The document discusses the development of primary care systems in Bangkok, addressing the meaning of primary health care (PHC), its design, and future actions. It covers various essential aspects of PHC, including basic medical services, health promotion, and the integration of services at different levels. The text also highlights challenges such as continuity and coordination of care, and proposes a focus on community-based healthcare solutions in the upcoming year.

1. Development of Primary Care Systems in Bangkok:
Opportunities and Challenges
ผศ.นพ.บวรศม ลีระพันธ์
การอบรมเชิงปฏิบัติการขับเคลื่อนการดำเนินงานทีมหมอครอบครัวในกรุงเทพมหานคร
โรงแรมมิราเคิล แกรนด์ คอนเวนชั่น
1 กันยายน 2559
Pix source: ra.mahidol.ac.th

2. Outline
Pix source: online.wsj.com
Q1: What do we
mean by “PHC”
in the contexts of
BKK/Thailand?
Q2: What are the
“care designs” for
PHC in BKK?
Q3: What can
we do (or try to do)
in the next year?

3. Q1: What do we mean by “PHC” in the
contexts of BKK/Thailand?
(ปฐมภูมิหมายถึงอะไร?)
Pix source: online.wsj.com

4. What Do You Mean by “Primary Care”?
1. Basic medical services
2. Self-care, and health for all
3. First-contact, continuous, coordinated, and
comprehensive care
4. Health promotion practices, and actions on social
determinants of health
(=What a layman usually thinks of primary care)
(The Declaration of Alma-Ata 1978)
(Starfield 1992, 1998)
(Ottawa Charter 1986, The 66th World Health Assembly 2013)

5. Action on Social
Determinants of Health
(การสร้างเสริมสุขภาพ)
Community-based
Primary Healthcare
(การสาธารณสุขมูลฐาน)
Primary Care Medicine,
Family Medicine
(เวชศาสตร์ปฐมภูมิ, เวชศาสตร์ครอบครัว)
Basic Medical Care
(บริการการแพทย์ระดับพืDนฐาน)
• Health promotion practice at
the population health level
• “Health in All Policies”
• Self-care
• Community health worker
• Community health volunteer
• “Health for All”
• First-contact care
• Continuous care
• Coordinated care
• Comprehensive Care
•Health center (สอ./รพ.สต.)
•OPD, physician office
•Mobile medical units
What Do You Mean by “Primary Care”?

6. Community-based
Primary Healthcare
Clinical Practices
at Primary Care
Level
“The Doughnut Hole” of Primary Care
• Primary care services in developed
countries
• Medical facilities in urban settings
• Medical facilities in private-sector
(without public health functions)
• Primary care services in
developing countries
• Medical facilities in rural settings
• Medical facilities in public-sector
(with public health functions)
Ø What exactly policies & systems are we talking about?

7. Q2: What are the “Care Designs”
for PHC in BKK?
(การออกแบบบริการระดับปฐมภูมิเกี่ยวข้องกับอะไรบ้าง?)
Pix source: online.wsj.com

8. “Level” of Healthcare Delivery Systems:
(Only Acute Care?)
Primary Health Care
(population-level, public health-type functions)
What’s probably missing?
• How’s about Sub-acute Care?
• How’s about Emergency Care?
• How’s about Long-term Care?
• How’s about Palliative Care?
• How’s about Hospice Care?
Community
(Self-care)
Primary Care Services
(family doctor-type services)
Secondary Care Services
Tertiary Care Services
Supra-tertiary/Quaternary Care Services
2
3
1

9. Source: W. Simpson del.; E. Walker lith.; Day & Son, Lithrs. to the Queen.
Pix source: http://en.wikipedia.org/wiki/History_of_hospitals#mediaviewer/File:Hospital_at_Scutari_2a.jpg
“Hospital at Scutari” - A ward of the hospital at Scutari where
Florence Nightingale worked and helped to restructure the modern hospital

10. Dealing with the Care Cycle
Source: Tishihiko Hasegawa (2013)

11. Source: Macagba, R. L. (1985). Hospitals and Primary Health Care: An International Study from the International
Hospital Federation. In M. Hardie (Ed.), World-wide survey on the Role of Hospitals in Primary Health Care. London:
International Hospital Federation.

12. Q3: What can we do in the next year?
(แนวทางการทำงานในระยะสั้นคืออะไร?)
Pix source: online.wsj.com

13. Delivery of PHC Services
Pix source: www.free-ed.net/free-ed/HealthCare/Physiology/default.asp
Structure & Organizations
of primary care services
• Patient Care Teams
• PCUs/Clinics
• Systems/Networks
• Governance policies
Four Cardinal Functions
of primary care services
• First Contact/Access
• Continuity
• Coordination
• Comprehensiveness
“Anatomy of Primary Care” “Physiology of Primary Care”

14. First
Contact/Access
Continuity Coordination Comprehensivenes
s
• Cost sharing
• Distance to PC
practice
• Distribution of
PC physicians
• List size
• Home visits in
PC
• Electronic access
• Computerization
of the practice
• Patient habits
with first contact
visits/referrals
• Endurance of
patient–provider
relationship
• PC practice
management
• Collaboration
among
practitioners
• Referral system
• Shared care
arrangements
• Premises,
equipment
• Medical
procedures
• Preventive,
rehabilitative,
educational
activities
• Disease
management
• Community links
• Technical skills
Desirable PHC Functions
Source: WHO/Europe (2010)
Ø Selected proxy measures from WHO/Europe’s Primary Care Evaluation Tool (PCET)

15. Traditional Work Flow in Clinics
(Cambridge Health Alliance, US)
Pix source: Southcentral Foundation & Institute of Healthcare Improvement (2010)

16. Redesign: Parallel Work Flow in Clinics
(Cambridge Health Alliance, US)
Pix source: Southcentral Foundation & Institute of Healthcare Improvement (2010)

17. Pre-visit Work in Geriatric Care
Pix source: Harvard Vanguard Medical Associates & Institute of Healthcare Improvement (2010)

18. Care Coordination: EMR
Pix source: Bates et al. (2003). A Proposal for Electronic Medical Records in U.S. Primary Care

19. Care Coordination Innovations
(UnitedHealth Group, US)
Pix source: Lewis G. Sandy (2010). AcademyHealth 2010 Annual Research Meeting June 29, 2010

20. Pix source: www.noogenesis.com/pineapple/blind_men_elephant.html
Integrated Healthcare & Systems Thinking
John Godfrey Saxe's ( 1816-1887) version of the famous Indian legend

21. Pix source: www.simoncamilleri.com/the_truth_of_the_elephant/
Integrated Healthcare & Systems Thinking

22. Source: alumni.harvard.edu (2010).

23. Pix source: www.davidco.com
“You can do anything, but not everything.”
--David Allen, Getting Things Done