Both purchasers have established technical capacities to enforce quality monitoring and financial compliance although there remains room for improvement especially on identifying fraud and taking legal actions. Contracting private healthcare facilities can fill the gap of public healthcare facilities, especially in urban settings. Purchasers need to balance the right level of incentives and accountability measures to ensure access to quality of care. In contracting private-for-profit providers, strong regulatory enforcement and auditing capacities are necessary. Further studies may explore various aspects contracting outcomes including access, equity, quality and efficiency impacts.

Participatory and responsive governance in universal health coverage: an analysis of legislative provisions in Thailand.

Participatory and responsive governance in universal health coverage (UHC) systems synergistically ensure the needs of citizens are protected and met. In Thailand, UHC constitutes of three public insurance schemes: Civil Servant Medical Benefit Scheme, Social Health Insurance and Universal Coverage Scheme. Each scheme is governed through individual laws. This study aimed to identify, analyse and compare the legislative provisions related to participatory and responsive governance within the three public health insurance schemes and draw lessons that can be useful for other low-income and middle-income countries in their legislative process for UHC. The legislative provisions in each policy document were analysed using a conceptual framework derived from key literature. The results found that overall the UHC legislative provisions promote citizen representation and involvement in UHC governance, implementation and management, support citizens' ability to voice concerns and improve UHC, protect citizens' access to information as well as ensure access to and provision of quality care. Participatory governance is legislated in 33 sections, of which 23 are in the Universal Coverage Scheme, 4 in the Social Health Insurance and none in the Civil Servant Medical Benefit Scheme. Responsive governance is legislated in 24 sections, of which 18 are in the Universal Coverage Scheme, 2 in the Social Health Insurance and 4 in the Civil Servant Medical Benefit Scheme. Therefore, while several legislative provisions on both participatory and responsive governance exist in the Thai UHC, not all schemes equally bolster citizen participation and government responsiveness. In addition, as legislations are merely enabling factors, adequate implementation capacity and commitment to the legislative provisions are equally important.

The efficacy of honey and a Thai Herbal Oil preparation in the treatment of pressure ulcers based on Thai traditional medicine wound diagnosis versus standard practice: An open-label randomized controlled trial.

BACKGROUND: Scientific support for Thai traditional medicine (TTM) practice is warranted for reintroduction into modern healthcare systems. A promising TTM practice for treatment of pressure ulcers was selected to conduct a clinical trial. This study aimed to evaluate the efficacy of the TTM practice for the treatment of pressure ulcers using honey or a Thai Herbal Oil preparation (THO) based on the TTM wound diagnosis comparing with the standard practice. METHODS: The study design was an open-label randomized controlled trial. Sixty-six participants, with pressure ulcers at least stage II-IV or unstageable, were allocated to two groups via minimization. A TTM practice group received honey or THO depending on the TTM diagnosis via the Thai Traditional Medicine Pressure Ulcer Assessment Tool (TTM-PUAT). A standard practice group received advanced dressings, including hydrogel, alginate, silver-impregnated, or hydrocolloid dressings. The primary outcome was the Pressure Ulcer Scale for Healing (PUSH). RESULTS: Both TTM practice and standard practice showed a significant reduction in PUSH scores after treatments. However, there was no significant difference in PUSH score reduction between the groups. The mean PUSH score reduction over the 6-week period was 2.58 ± 3.38 (95% CI 1.34-3.82) in the TTM practice group and 3.24 ± 3.49 (95% CI 1.91-4.57) in the standard practice group (p = 0.284). The TTM practice and standard practice accelerated pressure ulcer healing without statistically significant difference between the practices, during 6 weeks in a home-based care setting. This finding supported the TTM practice as an alternative treatment for pressure ulcer.

Medicinal plants used with Thai Traditional Medicine in modern healthcare services: a case study in Kabchoeng Hospital, Surin Province, Thailand.

ETHNOPHARMACOLOGICAL RELEVANCE: Thai Traditional Medicine (TTM) is available in many modern hospitals in Thailand. However, there have been difficulties in integrating TTM, particularly the practices of the use of herbal medicines, into modern healthcare services. Kabchoeng Hospital is one hospital that has been able to overcome these difficulties. Thus, this study aimed to document the successful utilization of herbal medicine at Kabchoeng Hospital. The documentation focused on both the knowledge of medicinal plants and the success factors that facilitated the utilization of herbal medicine in the context of a modern hospital in Thailand. MATERIALS AND METHODS: Kabchoeng Hospital was intentionally selected for this case study. Participatory observation was used for the data collection. There were six groups of key informants: three applied Thai Traditional Medicine practitioners (ATTMPs), a pharmacist, two physicians, two folk healers, the head of an herbal cultivation and collection group, and 190 patients. The plant specimens were collected and identified based on the botanical literature and a comparison with authentic specimens; these identifications were assisted by microscopic and thin layer chromatography (TLC) techniques. RESULTS: Eighty-nine medicinal plants were used for the herbal preparations. The ATTMPs used these plants to prepare 29 standard herbal preparations and occasional extemporaneous preparations. Moreover, in this hospital, seven herbal preparations were purchased from herbal medicine manufacturers. In total, 36 preparations were used for 10 groups of symptoms, such as the treatment of respiratory system disorders, musculo-skeletal system disorders, and digestive system disorders. Four success factors that facilitated the utilization of herbal medicine at Kabchoeng Hospital were determined. These factors included a proper understanding of the uses of herbal medicines, the successful integration of the modern and TTM healthcare teams, the support of an herbal cultivation and collection group, and the acceptance of the local people. CONCLUSIONS: The practices that support the use of herbal medicine at Kabchoeng Hospital illustrated the successful application of TTM and also represented a model for the integration of TTM, and particularly the use of herbal medicine, into modern hospitals. This integration will be beneficial for sustainable healthcare systems in Thailand and in other countries where modern medicine is the mainstream medical system.