How Does Primary Care Move?

An Analytical Evidence of Management for

Accessibility and Equity, Thailand

Siranee Intaranongpai1 , Somporn Pothinam2 , Songkramchai Leethongdee3 , Pramote

Tongkrajai4 Nenavath Sreenu5
1 2,4
Faculty of Nursing , Faculty of Medicine, Faculty of Public Health ,
Mahasarakham University , Thailand , 5School of Management Studies, University of
Hyderabad, India

Background: New paradigm of national health service development focusing on

improving primary healthcare equity had been experimented in Thailand
Objective: the main assessment of the study to evaluate primary healthcare
management for accessibility and equity in Thailand
Methods: This study has been developed based on literature review of research as
well as in-depth interview, participation observation, and policy ethnography
approach in primary healthcare management. To improve the performance healthcare
delivery services process and major step find the problems identification and
formation the planning implementation
Result: Themes Shifting of Tasks, Management for remote area to
accessibility, Shortage of staff management, Stakeholder management,
Formulate plans, Flexible and appropriate technologies were emerged. The
proposed model can be implemented in primary healthcare management services in
order to improve primary healthcare performance. It may also be applied to other
services.
Conclusion: The study suggests the adoption of an approach of management
practices in dealing with Thailand healthcare services system problems and provides
the quality healthcare service at primary healthcare level
Keywords: primary care, management, accessibility, equity, policy ethnography

Introduction
Primary Care as well as Primary health Care (WHO, 2008) is essential health
care based on practical, scientifically sound, and socially acceptable methods
and technology made universally accessible to individual and families in the
community by means acceptable to them and at a cost that the community
and the country can afford to maintain at every stage of their development in
a spirit of self-reliance and self-determination. (WHO, 1978). Characterteristics
define primary health, care : it is general, accountable, available,
comprehensive, accessible, integrated, affordable, continuous, holistic,
coordinated, community involvement, confidential, appropriated technologies,
approach to delivery, and plays an advocacy role. (Wendy Rogers, 2003;
Wonca Europe, 2002).

The original ideal of primary health care has become known as comprehensive PHC.
This is in contrast to selective primary health care which is more medically focused
with a reliance upon medical interventions and doctors for provision of and control
over health services. Despite significant philosophical differences, comprehensive
and selective primary health care may appear to offer similar services. Population
health shares many principles with comprehensive primary health care, in particular
the focus upon equity, community participation, integration, intersectoral
collaboration, multi-disciplinary teams and health promotion. (Prince Mahidol
Award Conference, 2008) World Health Report 2008 in conference of
Primary Health Care now more than ever focus that primary care should be
corporate primary health care. Destination at last are including 1)
transformation and regulation of existing health system: aiming for universal
access and social health protection; 2) dealing with the health of everyone in
the community ; 3) a comprehensive response to people’ s expectations and
needs, spanning the range of risks and illness; 4) promotion of healthier
lifestyle and migration of the health effects of social and environment hazards;
5) teams of health workers facilitating access to and appropriate use of
technology and medicines 6) institutionalized participation of civil society in
policy dialogue and accountability mechanism; 7) pluralistic health system
operating in a globalized context; 8) guiding the growth of resources for health
towards universal coverage; 9) global solidality and joint learning; 10) primary
care as coordinator of a comprehensive response at all level; 11) PHC is not
cheap : it requires considerable investment, but it provides better value for
money than its alternatives (WHO. 2008)
Thailand has a long history of primary health care (PHC). Primary Care has been
the key agenda for the recent Thai Health Care Reform. It was expect to
improve health of the population as well as to reduce health care cost.
(Pongpirul. 2008) The National PHC program was implemented nation-wide as
part of the Fourth National Health Development Plan (1977–1981) focusing on the
training management of ‘grass-root’ PHC workers consisting of village health
communicators and village health volunteers. Since then PHC has evolved through
many innovative health activities: community organization, community self-financing
and management, the restructuring of the health system and multisectoral co-
ordination. (Andy Haines, Richard Horton and Zulfiqar Bhutta . 2007)
Current Health Care System in Thailand
The Thai health care system has undergone several reforms. In 1952, the area of
responsibility for the Ministry of Public Health was extended by adding the health-
care infrastructure and the development of human resources to provide health-care
services throughout the country. Various health policies were on the agenda of
national development plans, beginning with the First National Economic
Development Plan of 1961, and notably the successive National Economic and Social
Development Plans, since 1971, and their implementation. Health care is organized
and provided by the public and private sectors. The Ministry of Public Health
(MOPH) is the principal agency responsible for promoting, supporting, controlling,
and coordinating all health service activities. In addition, there are several other
agencies playing significant roles in medical and health development programs such
as the Ministry of Education, the Ministry of Interior, the Ministry of Defense, the
Bangkok Metropolitan Administration, state enterprises, and private-sector
enterprises. They operate health facilities including hospitals that provide primary,
secondary and tertiary medical services. During the last ten years, private hospitals
and clinics have been expanding rapidly in Bangkok and provincial cities. In 2003,
public-sector and private-sector health care facilities were categorized as follows:
In Bangkok, there were five medical-school hospitals, 29 general hospitals, 19
specialized hospitals and institutions, as well as 61 health centres and 82 health centre
branches. Throughout the country, beyond the city of Bangkok, public health facilities
included four regional-level medical-school hospitals, 25 regional-level hospitals, 40
specialized hospitals, 70 provincial-level general hospitals under the auspices of the
MOPH, and 56 hospitals operated by the Ministry of Defense. These medical facilities
were underpinned by 725 community hospitals at district level as well as 214
municipal health centres. At the sub-district (tambon) level, there were 9,765 health
centres as well as 66,223 rural and 2,470 urban primary health care centres. The last
two types of health facilities were managed by village health volunteers (close to
800,000 in 2004) under the supervision of health workers of sub-district health
centres. The private sector has also played a significant role in providing curative
care. In 2003, there were one private medical school in Bangkok, 346 private
hospitals (100 in Bangkok and 246 in other provinces), 11,853 clinics, 12,878
drugstores (1st and 2nd class) and 2,106 traditional medicine drugstores. In 2002, the
overall ratio of hospital beds to population was 1:206 in Bangkok, compared to the
ratio of 1:462 in all other provinces. The ratio of physician to population was 1:3,295
for the whole country, ranging from 1:767 for Bangkok and 1:7,251 for the
Northeastern Region.
Health Care Financing
Thailand’s health care system reflects the entrepreneurial market-driven nature of its
economy. It is a cross-over system of public-sector and private-sector interfacing in
both health-care financing and provision. Overall, the resources allocated to health
care have markedly increased recently. The total health expenditure has increased
gradually, at a faster rate than the growth of the gross domestic product (GDP). In
2003, the total health expenditure equaled 3.3% of the GDP, of which a higher
proportion (61.6%) was covered By the public sector than by the private sector
(38.4%). (Suvaj Siasiriwattana, 2006)
Primary healthcare elements
The following list of key elements1 of primary health care were drafted to follow
the principle statements and to provide a “checklist” of the critical features a
primary health care organization should have in order to meet the vision and
principles.
1. Community involvement – uses appropriate resources for meaningful
community involvement and develops the capacity of the community to
address health issues
2. Accessible – services are provided as close to the client as possible and
community members can access the service and/or provider of choice easily
3. Available – primary health care services are available based on the
requirements of the community being served
 4. Comprehensive - a full range of services is provided with an emphasis on
disease/injury prevention and health promotion. Clients are involved in
discussion of broader health needs
5. Integrated and coordinated - involves a wide range of multidisciplinary service
providers, use of community staff, and coordinated services to avoid
duplication and make the best use of available resources
6. Approach to delivery considers the broader determinants of health Appropriate
technologies – cooperates to develop and use the most appropriate tools,
techniques and information technology.
7. Quality – helps local providers to deliver a high quality of service by
rewarding continuous quality improvement and using evaluation research
findings to develop the most effective services and linkages between service
providers
8. Accountable – addresses the needs of individual communities, adheres to
provincial government policy, and contributes to ongoing improvement of
services; the system answers the questions of accountability of whom, for
what, and to whom
9. Affordable – provides services within the limits of the community’s resources
10. Ongoing evaluation – uses information and ongoing evaluation to improve
quality, delivery and outcomes (Wendy Rogers, 2003)
Challenges for the future of primary health care in Thailand
National governments and the international community are renewing their efforts to
expand access to PHC and they have committed a lot of money for this purpose. But
there have been many major changes in these last three decades that pose big
challenges for the future of PHC. The drafters of the Alma Ata Declaration drew
largely on the experiences of those post-revolutionary and post-colonial regimes,
which were rapidly overcoming a lack of health facilities, health workers and drugs.
Whilst some remote areas still lack health services many settings have both trained
and untrained people, providing health care and selling drugs. The boundary between
public and private sectors is blurred and government health workers frequently ask for
informal payments or see patients privately. Many of these activities occur outside an
organised, regulated framework of health care provision. Potential users are much
more likely to live near a health facility or some kind of provider than 30 years ago,
but now they face major challenges in paying for care and finding competent
providers and effective and appropriate drugs.
PHC was designed to deal with prevention/health promotion and with infectious
diseases associated with poverty, poor sanitation and certain insect vectors. Although
these illnesses persist, there is growing pressure on health systems to address other
problems. One dramatic change has been the transformation of HIV infection into a
chronic and progressive disease for which people can claim entitlement to treatment.
People are also affected by other chronic conditions, associated with ageing and
“lifestyle” changes. This raises difficult questions about which treatments are
appropriate, who should pay for them and how health systems should be organised to
help people manage long-term conditions. Concern is growing about the potential
threat of epidemics of new diseases or organisms resistant to the available drugs.
Recent examples are SARS, multi-drug resistant tuberculosis and a possible influenza
pandemic. Government responses rely heavily on convincing people to report
suspicious outbreaks and cooperate with public health measures they may perceive to
be against their short-term interest. This requires high levels of trust between the
population and their health system.
More actors are involved in health systems than thirty years ago, including a variety
of private providers of health-related goods and services, national and international
NGOs, citizen advocacy groups and political parties (where competitive electoral
politics have been introduced). Governments are seeking new ways to influence
health systems with their powers to allocate money, enact and enforce laws and
publish information. This sometimes involves new types of partnership for service
delivery and regulation. Finally, there have been dramatic developments of new
technologies for diagnosis and treatment of disease, which influence the design of
health systems. In addition, the rapid changes in information and communication
technologies are having a big impact. Providers and users of health services
increasingly have access to the mass media, mobile telephones and the internet. They
carry health information produced by governments, professions, citizen advocacy
groups and private companies. In contrast to 30 years ago, when health professionals
were the major source of expert knowledge, people have a variety of sources from
which to find information. The anniversary of the Alma Ata Declaration provides a
good opportunity to reaffirm national and international commitments to expand access
to PHC. But, it is important to understand the changed context when formulating
strategies for achieving this. Many innovations have emerged that involve quite
different roles for governments, markets, civil society and individuals than the
drafters of the Alma Ata Declaration envisaged. We need to find ways to involve all
actors in an intensive process of innovation and learning if the latest statements of
good intentions are to be translated into major improvements for poor people.
(sanguan nitayarumphong. 2008)

Institute of Medicine (2008) suggested that at the macro-level there is a

need understand better how sustainable primary health care-oriented health
system may be developed and how primary health care, through intersectoral
action for health may contribute to address the social determinants of health.
Primary care research should address the assessment of improvements that the
Quality Chasm report is calling for in 6 dimensions of health care
performance: safety, effectiveness, patient-centrednesscenteredness, timeliness,
efficiency and equity. At the meso-level, it need research about models that
bridge the gap between hospital care, primary health care and public health ,
that investigate how professional, civil society organizations and population can
interact to strengthen primary care, and what are the best ways of organizing
the micro systems that deliver care as well as how does management in
primary care. This research aim to evaluate primary care management for
accessibility and equity in Thailand to look at the primary care as a complex
adaptive system.
Research framework
From the in formation gathered in the literature review and the Kalasin
Provincial Hall(2009) a framework was established to form the basis of the
questions for inclusion within the case study as shown below in Table 1
Table 1 Research framework
Framework questions Literature examples

What defines the primary care carried out in a Nation

Management prospective Thai

Why has management need to use in primary Equity

care delivery Accessibility ect.

Who and How has corporated improving Hospital level

health in primary care management Community level

What are the benefits and problems of Benefits

management in primary care Problems

Method
Design
This qualitative study used the policy ethnography approach to investigate the
perspectives of actors within a health care system as primary care management
person. Subtle realism points to the imperfect attempts of researcher to reach
practical understandings of primary care management phenomena, and adopting
this approach is the best way to knows of responding to the charge of naïve
realism. Guided interviews and participation observation were used with the
director of community hospital, family medical doctor and health care team
management. Participation observation occurred during the interviews and in
neighborhood Home health care team during a typical “ Home care
management ”. The study was approved by both the … and …
Sample
A purposive sample of the director of community hospital, family medical
doctor were choosed. ….
Data collection
Participation observation
Data analysis
Data collection and analysis occur concurrently and are based on constant
comparative analysis that involves comparing primary care service incidents,
participants or segments of data within community staffs and between hospital
staffs in order to generate categories, concepts relevant to primary care
management area. The interview data and field memos were subjected to
thematic analysis independently by the authors and the result were then
compared. Joint analysis continued until consensus between the researchers was
reached. The data from the participant observation were used to provide
context, validation, and refinement.
Result
Themes Shifting of Tasks, Management for remote area to accessibility,
Shortage of staff management, Stakeholder management, Formulate plans,
Flexible and appropriate technologies were emerged.
Shifting of Tasks
“ the delivery of primary care for disability people is via physical extremely
services, community nurses services, and community volunteers. It works best
where there is a multidisciplinary team approach to care”
“ Apply home care team ; no nutritionist no pharmacist ; no physician
sometimes ; was done to fit of north-east Thailand context where shortage
staffs unlike central area that health providers and medical technologies are
highly concentrated in big cities rather than rural areas”
Management for Remote area to Accessibility
Physicians moved outside the hospital setting and there was a shift from
specialist-in-hospital-care to practitioner-in-community-family-care
“By decision making of , the most far community health center was set up
to be community medical unit where client easy to use service ”

“home care clients for all disability people enhanced them to manage care”

Insufficient of finance to go hospital

“By nature of disability in remote area, they have health insurance by policy
but do not follow up at health service setting because of economic burden ”
Shortage of staff management
“ different figure western Home Health Care Team, Contracting Unit of
Primary care integrate with stakeholder as community care were set up ”
“very physician shortage, physical extremely as main group and other hospital
staffs were trained to practice Home Health Care under family medicine
concept. ”
“ Linkages between home health care hospital team and public health team as
well as stakeholder in community to co-service providers helps local providers to
deliver a high quality of service by rewarding continuous quality improvement and
using knowledge management ; KM (pre-post conference before and after home
care)to develop the most effective services ”
Stakeholder management
Involves a wide range of multidisciplinary service providers, use of community staff,
and coordinated services to avoid duplication and make the best use of available
resources
“ New organization, more progressive in embracing the challenges of servicing
primary care director of district hospital think broadly and identify relevant
stakeholder, community health volunteers and local government are main group
that have a stake in the decisions and actions of new organization call
disability association ”
Formulate plans
“primary care service under provincial strategic plan has been controlling by
director of community hospital but to response local health need hospital health
team and community health team with stakeholder do primary care practice
depend on bottom up new formulate plan ”
“ Balancing local health need, Insufficient budget and Health indicators under
policy was done by director of community hospital
Flexible and appropriate technologies
The provision of primary care service for disability clients focused on health
facilities at the community level because this level is cost effective and
appropriate for the majority of the client who are facing minor disability
“ to save cost, home health care team set up equipment for rehabilitation and
palliation disability person by using apply low cost tools based on
understanding the socio-cultural backgrounds of their families and community
health volunteers in which Contracting Unit of Primary care are provided ”
Literature review
In the UK definition, the delivery of primary care is via GP services, PCT medical
services, and alternative provider (e.g. private health company) medical services, as
well as NHS walk-in centers and other community services outside the hospital
service. It works best where there is a multidisciplinary team approach to care. In
Thailand, until the 1990s, primary health care consist of health centers that
started out as “ antennas of hospital ” The focus of the care was on technical
adequacy and clinical decisions, not on patient centeredness and quality of
human relations. Family medicine appeared as a new specialty in Thailand in
1998. The first health center to feature the family practice model was
established in 1991. It was intended as a step in changing the health care
system. (Pongsupap, P. 2007)
Today, family medicine, embedded in primary health care, health policy
explicitly links universal coverage, frrst-line health health service strengthening
and family medicine development. The Ministry of Public Health sees in
family practice the potential to change health care delivery in Thailand. Base
on hope that family practice can bring a new style of relating to patients, with
a new understanding process of health and illness, and a new emphasis on
illness prevention and coordination of care. By family practice, it will lead to
improved access to care, increased emphasis on prevention at the community
level and reduced cost of care. Recent statistics indicate that health centers
and community hospitals are the most popular source of health care although
shortage of human resource, budget, material. Four in five patients used the
out-patient health services at the government health facilities. (Churnrurtai,
K.et.al. 2009 : 10)
In spite of the current volatile political situation of Thailand, several factors
are essential for an alternative community care and have emerged. Community
health fund was decentralization out come of power and budget to local
communities (Kamnuansilpa P, 2003)
*
PHC has been successful in Thailand because of community involvement in health,
collaboration between government and non-government organizations, the integration
of the PHC programme, the decentralization of planning and management,
intersectors collaboration at operational levels, resource allocation in favour of PHC,
the management and continuous supervision of the PHC programme from the national
down to the district level, and the horizontal training of villagers to villagers (Andy
Haines, Richard Horton and Zulfiqar Bhutta . 2007)
*
In the Thai primary health care system, the problem of over-use of medicine,
especially expensive antibiotic drug and new medical technologies is not only found
with the Civil Servant Medical Benefit Scheme, but it is also evident in health service
provision of private for profit health care providers. The limited capacity of the
government to regulate private for-profit providers facilitates inefficient use of public
and private health resources. The 10th National Development Plan of Thailand
makes the policy recommendations for improving efficiency in public health resource
use.(Andy Haines, Richard Horton and Zulfiqar Bhutta . 2007)
*
The primary health care management plays a pivotal role in health achievements and
efficiency improvements of the Thai health care system. Contracting the district-level
health providers to provide primary care and close-to-client services for Universal
Coverage beneficiaries is an important means of ensuring efficient and rational use of
services while ensuring proper referral systems. When the majority of Universal
Coverage members who are poor and residing in rural areas can actually exercise their
rights in using a comprehensive range of services provided by the primary health care
network, it results in equity in health service use and efficient use of public resources.
Using fee-for-service reimbursement to pay health care providers of the Civil Servant
Medical Benefit Scheme sends a strong signal to healthcare providers who are
supreme commanders of health resources to provide more diagnostics, medicines, and
probably unnecessary medical treatment. Empirical evidence consistently confirms
Civil Servant Medical Benefit Scheme beneficiaries receive more branded and more
expensive medicines than beneficiaries in other public health insurance schemes.
Moreover, evidence shows that Civil Servant Medical Benefit Scheme beneficiaries
have higher hospital admission and greater cesarean section rate than other schemes.
It is found that even though Civil Servant Medical Benefit Scheme finances five times
higher per capita, clinical outcome is more or less similar to beneficiaries of the
Universal Coverage scheme. In the Thai primary health care system, the problem of
over-use of medicine, especially expensive antibiotic drug and new medical
technologies is not only found with the Civil Servant Medical Benefit Scheme, but it
is also evident in health service provision of private for profit health care providers.
The limited capacity of the government to regulate private for-profit providers
facilitates inefficient use of public and private health resources. The 10th National
Development Plan of Thailand makes the policy recommendations for improving
efficiency in public health resource use. (Andy Haines, Richard Horton and Zulfiqar
Bhutta . 2007)
achieving intersectoral collaboration and local planning and management of primary
health care services requires an explicit commitment to equity in health care and
strategic planning across all levels of government as well as across traditional
departmental barriers. Possible organisational changes to strengthen primary health
care in Australia include the creation of formal structures to support community and
consumer involvement, the organisation of health care services to decrease
competition between providers, and the creation of primary health care teams as
functional units. (Prince Mahidol Award Conference, 2008)
The first stakeholder management capability calls on the organization to analyze who
the stakeholders are and what they want. Recall that Blair and buesseler (1988:9)
define Stakeholders as “any individual, groups, or organizations that have a stake in
the decisions and actions of an organization, and who attempt to influence these
decisions and actions.”
Blum’s (1974:1983) health and well-being paradigms show health resulting from
four forces: environment, genetics, lifestyles, and medical care. A hospital trying to
improve health must now consider new and different types off stakeholders working
with the environment, lifestyles, and genetic composition of the population. The
hospital must analyze who all these stakeholders are, what their stakes are, and how
salient they are. How can the hospital do this? By using Blair and Buesseler’s (1998)
conceptualization of stakeholders with Blum’s (1974:1983) model of health, a
hospital con think broadly and identify relevant stakelolders.
/Recall that stakeholder salience is a function of perceived legitimacy, power, and
urgency so that, if hospital leaders perceive a stakeholder as having little legitimacy,
power or urgency, then they may view the stakelholder with little salience, /The
characteristics of hospital executives, such as their values and environmental scanning
behavior, will affect their perceptions and thus their perceived salience of
stakeholders (Mitchell, Agle, and Wood, 1997) and so Daake and Anthony (1998)
recommend formal assessment of stakeholder power.
Proenca’s (1998) community sensing approach advises that front-line employees who
are close to actual patients, residents, and the community, can often related better than
executives to cultures, backgrounds, and traits of “non-traditional” local stakeholders.
This can help leaders to better discern the salience of unfamiliar community health
stakeholders such as grass roots support groups for unwed teen mothers. Such a
group could be more salient than first thought because it has influence over the people
whom the hospital wants to reach. Some stakeholders that have been viewed as low
salience for acute medical care (e.g., schools) would be more salient for community
health and might not allow a hospital’s ecucators to go into classrooms if the hospital
does not treat the schools as salient CH stakeholders.
To start, Freeman (1984) proposes that organizations with high stakeholder capability
will have effective communication processes with stakeholders, will use marketing
techniques and research to segment stakeholders into distinct groups to better
understand them, will support boundary spanners which help bring external
stakeholders into the organization’s considerations, will allocate resources for salient
stakeholders, and will have a culture that is proactive toward stakeholders. These are
basic organizational functions of marketing, management, decision-making,
consensus building, interorganizational relationships, internal operations, and so forth.
The hospital that seeks to improve community health is likely to formulate plans, then
implement implement programs and services, and finally evaluate those activities.
Processes by which plans are foumulated-such as strategic planning, goal setting, and
program planning-should include CH stakeholders. A hospital’s planning processes
probably do consider the traditional stakeholders (e.g., physicians, payers); it should
now include what the organization will do in order to consider community health
stakeholders and their interests. Importantly, as stated by a Hartford (CN) Hospital
executive and a local citizen, a hospital must plan with local people rather than
planner them so that a hospital’s CH work is not viewed skeptically as a marketing
ploy (Community Health Intersection, 2001).
The stakeholder management process should be modified to stakeholder
collaboration. The same should be done for implementation of programs and services
such as having processes by which to involve community stakeholders and their
stakes that would shape the actual services, their distribution, and so forth. In
economically depressed Camden, NJ, Our Lady of Loureds Hospital collaborated with
stakeholders and the diverse under-educated citizens to improve health by involving
them in planning which CH services to deliver and how to deliver them (Weech-
Maldonado and Merrill, 2000).
The organizational processed by which a hospital has considered its traditional
stakeholders and interests would be a starting point for developing processes also to
consider CH stakeholders and their interests. Acquiring qualitative and quantitative
data, using oral and written input, working with stakeholders on community task
forces and committees, and listening, should all help. So too would a culture that sees
these stakeholders as essential, respects and involves them as valued partners for
community health. The Harford Hospital cited earler realized it had to change its
culture to go from its organizational focus to a neighborhood focus (Community
Health Intersection, 2001).
To really consider CH stakeholders’ interests, hospitals should use organizational
processes to facilitate communicating, working in groups, making decisions, using
power, allocating rewards, accepting behaviors, styles, and normas of all stakeholders
rather than just those of the hospital and medical care stakeholders. Thus, a hospital
may adapt existing processes to better seek and utilize more qualitative data form
grassroots stories (lbid.). This will take more time and slow the process but will help
overcome the low trust some salient stakeholders feel toward hospitals. These
organizational processes will help to collectively create consensus on mission, goals,
clientele, and services for CH improvement and will decrease stakeholder conflict
while increasing stakeholder support (Mitchell and Shortell, 2000).
Analysis
1. The original ideal of primary health care has become known as comprehensive
PHC. This is in contrast to selective primary health care which is more
medically focused with a reliance upon medical interventions and doctors for
provision of and control over health services.
2. Close to 800,000 in 2004) under the supervision of health workers of sub-
district health centres. The private sector has also played a significant role in
providing curative care. In 2003, there were one private medical school in
Bangkok, 346 private hospitals (100 in Bangkok and 246 in other provinces),
11,853 clinics, 12,878 drugstores (1st and 2nd class) and 2,106 traditional
medicine drugstores.
3. The Thai primary health care system, the problem of over-use of medicine,
especially expensive antibiotic drug and new medical technologies is not only
 found with the Civil Servant Medical Benefit Scheme, but it is also evident in
health service provision of private for profit health care providers. The limited
capacity of the government to regulate private for-profit providers facilitates
inefficient use of public and private health resources.
4. The boundary between public and private sectors is blurred and government
health workers frequently ask for informal payments or see patients privately.
Many of these activities occur outside an organised, regulated framework of
health care provision.
5. The organizational processed by which a hospital has considered its traditional
stakeholders and interests would be a starting point for developing processes
also to consider CH stakeholders and their interests.
Conclusion
This study ha explained how the stakeholder management approaches that hospitals
often use in the medical care domain can be modified for the community health
domain. The stakeholder management approach has value such as its emphasis on
clearly identifying what the interests of stakeholders are. But community health
should not be managed by hospitals as “another line of business” but requires a
different way of “doing business” and a different approach to stakeholders as
explained earlier. Modification of stakeholder management into stakeholders
collaboration is needed for hospitals and other health care organizations to work
effectively in the community health domain with other stakeholders. Research is
needed to study the extent to which executive collaborate with these stakeholders,
especially stakeholders who are not viewed with great salience yet are important in
community health. Future research should also be performed to evaluate the
outcomes of stakeholder collaboration. Important outcome would include stakeholder
commitment and stakeholder satisfaction. Actual community health status should
also be studied as an outcome although it might not be easy to measure stakeholder
collaboration as and explanatory variable. These and other advances in CH research
methods and findings will be important to guide future community health efforts by
hospitals and other health care organizations.

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