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Chapter One: Introduction Chapter One: Introduction 1.1 Introduction This chapter introduces the background of the research conducted for this thesis. The first part of the chapter discusses the concept of primary health care (PHC), the reforms to PHC in the Thai healthcare system, the details of the Sub-district Health Promoting Hospital (SHPH) Policy, who frontline managers are and the challenges they face, the importance of leadership and management development for frontline managers, and the research literature relevant to this thesis topic. The second part of the chapter presents the aims and the significance of the thesis. The final part of the chapter discusses the research methodology, the researcher‘s perspective, the limitations of the research and the thesis structure. 1.2 Background of the thesis PHC is one of the crucial components in a healthcare system. It is a first point of contact for a patient in the healthcare system and provides an integrated and continued health service by a multidisciplinary team. PHC, therefore, needs to be accessible, acceptable and affordable to the entire population (Pritchard, 1978, p. 11; Saltman et al., 2006, pp. 5-17; Starfield, 1998, p. 26; WHO, 1978, 2008). PHC, based on the holistic comprehensive approach, has been implemented worldwide, including in Thailand, with the ultimate goal of reducing health problems, improving the effectiveness of the health service system (Jirojwong & Liamputtong, 2009, p. 27; Walley et al., 2008), building community capacity (Green, 1999, p. 55; Walley et al., 2008), increasing social justice (Braveman & Tarimo, 2002; Gillam, 2008; Green, 1999, p. 51) and achieving the sustainable development of health and wellbeing (McMurray, 2007; Walley et al., 2008). In accordance with the 1978 Alma-Ata Declaration (WHO, 1978), there was a major policy shift to the PHC philosophy in the 4th – 5th Five-Year National Health Development Plan (1977-1986) of Thailand in order to achieve the long-term goal of ―Health for All by the Year 2000‖ (Bureau of Policy and Strategy, 2009, p. 15; Office of Primary Health Care, 1 1985, p. 32). The Thai government attempted to expand the health infrastructure to cover all rural communities and to decentralize health sector management to provincial, district, sub- district and village levels (Bureau of Policy and Strategy, 2009, p. 11). In 1980, the Tambon (sub-district) health centre1 was created as the place for interaction between the government and villages (Ingavata, 1990). Over the past three decades, the Thai government has attempted to develop the PHC system by implementing various reforms and innovations (Wibulpolprasert, 2011; Wibulpolprasert, Tangcharoensathien, & Kanchanachitra, 2008), including implementing the Healthy Public Policy strategy in line with the Ottawa Charter Promotion in 1986 (Bureau of Policy and Strategy, 2009, p. 15), the decade of healthcare development in 1992 (Ramasoota, 1997), the Health Decentralization Policy in 1999 (Krueathep, 2004; Srisalux et al., 2009; Tima, Srisasalux, & Taearak, 2009; WHO, 2002), the Universal Health Coverage Policy in 2001 (Bureau of Policy and Strategy, 2009, p. 16; Ramesh, 2009), the Healthy Thailand Policy in 2004 (Bureau of Policy and Strategy, 2009, p. 55) and, recently, the SHPH Policy in 2009. The SHPH policy was announced on 29 December 2008 and implemented by the MoPH in 2009 in order to reorient PHC services to focus more on proactive health promotion in the community. The policy aimed to improve the efficiency, quality and equity of the healthcare system by upgrading 9,769 Primary Care Units (PCUs) to SHPHs (MoPH, 2010a; Ministry of Public Health, Ministry of Social Development and Human Security, & Ministry of Labour, 2011; The Government Public Relations Department, 2009; Tima & Sealim, 2012; Wibulpolprasert, 2011, pp. 262, 280, 336). The SHPHs are public health agencies with 33,225 health personnel at the primary level of the administrative structure of the MoPH (Wibulpolprasert, 2011, pp. 336-337). Therefore, the SHPHs are the first point of contact for people in the catchment community to access PHC services (Bureau of Policy and Strategy, 2009). SHPHs are administrated by PHC managers who are either public health officers or registered nurses, endorsed to hold the position of manager (Bureau of Policy and Strategy, 2009; MoPH, 2011). There were 9,769 PHC managers in 2009. These frontline managers are 1 This name was changed to ‗Primary Care Unit‘ in line with the Universal Health Coverage Policy of 2001 and later to ‗Sub-district Health Promoting Hospital‘ in line with the Sub-district Health Promoting Policy of 2009. 2 the largest management group in the administrative structure of the MoPH (Bureau of Policy and Strategy, 2009; Wibulpolprasert, 2011, p. 337). They have a managerial role within the SHPHs, among stakeholders' organizations and in the catchment community, and the role is changing as the SHPH policy develops (Bureau of Policy and Strategy, 2009; Office of the Civil Service Commission, 2009). Health services organizations operate in complex and dynamic circumstances (Clinton, 2004, p. 99; Shortell & Kaluzny, 2006, p. 64). Frontline managers in health services organizations are faced with challenges, such as the variety of community needs beyond the sphere of influence of the managers (Clinton, 2004, pp. 104-105; Egger et al., 2005), the lack of functional support systems and inadequate working environment to support good management (WHO: SEARO, 2007), the low confidence and abilities in health services management (Burns, 2007; WHO, 2007), and the pressure of high expectations of both clients and top-down managers (Burns, 2007). Other challenges are changes in demographics with the ageing of the population shifting the incidence of disease from acute to chronic, and continuing technological development (Grant, 2010; Harris, 2006; Shortell & Kaluzny, 1997, p. 44). Changing healthcare policies and the restructuring of health services organizations can add additional complexity by affecting the clarity of roles of frontline managers (Clinton, 2004, p. 106; Egger et al., 2005). These challenges have influenced the performance of frontline managers and have contributed to high turnover and failure rates (Burns, 2007; Egger et al., 2005). As a consequence, healthcare systems are losing valuable human resources and incurring significant costs to repeatedly fill vacant positions (Burns, 2007; Egger et al., 2005). Given the challenges facing frontline managers and the attention placed on improving healthcare systems to achieve the Millennium Development Goals (MDGs), the search for ―managers who can lead and leaders who can manage‖ has become an important focus for health services policy (WHO, 2007, p. 1). Human resource development in leadership and management to increase the competencies of frontline managers to manage and lead complex healthcare organizations must be given a much higher priority in today‘s health services system (Burns, 2007; Egger et al., 2005; Filerman, 2003; Isouard, 2010; John & Sue, 2007). In Thailand, the Phitsanulok Declaration of the First International Conference on Health 3 Services Delivery Management affirms that leadership and effective health management are vital to the delivery of quality PHC in local rural district health services (Briggs at al., 2010). Since the 2009 SHPH reforms were introduced, studies have attempted to evaluate the successes and challenges of implementing the SPHP from various perspectives, such as from the perspective of health providers, clients and stakeholders (Kaewkim et al., 2012; Neelasri, 2011; Petcharatana et al., 2010; Suwanthong et al., 2012; Tima & Sealim, 2012). The studies, utilizing differing methodologies and study contexts, demonstrate that the implementation of the SHPH policy could enhance health services at the PHC level. Other studies have identified the competencies and characteristics of health professionals working at the SHPHs, such as nurses, public health officers and PHC managers (Arunperm & Sriruecha, 2011; Arunsang & Boortanarat, 2011; Bouphan, 2012; Iemrod et al., 2011; Iemrod & Jenausorn, 2012; Malai & Bouphan, 2010; Nontapet, Isaramalai et al., 2008; Puncha & Bouphan, 2011; Puphanpun & Bouphan, 2011; Yompuk et al., & Imame, 2012). Most of these studies were conducted based on the quantitative approach. Although PHC managers are directly affected by the SHPH policy and are considered as key to the success of the policy, there are no studies that have examined their perceptions of the leadership roles and management functions they need to employ to effectively implement the SHPH policy. 1.3 Aims of the thesis This thesis employs a hermeneutical phenomenological approach to deliberately narrate the lived experiences of PHC managers regarding their leadership roles, management functions and challenges in implementing the 2009 SHPH policy in Phitsanulok Province, Thailand. The thesis has the following three aims to address the research gap emerging from the literature review. 1. Explore the perceived knowledge, attitudes and practices regarding leadership roles and management functions of PHC managers working at SHPHs and implementing the 2009 SHPH policy in Phitsanulok Province, Thailand. 4 2. Explore the challenges regarding leadership roles and management functions of PHC managers working at SHPHs and implementing the 2009 SHPH policy in Phitsanulok Province, Thailand. 3. Identify the training needs regarding leadership roles and management functions of PHC managers working at
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