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Journal of Public Health and Development Vol. 14 No. 3 September-December 2016
INVITED ARTICLE
District Health System Management Learning: A big leap forward to people-centred District Health System in ThailandYongyuth Pongsupap1, Surakiat Archananuparp2, Tawekiat Boonyapaisarncharoen3, Phitthaya Srimuang4, Srisuda Ngamkham5, Chitsupang Tiptiengtae6, Piyanuch Promsaka na sakolnakorn7 and Patrick Martiny8
1Ph.D.NationalHealthSecurityOffice,Bangkok,Thailand2M.P.H.FolkDoctorFoundation,Bangkok,Thailand3M.P.H.InstituteofCommunityBasedHealthCareResearchandDevelopmentFoundation,BangkokThailand4Ph.D.SirindhornCollegeofPublicHealth,KhonKhaen,Thailand5Ph.D.BoromarajonaniCollegeofNursing,SawanpracharakNakhonsawan,Thailand6M.N.S.BoromarajonaniCollegeofNursing,Ratchaburi,Thailand7M.N.S.BoromarajonaniCollegeofNursing,Udonthani,Thailand8M.P.H.InstituteofHealthandSociety(IRSS),CatholicUniversityofLouvain(UCL),Belgium
Corresponding author:YongyuthPongsupapEmail: [email protected]:19September2016Revised:5October2016Accepted:20October2016Available online:October2016
Abstract
PongsupapY,ArchananuparpS,BoonyapaisarncharoenT,SrimuangP,NgamkhamS,TiptiengtaeC,Promsakana sakolnakornP andMartinyP.DistrictHealthSystemManagementLearning:Abig leap forward to people-centredDistrictHealthSystem inThailandJPubHealthDev.2016;14(3):3-12
ReinforcementofDistrictHealthSystemworkforcecapabilitieshasbeenboostedfrom2007onwardsthrougha“ContextBasedLearning”approach and evolved through actions and reflections of threemain sets of experiences: i) PrimaryCarePracticeLearning started in 2007; ii)FamilyPracticeLearning started in 2012; and iii)DistrictHealthManagementLearning (DHML) started in 2014. DHMLaimstofacilitateeffectivenetworkingforpeople-centredDistrictHealthSystemthroughtheprocessofParticipatoryInteractiveLearningthroughActions(PILA).ALearningTeam(LT)issetupineachparticipatingdistricttolearnfromonelocalhealthdrivenprojectexpectedtoimproveonDHSdevelopmentandqualityoflifeofthepeople.TheLTisusuallymadeof2-3membersfromthehospital,2-3fromthedistricthealthofficeandhealthcentres,2-3fromnon-health,especially,peoplesector.Forprojectimplementation,thelearningteaminteractswithseveralactorswithintheDHSandalsobeyonditslimits:the“operationalnetwork”.SystematiclinksareestablishedbetweenLTsandsupportiveactorsbuildinginthiswayalarge“learningnetwork”:alocalPreceptor(P)whodirectlysupportstheLTinthefield;aLearningandCoordinationCentre(LCC)inchargeoffacilitatingregularexchangeamong4-5LTswithinthesamelearningnetwork;AcademicInstitutions(AI),someagentsofwhichparticipatesystematicallyinalllearningprocess(assignedAI),othersparticipatingonlywhenspecificexpertiseisneededinrelationtoacademicmenus(AIondemand);andSources ofLearning (SL) for learning from site visits and relevant experts.Core competencies (self-control, vision and goals, planning,leadingforchange,workinginteam,andusingmanagementtools)andshadowcompetencies(values,relationships,communication,andpowermanagement) are expected to increase and to be accepted as necessary competencies formanagement ofDHS. Developmental evaluation, focusing on theory-driven, and realist evaluation, had been carried out systematically by the promoterssince the beginning of the implementation (from June 2014 toAugust 2016), with the periodic and systematic participation of an in-ternational guest expert, and supported by data collection of a Thai academic team. Themethods for collecting datawere participatoryobservationof theDHMLprocessesandreflections(atdistrict,provincial, regional,andnational levels),visitsofseveralDHMLlocalprojectsandinterviewsofkeypersonsrelatedtoDHMLandaquestionnairesurvey.From2014to2015,227LTs,216Ps,44LCCs,52AIs,andseveralSLsindifferentregionsofthecountryhaveparticipatedintheprocessasDHMLpioneers(from2015to2016,hadgraduallybeenincreasing).The definition of core and shadow competencies ofmanagement ofDHSwaswell accepted by all participants; significant improvement ofself-control(forbetterlistening)andworkinginteamamongthecorecompetencies,andofallfourcompetenciesamongtheshadowcompeten-cieswasqualitativelyexpressed throughstories telling,narrativeswriting,andsystematic interviews.Learningnetworks (AIs-LCCs-Ps-SLs) tosupport thecurrentandsubsequentbatchesofLTsweresuccessfullyestablished.Matrix teams/links/networks in thedistrictsweresignificantlyfacilitated and supported through the implementation of theDHMLprojectswith a clear direction towardperson- andpeople-centred care. DHMLfits into a sustainable comprehensive and continuous grounded capacity buildingwhich is now functioning inmost districts inThailand and still evolving.Several teams and facilitating conditions arebeing set up inorder toworkbetter together: functional relationship,continuously learn together: learning relationship, strengthen theorganisation together:managerial relationship, for sustainabledevelopment ofpeople-centreddistrict health systems.
Keywords:ContextBasedLearning,DistrictHealthSystemManagementLearning,DistrictHealthSystem,People-CentredCare.
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Introduction Moving from hospital- toward people-centred
district health systems has benefited in Thailand
from dramatic reinforcement of infrastructure and
staffing in the periphery (community hospitals,
healthcentres),andsimultaneouslyfromprogressive
physicians’concernforprimarycare.Theuniversalhealth
coverage scheme launched in the2000s encouraged
interactionbetweenlevelsofcare:primarycarestarted
tobefinancedthrough“contractingunitsforprimary
care”madeofproximityunitslinkedwithatleastone
physicianusuallyactiveinahospital.Reinforcement
ofDistrictHealthSystem(DHS)workforcecapabilities
has been boosted from 2007 onwards through a
“Context Based Learning (CBL)” approach1, the
mainfeaturesofwhicharestartingfromactivitiesin
theworkingcontextandeffectiveinteractionwithin,
andbetween,alllevelsoflocalhealthandsocialcare
system (district, sub-district, village, and family)2-3.
CBLaimsatbeing“participativeinteractivelearning
through action (PILA)4”: learning by doing specific
actionsinone’sowncontext,exchangingexperiences
of actions in different contexts, sharing common
values andprinciples inorder to learn fromand for
further actions.
In 2007,CBLwasfirst introduced by focusing
atexistinghealthcentrestaff,Primary Care Practice
Learning (PCPL), as a complementary strategy to
formal training in order to improve on their skills
in such away they could effectively contribute in
quality care provisionwithin their integrated health
care system5.Family practice learning (FPL)was
consequently organized in 2012 to provide family
doctorswithskillsrelatedtoqualitypatient-centered
careandsimultaneouslyskills tosupport thedistrict
healthsystem6-7.District Health System Management
Learning (DHML)was eventually set up in 2014.
EvolutionofCBLcouldbesummarizedasinFigure1.
Figure 1 Theprocesses of spirallingup through actions and reflections of evolutionofCBL
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Journal of Public Health and Development Vol. 14 No. 3 September-December 2016
DHML does not target the managers of the
health system,only,butall staff involved indistrict
healthsystemdevelopment.Itisamovetoreinforce
partnershipbetweenthedistrictkeystakeholdersand
actors, and their capabilities towork together for
improvingondistricthealthsystemmanagementand
strengthening,andconsequentlyhealthandwellness
of the target populations.
DHML: Design and Implementation DHMLconcernsanystaffinvolvedinreinforcing
health systemorganizationandaims to facilitate ef-
fectivenetworkingforpeople-centredDistrictHealth
Systemthrough theprocessofParticipatoryInterac-
tiveLearning throughActions(PILA). Inparticular,
itintendstotrainthedistricthealthsystemmanagers
andmanagementactorsthroughtheirsupportstoone
districthealthproject.Theyshouldhavecomprehensive
visionandprinciplesofhealthdistrictmanagement,as
wellascommongoalsandcomplementarymissions,
in order to fully cooperate and integrate their own
specific interventions, and resources, in thewhole
district development process: they are expected to
workandlearntogether,aswellastodeveloptogether
thehealthsystem.DHMLparticipantscanlearnfrom
theprojectthroughprojectimplementationespecially
onbetterunderstandingtheirlocalhealthsystemand
developingrelationshipsforeffectivenetworkingfor
people-centreddistrict health system.They can also
learn about new concepts,methods, and tools for
amore effective of the project implementation. It
is advised that selected project for learning should
focus on a specific but complex issue, and involve
different levels, i.e. village, health centre, hospital,
inthedistrict,andfromdifferentsectors,especially,
people sector.
Amanual of DHMLwas developed to be a
guideline for implementation8. To startDHML, a
coreteamwasestablishedandpromoterscoachedthe
processesandaprocessofdevelopmentalevaluation
in health system research9-10was also started.
Therearesixcorecompetencies tobeacquired:
self-control, vision and goals, planning, leading for
change,working in team, usingmanagement tools.
There are also four “shadow” competencies,which
should be “like one’s shadow” related to values
andnorms, relationships,communicationandpower
management.Objectivesgobeyondthereinforcement
of knowledge and know how,DHML aims at the
transformationofthebeingofindividuals,appropriate
egotoharmonizewithothers,aswellastostrengthen
teamsandsystemasawhole.Thesecoreandshadow
competencies have basically been developed from
commoncompetencies forallhealthcaremanagers,
complexitiesandpossibilitiesofdistricthealthsystem
management, and a reviewof the literature.11-13.
ALearning Team(LT)issetupineachpartici-
patingdistrict to learn fromone local health driven
project expected to improve onDHS development
andquality of life of the people.TheLT is usually
made of 2-3members from the hospital, 2-3 from
thedistricthealthofficeandhealthcentres,2-3from
not-health andpeople sector, all are involved in the
districtproject.Forprojectimplementation,thelearning
teaminteractswithseveralactorswithintheDHSand
alsobeyond its limits: the“Operational Networks”.
Systematic links are established between LTs
and supportive actors building in thisway a large
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“Learning Network” (Figure 2).The learning teams
are accompanied by a local “Preceptor” (P)who
providescoachingandtechnicalsupport inthefield.
Eachdistrictlearningteamclusterswithotherteams
(thereare4-5districtlearningteamsineachcluster);
they attend during one year at least five “two-day”
workshops in order to exchange on their district
projectdevelopmentandlearningprocess.Academic
Institutions (AI) provide additional support. Some
academics participate systematically in all learning
process (assignedAI): theyparticipate in thework-
shops, provide specific inputswhen it is necessary,
validatethelearningprocessandalsolearnthemselves
fromthefield(theyneedtofeedtheirteachingatthe
university).Othersaremobilizedonlywhenspecific
expertise is needed in relation to eleven academic
menus(AIondemand).Foreachcluster,anorgani-
zation plays the role ofLearning and Coordinating
Center” (LCC).There is no standardprofile for the
LCC: itmay be a community hospital, a teaching
institution, a provincial health office ... depending
on theirpotentials andwillingness.Within theclus-
ter, each learning team’s district is considered as a
learningsitefortheothers.Additionally,districtsand
expertsoutstandingforaspecificissueareidentified
as“Source for Learning”(SL)andusedondemand,
only.Theyareproposedtoanylearningdistrictteam,
orcluster, forstudyfieldvisits. It isnot foreseen to
have“demonstrationdistricts”, sincealldistrictsare
continuously developing and learning.Districts are
complex adaptive systems.
Figure 2 A learningnetwork forParticipatory InteractiveLearning throughActions inDHML
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Journal of Public Health and Development Vol. 14 No. 3 September-December 2016
Fourmain learning situations are defined: i)
continuouswork of learning teammemberswith
concernedactorsandoperationalnetworks;ii)meet-
ingsamonglearningteammembers;iii)meetingsof
learning teammembers and their preceptor; and iv)
workshopsattendedbyLTsandtheirsupportiveactors
under the samenetworkofLCC.Thefirst situation
isconsideredtobethemost importantsinceDHML
intends to transformnotonly the learning team,but
alsotheirmanagersandthedistricthealthsystemas
awhole,
In order to increase the capacities, learning
material, as supportive information in relation to
district health system, is offered in a set of eleven
“menus”14-15. Participants are expected to select and
mobilizethelearningmaterialtheyneed:structuring
papers, PowerPoint presentations, scientific papers,
textbooks, videos, list of resources persons to be
mobilized for conferences. Theymust decide on
their own, they are empowered.Theymayhowever
be supported to that effectby theirP,LCCandAI.
ThemenusforDHMLare thefollowing:vision
(principles)andgoals;situationanalysis;healthprob-
lems,includingriskfactorsanddeterminantsofhealth;
healthcareorganization;healthsystemmanagement;
healthplanningandmanagementcycle;managementof
humanresourcesandappropriateuseoftechnologies;
communityparticipationand intersectoralcollabora-
tion;healthmanagementinformationsystem;financial
management; and evaluation.
Evaluation of DHML Developmentalevaluation,focusingontheory-driven
and realist evaluation10,16,17, had been carried out
systematicallybythepromoterssinceatthebeginning
of the implementation, from June 2014 toAugust
2016,with a periodical and systematic participation
ofaninternationalguestexpert18-19,andthesupportof
datacollectionbyaThaiacademicteam20.Methodsof
datacollectionfordevelopmentalevaluationincluded:
• Systematicandparticipatoryobservationsand
reflections (at district, provincial, regional,
andnationallevels)includingvisitsofseveral
DHMLlocalprojectsforcontinuouslycontext
specific adaptation of theDHMLprocess by
thepromotersinalmostallclusters(eachclus-
ter havingLCC as a focal point) ofDHML
pioneers.
o The team of Thai academics and the
international guest expert have
periodically and systematically
participated in the process.
• Semi-structured interviews (purposive sam-
pling)by the teamofThai academics incol-
laborationwith the international guest expert
o Individual interviews included: execu-
tives ofMinistry of Public Health,
NationalHeath SecurityOffice, and
Academic Institutions (altogether 8
interviewees);
o Focus group interviews: academicians
from Academic Institutions who
participated to DHML process (12
academicians from different AIs);
Committees of Learning andCoordi-
nating Centres (40 persons from
differentLCCs);andPreceptors(10Ps)
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• A questionnaire surveywas carried out by
the team of the Thai academics in order to
understand experiences of Learning Teams
(180 respondents fromdifferentLTs).
All findingswere presented and discussed in
severalmeetings. Lessonswere sorted according
to a framework of analysiswhich focuses on five
issues:DHMLlearningprocessthroughthecommon
district project implementation, the development of
the supportive learningnetworks, the acquisitionof
newcompetencies,theimprovementofhealthdistricts
responsiveness and the teaching transformation in
related academics institutions.
The scenario has been effectively implemented
as expected. Learning networks have been set up
accordingtotheguidelines:From2014to2015,227
LTs, 216Ps, 44LCCs, 52AIs, and several SLs in
different regionsof the countryhaveparticipated in
theprocessasDHMLpioneers.From2015to2016,
the networkshavegradually been increasing.
Therewashighdiversityintheconcretesituations.
However,somecommonprojectssuchashome-based
long-term care, comprehensive interventions on
non-communicable diseases, community psychiatry,
andhealthpromotionfocusingonsocialdeterminants
of healthwere commonly selected as projects for
learning.
DHMLprocesses could significantly stimulate
developmental networks in the districts both intra-
andinter-sectoralcollaborationswithacleardirection
towardperson- andpeople-centred care. (Figure 3).
Matrix teams/links/networks in the districtswere
significantly facilitated and supported through the
DHMLproject implementation.
Figure 3 Overall directionof implementation of the projects inDHML
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Journal of Public Health and Development Vol. 14 No. 3 September-December 2016
Altogether, it was found that DHML was
feasible and delivering some valuable concrete
results.Synthesesofexperiencesofimplementationof
theprojectsarebeingdoneandcategorizedasparts
andforfurtherdevelopmentofacademicmenusand
sorts for learning.
Network development was impressive, both
within the districts and beyond their borders.Each
net-working has been growing up around eachLT.
Learning networks (AIs-LCCs-Ps-SLs) to support
the current and subsequent batches of LTswere
successfully established. Districts exchange their
experiences, and the linkbetween academic institu-
tions is reinforced.
Thedefinitionofcoreandshadowcompetencies
ofmanagement ofDHSwaswell accepted by all
participants; significant improvement of self-control
(individual’s change) andworking in team among
thecorecompetencies,andofall fourcompetencies
among the shadow competencieswas qualitatively
expressed through stories telling, narrativeswriting,
and systematic interviews. There was not much
focusontechnicalcapacities:itisfirstmakingbetter
use of their already existing tacit knowledge, then
if necessarymobilizing explicit knowledge from
external experts.
Individual’schange(changingtheself:self-control,
open-mindedness,listeningcapacities…)inorderto
synchronize and harmonizewith others had signifi-
cantly been focused inDHMLand considered as a
significantpartofDHMLinrelationtotransformative
learning21.
Many academics faced difficulties to play their
expected role in the frameworkofDHML: teaching
muchless,butsupportingthelearningprocess.Learners
mainly learnedfromtheirpractice in theframework
ofDHMLandcouldexchangetheirexperiencesand
challengesduringseveralmeetings:attheworkshops
of LCCs, and also at regional and national levels.
Consequently, formalworkshopswere organized to
prepare theAIs.
LittleusewasmadeofpossibleAIsondemands.
Transformation ofAIswas eventually significantly
observed in termsof interactionwithfield actors in
specificDHS contexts, aswell as of their teaching
methods in their institutions.
During the field visits, some resources persons
expressed theirconcernaboutDHMLsustainability,
continuity.All participants claimed that they enjoy
the DHML process and didn’t want to stop. On
participants’ demand, additional workshops have
alreadybeenorganized for a betterwrappingup of
theone-yearDHMLprocess.SomeLTsclaimedthat
theymaycontinuetomeetontheirownwithoutany
financialsupport.Therehasbeenrecruitmentofnew
learning teams (a second batch) and new districts.
Financial resourceswere thereforemobilized.Some
formerparticipantsmaytrytoattendasguestwork-
shops organized for the new learning teams. Some
first batchLTsplay now the role ofLCCs,making
profit of their experiences.
Discussion CBL (including PCPL and FPL as part of its
evolution)was initially introduced focusingmainly
onhealthcare services, especially targetingexisting
healthcareprofessions.Itwasconsideredasacom-
plementary strategy to their formal training, aiming
atimprovingontheirskillsinsuchawaytheymight
effectivelycontributeinqualitycareprovisionwithin
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their integrated health care system. Consequently,
DHML,anewsustainabledynamicinDHSmanage-
ment, putting the operational staff and community
first, bringing all actors related to health together,
beingsupportedbythoseinchargeofhealthmanage-
mentwithin the district.CBLprogressively became
a comprehensive concept, evolving through three
mainsetsofexperiences (PCPL,FPL,andDHML),
a “working-learning-developing” life style ofDHS.
It must be stated that CBL didn’t start from
scratch, but aimed at filing the gap between the
existing dynamic and the expectedDHS situation.
Each situation should be considered as specific to
each context of theDHS.Standardized introduction
ofCBLcouldhavedisempoweredandfrustratedthe
staff, destroying the already existing.
AlthoughDHMLwasanewintervention,based
on aworking hypothesis related to both feasibility
and results, it has been immediately initiated at
largescale,becauseofcontextualfeatures.However,
implementingDHMLon a large scale has created
anothermomentum, which has influenced a lot,
feelings and ideas, aswell as commitment of all
actors.Ownership ofDHML, at least as concerns
the general principles, is shared. It is a bottom-up
approach.DHMLbecame a booster of the synergy
between evolutionofCBLandmovements ofDHS
strengtheningasawhole:DHMLextensiveexperience
was able to influence policymakers and reinforce
advocacy for the district health system.
Ascapacitybuilding,DHMLfits intoasustain-
ablecomprehensiveandcontinuousgroundedcapacity
building systemwhich is now functioning inmost
districts inThailand and still evolving.
Asorganisationdevelopment,several teamsand
facilitatingconditionsarebeingsetup,forexamples
DistrictHealthBoard, FamilyCareTeam,Primary
CareCuster, etc., in synergisticwaywith evolution
ofDHMLandCBLinordertoworkbetter together
(functionalrelationship),continuouslylearntogether
(learning relationship), strengthen the organisation
together (managerial relationship), for ultimately
makingthesystemresponsivetopeople’sneedsand
demandsfordevelopmentofPeople-CentredDistrict
HealthSystemas awhole.
Asnetworking,especiallyforlearningteams,not
onlytheirknowledgeshouldbeshared,theirdynamic
should be expanded: horizontally (to actors at the
samelevel),vertically(toactorsatotherlevelsofthe
system),anddiagonally inorder to focusonquality
of life andwell-beingof every individual person in
the system.
Conclusion and Prospects DHMLfitsintoasustainablecomprehensiveand
continuousgroundedcapacitybuildingwhichisnow
functioning inmost districts in Thailand and still
evolving. Several teams and facilitating conditions
are being set up in order towork better together
(functionalrelationship),continuouslylearntogether
(learning relationship), strengthen the organisation
together (managerial relationship), for sustainable
developmentofpeople-centreddistricthealthsystems.
Movingfromhospital-focusedhealthcaretoward
people-centredDistrictHealthSystemhasbenefitedin
the frameworkofDHML from systemic interaction
amongactorsfromdifferentsectors:thehealthsector,
othernon-healthsectors,andespeciallypeoplesector.
DHMLdynamic is expected to last andextend, and
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Journal of Public Health and Development Vol. 14 No. 3 September-December 2016
contribute to a sustainable development of people-
centred District Health System, which is going
alongwiththeglobalstrategyonpeople-centredand
integratedservicesoftheWorldHealthOrganization22.
The strategywas recently approved by theWorld
HealthAssembly23.
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