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Patients’ perspectives regarding hospital visits in the universal health coverage system of Thailand: a qualitative study

Patients’ perspectives regarding hospital visits in the universal health coverage system of... Background: A universal health coverage policy was implemented in Thailand in 2002 and led to an increase in accessibility to, and equity of, healthcare services. The Thai government and academics have focused on the large- scale aspects, including effectiveness and impacts, of universal health coverage over one decade. Here, we aimed to identify patients’ perspectives on hospital visits under universal health coverage. Methods: A qualitative study was carried out in four public hospitals in rural Thailand. We collected data through focus group discussions (FGDs) and in-depth interviews (IDIs). The semi-structured interview guide was designed to elicit perspectives on hospital visits among participants covered by the Universal Coverage Scheme, Social Security Scheme or Civil Servant Medical Benefit Scheme. Data were transcribed and analysed using a thematic approach. Results: Twenty-nine participants (mean age, 56.76 ± 16.65 years) participated in five FGDs and one IDI. The emerg- ing themes and sub-themes were identified. Factors influencing decisions to visit hospitals were free healthcare ser - vices, perception of serious illness, the need for special tests, and continuity of care. Long waiting times were barriers to hospital visits. Employees, who could not leave their work during office hours, could not access some services such as health check-ups. From the viewpoint of participants, public hospitals provided quality and equitable healthcare services. Nevertheless, shared decision making for treatment plans was not common. Conclusions: The factors and barriers to utilisation of healthcare services provide exploratory data to understand the healthcare-seeking behaviours of patients. Perceptions towards free services under universal health coverage are pos- itive, but participation in decision making is rare. Future studies should focus on finding ways to balance the needs and barriers to hospital visits and to introduce the concept of shared decision making to both doctors and patients. Keywords: Health insurance, Hospital visit, Outpatient, Universal health coverage, Utilisation Background are under the Civil Servant Medical Benefit Scheme Thailand achieved universal health coverage in 2002, (CSMBS) [1, 2]. therefore, all Thais are guaranteed access to healthcare As the largest proportion, one goal of the UCS is to services [1]. The Universal Coverage Scheme (UCS) cov - ‘equally entitle all Thai citizens to quality healthcare ers 75% of the Thai population [ 1]. About 16% of the pop- according to their needs, regardless of their socioeco- ulation, who are private-sector employees, are covered by nomic status’ [3]. Consequently, between 2003 and 2010, the Social Security Scheme (SSS). Also, 9% of Thais, who the number of hospital admissions increased from 0.094 are government employees; retirees; and dependants, to 0.116 admissions/member/year, and the number of outpatient visits grew from 2.45 to 3.22 visits/member/ year [1]. According to universal health coverage, primary *Correspondence: apichai.wa@wu.ac.th School of Medicine, Walailak University, Thasala, Nakhon Si care or ambulatory care is provided across Thailand. A Thammarat 80161, Thailand total of 10,347 public health centres and 992 outpatient Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Wattanapisit and Saengow Asia Pac Fam Med (2018) 17:9 Page 2 of 8 departments (OPDs) of public hospitals belong to the and inpatient services. We did not conduct the study at Ministry of Public Health [4]. However, about 5% of pub- the authors’ workplaces because we did not wish to bias lic health centres have one or more doctor, and most of relationships between doctors and patients or between them are located in the capital city, Bangkok [4]. Most researchers and participants. doctors in the public sector work in public hospitals We recruited participants by purposive sampling. rather than in public health centres. Patients can also OPD patients aged ≥ 18  years from the study sites were seek outpatient services in the private sector (17,671 invited after their medical consultations to participate private clinics and 322 OPDs of private hospitals) [4]. It in the study. We invited 1–2 groups of participants each seems that patients have freedom to utilise healthcare day and conducted FGDs or IDIs on the same day. The facilities depending upon their predisposing factors (e.g., recruitment focused on all types of health insurance to social structure and health beliefs), enabling resource maximise the variety of participants. It was not limited to (e.g., income levels and type of insurance) and need (e.g., any age. We did not equalise the presentation of gender. chronic disease and disease severity) [5, 6]. All participants were covered by UCS, SSS or CSMBS. After more than one decade of launching universal health coverage in Thailand, several studies published Data collection recently have focused on: (i) coverage, effectiveness, and One author (AW), a family physician with training and economic evaluation of universal health coverage [7–11]; experience in qualitative methods, conducted all FGDs (ii) impacts of universal health coverage on other aspects and IDIs. FGDs were the main method of data collec- of health and the health system [12–14]; and (iii) univer- tion. IDIs were conducted depending on the preferences sal health coverage of specific health conditions (e.g., pre - of the participants. Each FGD consisted of 4–8 partici- vention of diabetes mellitus, and renal dialysis) [15, 16]. pants. The interviewer provided verbal information on all Studies focusing on the perspectives of patients on out- aspects of the study, and asked the permission of the par- patient services and hospital visits in public health sectors ticipants to record the conversations using a digital audio in the context of universal health coverage are scarce. This recorder. Participants were requested to complete a short is a gap in knowledge and an important research ques- questionnaire (five items) regarding personal informa - tion. This study aimed to identify the perspectives of Thai tion. The interviewer conducted FGDs and IDIs follow - patients on hospital visits using a qualitative method. ing an interview guide (Table 1) in Central Thai language or Southern Thai dialect depending on the participants’ Methods wishes. The authors developed the interview guide and Ethical approval of the study protocol revised the questions based on the comments and sug- The study protocol was approved by the Human Research gestions of the grant reviewers. One research assistant Ethics Committee Walailak University (protocol number took notes during the data collection process. Each FGD 030/2016). Participation in this study was voluntary and or IDI took 45–90 min. all participants provided written informed consent. Data analysis Study design The audio record files were transcribed verbatim. The two This qualitative study was part of a larger project to authors (AW and US—a physician and researcher with investigate the views of patients and doctors with regard experience in qualitative methods) conducted the thematic to hospital visits. The project was carried out between analysis following the method of Braun and colleagues [19]. October 2016 and September 2017. The qualitative First, the two researchers read the transcripts indepen- approach of this study was phenomenological [17]. dently to familiarise themselves with the data, and gen- Data were collected by focus group discussions (FGDs) erated the initial codes. Next, the researchers separately and in-depth interviews (IDIs), if appropriate, and evalu- searched for themes that were relevant to the research ated using interpretive thematic analyses. The number of questions, and reviewed those themes to develop the FGDs and IDIs was dependent on data saturation. The initial thematic maps. The researchers worked together Standard for Reporting Qualitative Research, which com- in defining and naming the final themes. We produced prises 21 items, was used to ensure the transparency of a report by writing up the themes and sub-themes with the study [18]. relevant quotations. We identified participants using the number of FGDs or IDIs and type of health insurance so Context and participants as to maintain the confidentiality and anonymity of par - The study was conducted at four district hospitals in ticipants. The results, including the themes and quota - rural areas of Nakhon Si Thammarat province, Thailand. tions, were translated from Thai to English at the time of All hospitals included in our study provided outpatient manuscript writing. Wattanapisit and Saengow Asia Pac Fam Med (2018) 17:9 Page 3 of 8 Table 1 Interview guide themes: (i) factors influencing decisions to use health - care services in public hospitals; (ii) barriers to access- Questions ing healthcare services in public hospitals; and (iii) How often do you visit the hospital? perceptions of free healthcare services in public hospi- Why do you visit the hospital? tals (Fig. 1). Which factors influence your decision to visit the hospital? Which symptoms or diseases make you visit a doctor at the outpatient department at the hospital? Theme 1: factors influencing decisions to use healthcare What are your feelings towards and how satisfied are you about the qual- services in public hospitals ity of free healthcare services? Self-care by seeking medications from nearby pharma- What are your feelings towards and how satisfied are you about the cists was the first choice for treatment of non-severe ill - process of free healthcare services? nesses. Patients, who needed to see doctors, could go Do you have any shared decision making with the healthcare team? to private clinics, private hospitals or public hospitals. What do you feel, in terms of equity and dignity, about using free health- care services? According to data analysis, the facilitators to visits to public hospitals were as described in the sub-themes detailed below. Table 2 Characteristics of participants (n = 29) Characteristic n (%) Free healthcare services Compared with services in the private sector, use Age (years) mean (SD) 56.76 (16.65) of healthcare services in public hospitals could save 21–30 1 (3.4) money for patients. Some participants sought diagno- 31–40 4 (13.8) ses and initial treatments from private clinics or private 41–50 6 (20.7) hospitals. Later, they decided to receive free healthcare 51–60 7 (24.1) services, for continuity of treatment or medications, in 61–70 4 (13.8) public hospitals to save money. ≥ 71 7 (24.1) Sex ‘…because I have the Social Security Scheme. It is Male 9 (31.0) my right and it is free.’ Female 20 (69.0) (FGD 3, SSS) Employment status Yes 19 (65.5) ‘Prior to this visit, I went to a private clinic but I No 10 (34.5) did not feel better after taking some medications. Education Next, I went to a private hospital and I got the Tertiary 6 (20.6) diagnoses—hypertension and dyslipidaemia. I just Secondary 9 (31.0) needed to know the diagnosis and paid for the ser- Primary or below 14 (48.3) vice. Today, I come here [a public hospital] because Income (Baht/month) mean (SD) 9160.34 (7667.99) I think doctors are the same but I can get free med- Health insurance ications here.’ UCS 12 (41.4) (FGD 3, SSS) SSS 7 (24.1) CSMBS 10 (34.5) Perception of serious illnesses Data presented as mean (SD) or n (%) Visiting public hospitals was the first priority if serious or UCS Universal Coverage Scheme, SSS Social Security Scheme, CSMBS Civil urgent conditions were presented. The decisions of par - Servant Medical Benefit Scheme, SD standard deviation a ticipants were based on the belief that public hospitals 35.79 Baht = US$1 had better capacities and facilities for such severe condi- tions compared with private clinics. Results ‘…severe conditions such as stomach pain—very We conducted five FGDs and one IDI between Novem - painful. I will not go to a private clinic. Obviously, ber 2016 and April 2017. Twenty-nine participants I have to go to the hospital. I have to stop drinking (mean age, 56.76 ± 16.65  years) participated in the and eating here for pre-operative preparation if an study. Table  2 presents the characteristics of the par- operation is needed. The doctor at the private clinic ticipants. The findings consisted of three emerging Wattanapisit and Saengow Asia Pac Fam Med (2018) 17:9 Page 4 of 8 Theme 1: Theme 2: Theme 3: Factors influencing decisions Barriers to accessing Perceptions of free to use healthcare services in healthcare services in public healthcare services in public public hospitals hospitals hospitals Free Long waiting Acceptable healthcare times quality of care services Limited Different Perception of services quality of care serious outside of with different illnesses office hours insurance Minimal A restricted Need for shared choice of special tests decision physician making Continuity of Equity of care healthcare Fig. 1 Summary of themes and sub-themes does not do any major surgery and he would refer lic] hospital. They have my profile and can start my me to this hospital. So, I decide to visit the [public] treatment immediately.’ hospital.’ (FGD 3, SSS) (FGD 1, UCS) Theme 2: barriers to accessing healthcare services in public Need for special tests hospitals Participants, who needed blood tests or laboratory tests, Using healthcare services at private clinics or private hos- preferred visiting public hospitals rather than seeking pitals required paying out-of-pocket. Nevertheless, par- advice from private clinics. Past experiences with regard ticipants sometimes went to the private sector due to the to special tests (e.g., a next-to-kin had a similar symptom limitations of public hospitals. and obtained the definitive diagnosis from blood tests) influenced their decision to visit hospitals. Long waiting times From the perspectives of patients, there was an imbal- ‘I need a blood test to know the definitive diagnosis, ance between demand and supply. A hospital visit con- so I come here [a public hospital]. If I went to a pri- sumed a lot of time. Patients had to wait in a queue in the vate clinic, they could not be able to take my blood early morning before office hours, and waited for a long for the test and they would refer me to the [public] time to see a doctor. Sometimes, this wait took a full day. hospital.’ (FGD 2, UCS) ‘Many people! Wait in the queue with one or two hundred people. The service, itself, is good but very slow. I spend a whole day in the hospital.’ Continuity of care (FGD 2, UCS) Patients with an underlying disease or chronic illness were more likely to visit the same hospital even though they had other illnesses that were not associated with the Limited services outside of office hours underlying disease. They believed that the hospital could Some services, including health check-ups and special- provide informational continuity and suitable care. ist clinics, were provided only during office hours. It was inconvenient for people or patients’ carers who could not ‘If I get sick from any disease, I will go to the [pub- Wattanapisit and Saengow Asia Pac Fam Med (2018) 17:9 Page 5 of 8 leave their work to visit hospitals. Therefore, some partic - payment for an admission in a private room was not cov- ipants went to private clinics or private hospitals to seek ered by UCS. healthcare services. ‘Actually, we get a lot of things, but we have to pay ‘I used to go to the [public] hospital on Saturday for for some items.’ a PAP smear. It is available from Monday to Friday. (FGD 2, UCS) As a teacher, it is not easy to leave my students and the service is not available at the weekend. So, I go Minimal shared decision making to a private clinic because I am free in the evenings Most participants were not familiar with the concept of and can see a specialist. The payment is quite high shared decision making. Doctors made decisions regard- and my insurance does not cover the cost from pri- ing treatments for their patients. If patients disagreed vate clinics. Although I cannot claim that payment, with the doctors’ recommendations, they could discuss it I must pay. If I leave for a check-up and I am not ill, with the doctors in advance. my boss will suspect me. Of course, I am concerned about my students.’ ‘I always follow the doctor’s recommendations. (FGD 4, CSMBS) Whether the doctor says oral drugs or injection, I will do it.’ (FGD 2, UCS) A restricted choice of physician There were fewer opportunities to see a specific doctor at public hospitals. If patients wanted to see well-known Equity of healthcare doctors in their neighbourhoods, they had to go to the Health insurance was considered to be a type of human private clinics of those doctors. right enabling access to healthcare and it was not a type of social class. ‘I cannot choose a doctor here [a public hospital]. I can choose a doctor if I go to his private clinic’ ‘Free healthcare service! It is not a second-class ser- (FGD 4, CSMBS) vice. All the things—treatments, services, and doc- tors—are normal. There is no discrimination.’ (IDI 1, SSS) Theme 3: perceptions of free healthcare services in public hospitals ‘For me, I have a social security card. It is fair for Quality of care among various types of health insurance workers.’ was not different. Some participants mentioned that the (FGD 3, SSS) quality of medications was different between the UCS and CSMBS. However, some participants argued that doctors made their decisions based on patients’ condi- Discussion tions rather than the types of health insurance available. This study identified the perspectives of patients towards hospital visits. Free healthcare services, per- ception of serious illnesses, the need for special tests, Acceptable quality of care and continuity of care were factors that influenced Compared with services in the private sector, the qual- patients’ decisions with regard to visiting public hos- ity of medical advice proffered by doctors and treatments pitals. Barriers to visiting public hospitals included was similar. long waiting times, limited services outside of office ‘My rights are not different from those of people who hours and a restricted choice of physician in the pub- have the Civil Servant Medical Benefit Scheme. The lic system. Free healthcare services were characterised doctor told me that medications are the same, and as acceptable quality, paternalistic care, and equitable that there is no need to go to a private hospital. The service. standard of treatment is the same whether or not I We found that free healthcare services were one of the pay. It happened to me.’ factors influencing the administration of public utilities. (FGD 5, UCS) Studies in Thailand have supported the notion that uni - versal health coverage increases healthcare utilisation in terms of hospital admissions and outpatient visits [14, Different quality of care with different insurance 20]. This finding could reflect that patients, as consum - Some participants expressed that the coverage of UCS ers, may not be concerned about the cost associated and SSS was different from CSMBS. For example, the Wattanapisit and Saengow Asia Pac Fam Med (2018) 17:9 Page 6 of 8 with healthcare, which leads to the overuse of healthcare increasing the participation of patients in decision mak- services [21]. A systematic review by Babitsch et  al. [22] ing or shared decision making can reduce use and cost of stated that perceived health status is one of the factors unnecessary healthcare [35, 36], therefore, shared deci- associated with use of healthcare services. This observa - sion making might be an additional practice to improve tion could explain our finding that people with serious or care and reduce costs in the Thai healthcare system. We severe illnesses are more likely to visit hospitals. Patients’ also asked the participants about their feeling in terms of expectations relating to test results could explain why dignity because patients are vulnerable and depend on they visit hospitals [23, 24]. We found that chronic ill- the judgement, skill, and attitudes of the healthcare pro- nesses are reasons for using healthcare services. This viders [37]. This may have an impact on the perspectives trend has also been found in different settings in Italy, of patients regarding the healthcare services. China and Korea [6, 10, 25]. A main strength of this qualitative study was that it Long waiting times in OPDs were considered to be bar- comprised participants with different characteristics, riers for utilisation of healthcare services by study partic- ages, and health insurance programmes which referred ipants. Several studies in low-, middle- and high-income to universal health coverage. Moreover, it was conducted countries support the notion that long waiting times can in several public hospitals. The different settings may be cause stress and dissatisfaction in patients [26–28]. Simi- responsible for some variation in participants’ percep- lar to our study, research conducted in northern Nigeria tions. A limitation of the study was that it was conducted found that the main reason for long waiting times was in rural areas, so private hospitals in this context might an imbalance in demand and supply (large numbers of not have been comparable with public hospitals, and the patients with few healthcare workers) [27]. Accordingly, findings from a qualitative approach will not be general - it seems that long waiting times in hospitals are common isable to other populations, especially in urban settings. in developing countries [29]. Thailand has an 8-h working It is not known to what extent participants in this study day, so public hospitals provide full services with maxi- represent rural hospital attendees in Thailand. mum capacity of resources during office hours during the week. Conversely, they allocate some services with fewer Conclusions resources outside of office hours. This scenario may be The present study highlighted the perspectives of patients perceived as limited accessibility to the services required in rural areas in Thailand with regard to hospital visits. by employed people [2]. In contrast, the private sector The factors and barriers to utilisation of healthcare ser - has greater availability and more flexible services outside vices provide exploratory data to understand the health- working hours and at weekends. Moreover, patients have care-seeking behaviours of patients. Long waiting times less opportunities to choose their preferred doctors in in hospitals are due to an imbalance between the number the public system. This might lead to the discontinuity of of patients and providers, so effective management would care. entail resource optimisation. Services outside of office In Thailand, the coverage of health insurance has been hours should be balanced between the requirements expanded since UCS implementation in 2002 [30]. The of patients and the resources available. In other words, UCS may lead to equity of healthcare among the Thai enhancing the accessibility to healthcare must be realis- population, especially for those on low incomes, the tic and cost-effective. A lack of choice to see a preferred unemployed, and people with chronic illnesses [2]. How- doctor can interrupt the continuity of care. Perceptions ever, there is a need to deliver effective interventions to towards free services in the context of universal health reach a higher standard of care, particularly for non- coverage were positive but participation in decision mak- communicable diseases and long-term care [31]. Most ing was sparse. To improve the quality of healthcare ser- importantly, the cost-effectiveness of the healthcare sys - vices, there is a need to balance the needs and barriers to tem should be considered based on the state of Thailand’s hospital visits, introduce the concept of shared decision finances. making to healthcare providers, and reduce the inequity Our findings suggest that paternalistic healthcare of access to healthcare. is a common approach in a Thai context. Paternal - ism is thought to be able to control healthcare utilisa- Abbreviations tion because doctors believe that he or she knows best, CSMBS: Civil Servant Medical Benefit Scheme; OPD: outpatient department; and makes decisions based on his or her views without SSS: Social Security Scheme; UCS: Universal Coverage Scheme. the involvement of patients [32, 33]. A lack of shared Authors’ contributions decision-making between patients and doctors in clini- AW and US initiated the study design. AW conducted all the focus group cal practice can be the effect of time constraints, patient discussions and in-depth interviews. AW and US analysed the data. AW wrote characteristics, and clinical situations [34]. Whether Wattanapisit and Saengow Asia Pac Fam Med (2018) 17:9 Page 7 of 8 the first draft of the manuscript. Both authors read and approved the final goals in Thailand: the vital role of strategic purchasing. Health Policy Plan. manuscript. 2015;30:1152–61. 12. Kijsanayotin B. Impact of Thailand universal coverage scheme on the Author details country’s health information systems and health information technology. School of Medicine, Walailak University, Thasala, Nakhon Si Tham- Stud Health Technol Inform. 2013;192:989. marat 80161, Thailand. Center of Excellence in Health System and Medical 13. Mee-Udon F. Universal Health Coverage Scheme impact on well-being in Research, Walailak University, Thasala, Nakhon Si Thammarat 80161, Thailand. rural Thailand. 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Patients’ perspectives regarding hospital visits in the universal health coverage system of Thailand: a qualitative study

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Publisher
Springer Journals
Copyright
Copyright © 2018 by The Author(s)
Subject
Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
eISSN
1447-056X
DOI
10.1186/s12930-018-0046-x
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Abstract

Background: A universal health coverage policy was implemented in Thailand in 2002 and led to an increase in accessibility to, and equity of, healthcare services. The Thai government and academics have focused on the large- scale aspects, including effectiveness and impacts, of universal health coverage over one decade. Here, we aimed to identify patients’ perspectives on hospital visits under universal health coverage. Methods: A qualitative study was carried out in four public hospitals in rural Thailand. We collected data through focus group discussions (FGDs) and in-depth interviews (IDIs). The semi-structured interview guide was designed to elicit perspectives on hospital visits among participants covered by the Universal Coverage Scheme, Social Security Scheme or Civil Servant Medical Benefit Scheme. Data were transcribed and analysed using a thematic approach. Results: Twenty-nine participants (mean age, 56.76 ± 16.65 years) participated in five FGDs and one IDI. The emerg- ing themes and sub-themes were identified. Factors influencing decisions to visit hospitals were free healthcare ser - vices, perception of serious illness, the need for special tests, and continuity of care. Long waiting times were barriers to hospital visits. Employees, who could not leave their work during office hours, could not access some services such as health check-ups. From the viewpoint of participants, public hospitals provided quality and equitable healthcare services. Nevertheless, shared decision making for treatment plans was not common. Conclusions: The factors and barriers to utilisation of healthcare services provide exploratory data to understand the healthcare-seeking behaviours of patients. Perceptions towards free services under universal health coverage are pos- itive, but participation in decision making is rare. Future studies should focus on finding ways to balance the needs and barriers to hospital visits and to introduce the concept of shared decision making to both doctors and patients. Keywords: Health insurance, Hospital visit, Outpatient, Universal health coverage, Utilisation Background are under the Civil Servant Medical Benefit Scheme Thailand achieved universal health coverage in 2002, (CSMBS) [1, 2]. therefore, all Thais are guaranteed access to healthcare As the largest proportion, one goal of the UCS is to services [1]. The Universal Coverage Scheme (UCS) cov - ‘equally entitle all Thai citizens to quality healthcare ers 75% of the Thai population [ 1]. About 16% of the pop- according to their needs, regardless of their socioeco- ulation, who are private-sector employees, are covered by nomic status’ [3]. Consequently, between 2003 and 2010, the Social Security Scheme (SSS). Also, 9% of Thais, who the number of hospital admissions increased from 0.094 are government employees; retirees; and dependants, to 0.116 admissions/member/year, and the number of outpatient visits grew from 2.45 to 3.22 visits/member/ year [1]. According to universal health coverage, primary *Correspondence: apichai.wa@wu.ac.th School of Medicine, Walailak University, Thasala, Nakhon Si care or ambulatory care is provided across Thailand. A Thammarat 80161, Thailand total of 10,347 public health centres and 992 outpatient Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Wattanapisit and Saengow Asia Pac Fam Med (2018) 17:9 Page 2 of 8 departments (OPDs) of public hospitals belong to the and inpatient services. We did not conduct the study at Ministry of Public Health [4]. However, about 5% of pub- the authors’ workplaces because we did not wish to bias lic health centres have one or more doctor, and most of relationships between doctors and patients or between them are located in the capital city, Bangkok [4]. Most researchers and participants. doctors in the public sector work in public hospitals We recruited participants by purposive sampling. rather than in public health centres. Patients can also OPD patients aged ≥ 18  years from the study sites were seek outpatient services in the private sector (17,671 invited after their medical consultations to participate private clinics and 322 OPDs of private hospitals) [4]. It in the study. We invited 1–2 groups of participants each seems that patients have freedom to utilise healthcare day and conducted FGDs or IDIs on the same day. The facilities depending upon their predisposing factors (e.g., recruitment focused on all types of health insurance to social structure and health beliefs), enabling resource maximise the variety of participants. It was not limited to (e.g., income levels and type of insurance) and need (e.g., any age. We did not equalise the presentation of gender. chronic disease and disease severity) [5, 6]. All participants were covered by UCS, SSS or CSMBS. After more than one decade of launching universal health coverage in Thailand, several studies published Data collection recently have focused on: (i) coverage, effectiveness, and One author (AW), a family physician with training and economic evaluation of universal health coverage [7–11]; experience in qualitative methods, conducted all FGDs (ii) impacts of universal health coverage on other aspects and IDIs. FGDs were the main method of data collec- of health and the health system [12–14]; and (iii) univer- tion. IDIs were conducted depending on the preferences sal health coverage of specific health conditions (e.g., pre - of the participants. Each FGD consisted of 4–8 partici- vention of diabetes mellitus, and renal dialysis) [15, 16]. pants. The interviewer provided verbal information on all Studies focusing on the perspectives of patients on out- aspects of the study, and asked the permission of the par- patient services and hospital visits in public health sectors ticipants to record the conversations using a digital audio in the context of universal health coverage are scarce. This recorder. Participants were requested to complete a short is a gap in knowledge and an important research ques- questionnaire (five items) regarding personal informa - tion. This study aimed to identify the perspectives of Thai tion. The interviewer conducted FGDs and IDIs follow - patients on hospital visits using a qualitative method. ing an interview guide (Table 1) in Central Thai language or Southern Thai dialect depending on the participants’ Methods wishes. The authors developed the interview guide and Ethical approval of the study protocol revised the questions based on the comments and sug- The study protocol was approved by the Human Research gestions of the grant reviewers. One research assistant Ethics Committee Walailak University (protocol number took notes during the data collection process. Each FGD 030/2016). Participation in this study was voluntary and or IDI took 45–90 min. all participants provided written informed consent. Data analysis Study design The audio record files were transcribed verbatim. The two This qualitative study was part of a larger project to authors (AW and US—a physician and researcher with investigate the views of patients and doctors with regard experience in qualitative methods) conducted the thematic to hospital visits. The project was carried out between analysis following the method of Braun and colleagues [19]. October 2016 and September 2017. The qualitative First, the two researchers read the transcripts indepen- approach of this study was phenomenological [17]. dently to familiarise themselves with the data, and gen- Data were collected by focus group discussions (FGDs) erated the initial codes. Next, the researchers separately and in-depth interviews (IDIs), if appropriate, and evalu- searched for themes that were relevant to the research ated using interpretive thematic analyses. The number of questions, and reviewed those themes to develop the FGDs and IDIs was dependent on data saturation. The initial thematic maps. The researchers worked together Standard for Reporting Qualitative Research, which com- in defining and naming the final themes. We produced prises 21 items, was used to ensure the transparency of a report by writing up the themes and sub-themes with the study [18]. relevant quotations. We identified participants using the number of FGDs or IDIs and type of health insurance so Context and participants as to maintain the confidentiality and anonymity of par - The study was conducted at four district hospitals in ticipants. The results, including the themes and quota - rural areas of Nakhon Si Thammarat province, Thailand. tions, were translated from Thai to English at the time of All hospitals included in our study provided outpatient manuscript writing. Wattanapisit and Saengow Asia Pac Fam Med (2018) 17:9 Page 3 of 8 Table 1 Interview guide themes: (i) factors influencing decisions to use health - care services in public hospitals; (ii) barriers to access- Questions ing healthcare services in public hospitals; and (iii) How often do you visit the hospital? perceptions of free healthcare services in public hospi- Why do you visit the hospital? tals (Fig. 1). Which factors influence your decision to visit the hospital? Which symptoms or diseases make you visit a doctor at the outpatient department at the hospital? Theme 1: factors influencing decisions to use healthcare What are your feelings towards and how satisfied are you about the qual- services in public hospitals ity of free healthcare services? Self-care by seeking medications from nearby pharma- What are your feelings towards and how satisfied are you about the cists was the first choice for treatment of non-severe ill - process of free healthcare services? nesses. Patients, who needed to see doctors, could go Do you have any shared decision making with the healthcare team? to private clinics, private hospitals or public hospitals. What do you feel, in terms of equity and dignity, about using free health- care services? According to data analysis, the facilitators to visits to public hospitals were as described in the sub-themes detailed below. Table 2 Characteristics of participants (n = 29) Characteristic n (%) Free healthcare services Compared with services in the private sector, use Age (years) mean (SD) 56.76 (16.65) of healthcare services in public hospitals could save 21–30 1 (3.4) money for patients. Some participants sought diagno- 31–40 4 (13.8) ses and initial treatments from private clinics or private 41–50 6 (20.7) hospitals. Later, they decided to receive free healthcare 51–60 7 (24.1) services, for continuity of treatment or medications, in 61–70 4 (13.8) public hospitals to save money. ≥ 71 7 (24.1) Sex ‘…because I have the Social Security Scheme. It is Male 9 (31.0) my right and it is free.’ Female 20 (69.0) (FGD 3, SSS) Employment status Yes 19 (65.5) ‘Prior to this visit, I went to a private clinic but I No 10 (34.5) did not feel better after taking some medications. Education Next, I went to a private hospital and I got the Tertiary 6 (20.6) diagnoses—hypertension and dyslipidaemia. I just Secondary 9 (31.0) needed to know the diagnosis and paid for the ser- Primary or below 14 (48.3) vice. Today, I come here [a public hospital] because Income (Baht/month) mean (SD) 9160.34 (7667.99) I think doctors are the same but I can get free med- Health insurance ications here.’ UCS 12 (41.4) (FGD 3, SSS) SSS 7 (24.1) CSMBS 10 (34.5) Perception of serious illnesses Data presented as mean (SD) or n (%) Visiting public hospitals was the first priority if serious or UCS Universal Coverage Scheme, SSS Social Security Scheme, CSMBS Civil urgent conditions were presented. The decisions of par - Servant Medical Benefit Scheme, SD standard deviation a ticipants were based on the belief that public hospitals 35.79 Baht = US$1 had better capacities and facilities for such severe condi- tions compared with private clinics. Results ‘…severe conditions such as stomach pain—very We conducted five FGDs and one IDI between Novem - painful. I will not go to a private clinic. Obviously, ber 2016 and April 2017. Twenty-nine participants I have to go to the hospital. I have to stop drinking (mean age, 56.76 ± 16.65  years) participated in the and eating here for pre-operative preparation if an study. Table  2 presents the characteristics of the par- operation is needed. The doctor at the private clinic ticipants. The findings consisted of three emerging Wattanapisit and Saengow Asia Pac Fam Med (2018) 17:9 Page 4 of 8 Theme 1: Theme 2: Theme 3: Factors influencing decisions Barriers to accessing Perceptions of free to use healthcare services in healthcare services in public healthcare services in public public hospitals hospitals hospitals Free Long waiting Acceptable healthcare times quality of care services Limited Different Perception of services quality of care serious outside of with different illnesses office hours insurance Minimal A restricted Need for shared choice of special tests decision physician making Continuity of Equity of care healthcare Fig. 1 Summary of themes and sub-themes does not do any major surgery and he would refer lic] hospital. They have my profile and can start my me to this hospital. So, I decide to visit the [public] treatment immediately.’ hospital.’ (FGD 3, SSS) (FGD 1, UCS) Theme 2: barriers to accessing healthcare services in public Need for special tests hospitals Participants, who needed blood tests or laboratory tests, Using healthcare services at private clinics or private hos- preferred visiting public hospitals rather than seeking pitals required paying out-of-pocket. Nevertheless, par- advice from private clinics. Past experiences with regard ticipants sometimes went to the private sector due to the to special tests (e.g., a next-to-kin had a similar symptom limitations of public hospitals. and obtained the definitive diagnosis from blood tests) influenced their decision to visit hospitals. Long waiting times From the perspectives of patients, there was an imbal- ‘I need a blood test to know the definitive diagnosis, ance between demand and supply. A hospital visit con- so I come here [a public hospital]. If I went to a pri- sumed a lot of time. Patients had to wait in a queue in the vate clinic, they could not be able to take my blood early morning before office hours, and waited for a long for the test and they would refer me to the [public] time to see a doctor. Sometimes, this wait took a full day. hospital.’ (FGD 2, UCS) ‘Many people! Wait in the queue with one or two hundred people. The service, itself, is good but very slow. I spend a whole day in the hospital.’ Continuity of care (FGD 2, UCS) Patients with an underlying disease or chronic illness were more likely to visit the same hospital even though they had other illnesses that were not associated with the Limited services outside of office hours underlying disease. They believed that the hospital could Some services, including health check-ups and special- provide informational continuity and suitable care. ist clinics, were provided only during office hours. It was inconvenient for people or patients’ carers who could not ‘If I get sick from any disease, I will go to the [pub- Wattanapisit and Saengow Asia Pac Fam Med (2018) 17:9 Page 5 of 8 leave their work to visit hospitals. Therefore, some partic - payment for an admission in a private room was not cov- ipants went to private clinics or private hospitals to seek ered by UCS. healthcare services. ‘Actually, we get a lot of things, but we have to pay ‘I used to go to the [public] hospital on Saturday for for some items.’ a PAP smear. It is available from Monday to Friday. (FGD 2, UCS) As a teacher, it is not easy to leave my students and the service is not available at the weekend. So, I go Minimal shared decision making to a private clinic because I am free in the evenings Most participants were not familiar with the concept of and can see a specialist. The payment is quite high shared decision making. Doctors made decisions regard- and my insurance does not cover the cost from pri- ing treatments for their patients. If patients disagreed vate clinics. Although I cannot claim that payment, with the doctors’ recommendations, they could discuss it I must pay. If I leave for a check-up and I am not ill, with the doctors in advance. my boss will suspect me. Of course, I am concerned about my students.’ ‘I always follow the doctor’s recommendations. (FGD 4, CSMBS) Whether the doctor says oral drugs or injection, I will do it.’ (FGD 2, UCS) A restricted choice of physician There were fewer opportunities to see a specific doctor at public hospitals. If patients wanted to see well-known Equity of healthcare doctors in their neighbourhoods, they had to go to the Health insurance was considered to be a type of human private clinics of those doctors. right enabling access to healthcare and it was not a type of social class. ‘I cannot choose a doctor here [a public hospital]. I can choose a doctor if I go to his private clinic’ ‘Free healthcare service! It is not a second-class ser- (FGD 4, CSMBS) vice. All the things—treatments, services, and doc- tors—are normal. There is no discrimination.’ (IDI 1, SSS) Theme 3: perceptions of free healthcare services in public hospitals ‘For me, I have a social security card. It is fair for Quality of care among various types of health insurance workers.’ was not different. Some participants mentioned that the (FGD 3, SSS) quality of medications was different between the UCS and CSMBS. However, some participants argued that doctors made their decisions based on patients’ condi- Discussion tions rather than the types of health insurance available. This study identified the perspectives of patients towards hospital visits. Free healthcare services, per- ception of serious illnesses, the need for special tests, Acceptable quality of care and continuity of care were factors that influenced Compared with services in the private sector, the qual- patients’ decisions with regard to visiting public hos- ity of medical advice proffered by doctors and treatments pitals. Barriers to visiting public hospitals included was similar. long waiting times, limited services outside of office ‘My rights are not different from those of people who hours and a restricted choice of physician in the pub- have the Civil Servant Medical Benefit Scheme. The lic system. Free healthcare services were characterised doctor told me that medications are the same, and as acceptable quality, paternalistic care, and equitable that there is no need to go to a private hospital. The service. standard of treatment is the same whether or not I We found that free healthcare services were one of the pay. It happened to me.’ factors influencing the administration of public utilities. (FGD 5, UCS) Studies in Thailand have supported the notion that uni - versal health coverage increases healthcare utilisation in terms of hospital admissions and outpatient visits [14, Different quality of care with different insurance 20]. This finding could reflect that patients, as consum - Some participants expressed that the coverage of UCS ers, may not be concerned about the cost associated and SSS was different from CSMBS. For example, the Wattanapisit and Saengow Asia Pac Fam Med (2018) 17:9 Page 6 of 8 with healthcare, which leads to the overuse of healthcare increasing the participation of patients in decision mak- services [21]. A systematic review by Babitsch et  al. [22] ing or shared decision making can reduce use and cost of stated that perceived health status is one of the factors unnecessary healthcare [35, 36], therefore, shared deci- associated with use of healthcare services. This observa - sion making might be an additional practice to improve tion could explain our finding that people with serious or care and reduce costs in the Thai healthcare system. We severe illnesses are more likely to visit hospitals. Patients’ also asked the participants about their feeling in terms of expectations relating to test results could explain why dignity because patients are vulnerable and depend on they visit hospitals [23, 24]. We found that chronic ill- the judgement, skill, and attitudes of the healthcare pro- nesses are reasons for using healthcare services. This viders [37]. This may have an impact on the perspectives trend has also been found in different settings in Italy, of patients regarding the healthcare services. China and Korea [6, 10, 25]. A main strength of this qualitative study was that it Long waiting times in OPDs were considered to be bar- comprised participants with different characteristics, riers for utilisation of healthcare services by study partic- ages, and health insurance programmes which referred ipants. Several studies in low-, middle- and high-income to universal health coverage. Moreover, it was conducted countries support the notion that long waiting times can in several public hospitals. The different settings may be cause stress and dissatisfaction in patients [26–28]. Simi- responsible for some variation in participants’ percep- lar to our study, research conducted in northern Nigeria tions. A limitation of the study was that it was conducted found that the main reason for long waiting times was in rural areas, so private hospitals in this context might an imbalance in demand and supply (large numbers of not have been comparable with public hospitals, and the patients with few healthcare workers) [27]. Accordingly, findings from a qualitative approach will not be general - it seems that long waiting times in hospitals are common isable to other populations, especially in urban settings. in developing countries [29]. Thailand has an 8-h working It is not known to what extent participants in this study day, so public hospitals provide full services with maxi- represent rural hospital attendees in Thailand. mum capacity of resources during office hours during the week. Conversely, they allocate some services with fewer Conclusions resources outside of office hours. This scenario may be The present study highlighted the perspectives of patients perceived as limited accessibility to the services required in rural areas in Thailand with regard to hospital visits. by employed people [2]. In contrast, the private sector The factors and barriers to utilisation of healthcare ser - has greater availability and more flexible services outside vices provide exploratory data to understand the health- working hours and at weekends. Moreover, patients have care-seeking behaviours of patients. Long waiting times less opportunities to choose their preferred doctors in in hospitals are due to an imbalance between the number the public system. This might lead to the discontinuity of of patients and providers, so effective management would care. entail resource optimisation. Services outside of office In Thailand, the coverage of health insurance has been hours should be balanced between the requirements expanded since UCS implementation in 2002 [30]. The of patients and the resources available. In other words, UCS may lead to equity of healthcare among the Thai enhancing the accessibility to healthcare must be realis- population, especially for those on low incomes, the tic and cost-effective. A lack of choice to see a preferred unemployed, and people with chronic illnesses [2]. How- doctor can interrupt the continuity of care. Perceptions ever, there is a need to deliver effective interventions to towards free services in the context of universal health reach a higher standard of care, particularly for non- coverage were positive but participation in decision mak- communicable diseases and long-term care [31]. Most ing was sparse. To improve the quality of healthcare ser- importantly, the cost-effectiveness of the healthcare sys - vices, there is a need to balance the needs and barriers to tem should be considered based on the state of Thailand’s hospital visits, introduce the concept of shared decision finances. making to healthcare providers, and reduce the inequity Our findings suggest that paternalistic healthcare of access to healthcare. is a common approach in a Thai context. Paternal - ism is thought to be able to control healthcare utilisa- Abbreviations tion because doctors believe that he or she knows best, CSMBS: Civil Servant Medical Benefit Scheme; OPD: outpatient department; and makes decisions based on his or her views without SSS: Social Security Scheme; UCS: Universal Coverage Scheme. the involvement of patients [32, 33]. A lack of shared Authors’ contributions decision-making between patients and doctors in clini- AW and US initiated the study design. AW conducted all the focus group cal practice can be the effect of time constraints, patient discussions and in-depth interviews. AW and US analysed the data. AW wrote characteristics, and clinical situations [34]. Whether Wattanapisit and Saengow Asia Pac Fam Med (2018) 17:9 Page 7 of 8 the first draft of the manuscript. Both authors read and approved the final goals in Thailand: the vital role of strategic purchasing. Health Policy Plan. manuscript. 2015;30:1152–61. 12. Kijsanayotin B. Impact of Thailand universal coverage scheme on the Author details country’s health information systems and health information technology. School of Medicine, Walailak University, Thasala, Nakhon Si Tham- Stud Health Technol Inform. 2013;192:989. marat 80161, Thailand. Center of Excellence in Health System and Medical 13. Mee-Udon F. Universal Health Coverage Scheme impact on well-being in Research, Walailak University, Thasala, Nakhon Si Thammarat 80161, Thailand. rural Thailand. 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Asia Pacific Family MedicineSpringer Journals

Published: Sep 3, 2018

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