_________________________________________________________________________Swansea University E-Theses Health sector reform in Thailand: Policy implementation in three provinces. Leethongdee, Songkramchai How to cite: _________________________________________________________________________ Leethongdee, Songkramchai (2007) Health sector reform in Thailand: Policy implementation in three provinces.. thesis, Swansea University. http://cronfa.swan.ac.uk/Record/cronfa42881 Use policy: _________________________________________________________________________ This item is brought to you by Swansea University. Any person downloading material is agreeing to abide by the terms of the repository licence: copies of full text items may be used or reproduced in any format or medium, without prior permission for personal research or study, educational or non-commercial purposes only. The copyright for any work remains with the original author unless otherwise specified. The full-text must not be sold in any format or medium without the formal permission of the copyright holder. Permission for multiple reproductions should be obtained from the original author. Authors are personally responsible for adhering to copyright and publisher restrictions when uploading content to the repository. Please link to the metadata record in the Swansea University repository, Cronfa (link given in the citation reference above.) http://www.swansea.ac.uk/library/researchsupport/ris-support/ Health Sector Reform in Thailand: Policy Implementation in Three Provinces Songkramchai Leethongdee A thesis submitted to the University of Wales Swansea in fulfilment of the requirement for the degree of Doctor of Philosophy (Health Science) May 2007 ProQuest Number: 10821271 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a com plete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. uest ProQuest 10821271 Published by ProQuest LLC(2018). Copyright of the Dissertation is held by the Author. All rights reserved. This work is protected against unauthorized copying under Title 17, United States C ode Microform Edition © ProQuest LLC. ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106- 1346 DECLARATION AND STATEMENTS DECLARATION This work has not previously been accepted in substance for any degree and is not being concurrently submitted in candidature for any degree. Signed (candidate) Date STATEMENT 1 This thesis is the result of my own investigations, except where otherwise stated. Where correction services have been used, the extent and nature of the correction is clearly marked in a footnote(s). Other sources are acknowledged by footnotes giving explicit references. A bibliography is appended. Signed ........................................................................... (candidate) Date STATEMENT 2 I hereby give consent for my thesis, if accepted, to be available for photocopying and for inter-library loan, and for the title and summary to be made available to outside organisations. Signed ........................................................................... (candidate) Date.............................................................................. SUMMARY This thesis examines the implementation of the universal coverage (UC) health care reforms in Thailand, introduced from 2001 onwards. It aims to investigate the interaction between top-down and bottom-up influences on policy implementation in the local health system, based on comparative case studies of three provinces. The study was conceived as a ‘policy ethnography’, an approach which uses mixed methods to investigate the perspectives of local policy actors. The Thai Ministry of Public Health (MoPH) did not specify all aspects of the UC policy ‘blueprint’ in detail, and allowed provinces to make important decisions in certain areas, such as the choice of financing model. The research found that it was generally actors at the higher levels of the provincial health administrations who had actual potential to influence the way the reforms were implemented. However, there were interesting examples where middle-level provincial actors gained influence at particular junctures of the implementation process, usually either when they were in a strategic position with regard to the roll-out of a particular policy, or if they could get support from powerful allies higher up the MoPH hierarchy. The degree of engagement and knowledge of lower- level actors were more limited, and many at this level saw the reforms as overly top-down. Over the period covered by the study, the relative influence of top-down and bottom-up influences ebbed and flowed. There was a cycle whereby local adaptations usually led to a reaction at the centre, and further policy statements and top-down directions. Many problems arose in implementing the UC reforms, including difficulties in achieving progress on the original objectives of reducing geographical inequalities of funding and workforce distribution, problems in allocating resources fairly within the local health system, lack of progress in developing primary care, and tension between curative and preventative approaches. LIST OF CONTENTS DECLARATIONS AND STATEMENTS ii SUMMARY iii LIST OF CONTENTS iv LIST OF TABLES viii LIST OF FIGURES ix LIST OF ABBREVIATIONS x ACKNOWLEDGEMENTS xii CHAPTER 1. Introducing the research 1 1.1 The research idea 2 1.2 Research questions and objectives 3 1.3 From primary health care to health sector reform and UC 4 1.4 Thailand’s movement from PHC to UC reforms 8 1.5 Organisational structure of the Thai health care system 10 1.6 The universal coverage reforms: health sector reform in Thailand 13 1.6.1 The ‘big bang’ reform phase 14 1.6.2 The longer-term implementation task 17 1.6.3 Thailand’s purchaser/provider split 18 1.6.4 Implementing the new financing system at provincial level 20 1.7 Emergent problems 21 1.8 Summary of chapter 24 CHAPTER 2. The literature on the policy process and implementation 25 2.1 Introduction 26 2.2 The health policy process 26 2.3 Theoretical perspectives on implementation 29 2.3.1 Policy implementation 29 2.3.2 The ‘discovery’ of implementation 29 2.3.3 The top-down model 30 2.3.4 The bottom-up model 33 2.3.5 The main points of controversy 38 2.3.6 The synthesisers of implementation theory 40 2.4 Studying policy implementation in developing countries 43 2.5 Summary of chapter 46 CHAPTER 3. Methodology 47 3.1 Introduction 48 3.2 The policy ethnography approach 48 3.3 The case study approach 51 3.4 The doctoral project and its companion study 53 3.5 The research process 53 3.5.1 First phase: define and design 54 3.5.2 Second phase: prepare, collect and start preliminary analysis 55 3.5.3 Third phase: supplemental data-collection, additional analysis and conclusions 58 3.6 The three main data collection methods 60 3.6.1 Semi-structured interviews 60 3.6.2 Documentary analysis 61 - iv - 3.6.3 Focus group discussions 61 3.7 Data analysis 63 3.8 Quality controls of the study 65 3.9 Ethical issues 66 3.10 Limitations of this study 67 3.11 Summary of chapter 69 CHAPTER 4. The three cases study provinces: characteristics and comparisons 70 4.1 Introduction 71 4.2 Thailand’s Esam region 71 4.3 Mahasarakham 74 4.4 Kalasin 76 4.5 Roi Et 77 4.6 Comparing the provinces 78 4.6.1 General information 79 4.6.2 Economic characteristics 79 4.6.3 Epidemiology and health facilities 80 4.7 Health finance and the 30 baht Scheme 84 4.8 Implementing reforms at provincial level: ‘76 flowers bloom' 89 4.9 Chapter summary 90 CHAPTER 5. Mahasarakham province: distributed power and civil society engagement 91 5.1 Introduction 92 5.2 Implementing the UC Reforms in Mahasarakham 92 5.2.1 Actors, networks and power 92 5.2.2 Recent changes in organisational structure 99 5.3 How the financing framework was adapted to local conditions 103 5.3.1 Adapting to the new financial framework 103 5.3.2 Choosing a budget allocation model 105 5.3.3 Safeguarding the service units 108 5.3.4 Referrals and the Clearing House 110 5.3.5 Summary of financial changes in Mahasarakham in FY 2001-02, 2002- 03 and 2003-04 115 5.4 The view of actors in the local health care system 121 5.4.1 The view from the community hospitals 121 5.4.2 The perspective of the DHOs and health centres 126 5.5 Civil society engagement 129 5.5.1 The emphasis on ‘civil society’ 129 5.5.2 Civil society at provincial level 130 5.5.3 Civil society and the UC reforms 132 5.6 Relations with the Ministry and the Health Region 138 5.7 Summary of chapter 139 CHAPTER 6: Kalasin: fragmented power and struggles between professional interest groups 140 6.1 Introduction 141 6.2 Implementing the UC reforms in Kalasin 141 6.2.1 Actors, networks and power 142 6.2.2 Recent changes in organisational structure 147 - V - 6.3 How the financing framework was adapted to local conditions 151 6.3.1. Adapting to the new financial framework 151 6.3.2 Choosing a budget allocation model 152 6.3.3 Safeguarding the service units 154 6.3.4 Referrals and the Clearing House 156 6.3.5 Summary of financial changes in Kalasin in FY 2001-02, 2002-03 and 159 2003-04 6.4 The view of actors in the local health care system 166 6.4.1 The view from the community hospitals 166 6.4.2 The perspective of the DHOs and health centres 169 6.4.3 The role of the private sector 174 6.5 Professional struggle and the change of approach 177 6.5.1 How middle-level policy actors gained influence 177 6.5.2 Struggle between professional interest groups 178 6.6 Relations with the Ministry and the Health Region 182 6.7 Summary of chapter 183 CHAPTER 7: Roi Et: using active purchasing to steer the local system 185 7.1 Introduction 186 7.2 7.2 Implementing the UC reforms in Roi Et 186 7.2.1 Actors, networks and power 186 7.2.2 Recent changes in organisational structure 191 7.3 How the financing framework was adapted to local conditions 199 7.3.1.