By Dr. Zhanming Liang and Dr. Phudit Tejativaddhana
Healthcare reform is often driven by the desire to improve system performance and a political agenda. A lack of expertise in planning and managing the implementation of the reform agenda has often contributed to reforms not achieving or sustaining their expected outcomes.1,2 In this context, the Thai healthcare system reform, by providing universal insurance coverage to its population in 2002 has been an exemption, has achieved significant success by maximising the coverage across the Thai population from 70% in 2001 to 98% coverage in 2011, and reducing the out-of-pocket health expenditure from 35% in 2001 to 14% in 2011.3
Achieving universal health insurance has certainly made Thailand proud. However, the complex three-tier health insurance arrangements together with the increasing healthcare needs threaten its sustainability. Although the old age dependency rate (number of people aged 65 and above per 100 population aged 15 to 64) of 13% in Thailand is relatively low, the rate is predicted to increase to 53.1% in 2050.4
The significant increase of the proportion of aged population not only predicts a significant increase in health service demand, but also a significant decrease in tax contribution from this retired population. In addition, more than 60% of the population are working in the informal sector in Thailand – a population that may not be subject to tax contributions. These two key factors make significant increases of tax revenue by the Thai Government impossible in a long run, at least not at a rate that can match the increasing healthcare demands.5 It is clear that significant injection into healthcare expenditure to meet the increasing demand alone is not a feasible solution in Thailand. Efforts to improve the effectiveness and efficiency of service delivery are strongly recommended.
WHO (2010) describes a health system by the following six building blocks : i) service delivery, ii) health workforce, iii) health information systems, iv) access to essential medicines and technologies, v) financing, and vi) leadership/governance (p. vi). Strengthening these building blocks will improve overall health system performance and service outcomes, resulting in improved health of the population. For service delivery, one of the eight key characteristics is ‘accountability and efficiency’, “Health services are well managed as to achieve the other core elements with a minimum wastage of resources. Managers are allocated the necessary authority to achieve planned objectives and held accountable for overall performance and results”.6(p3) Strengthening of the health workforce, requires effective performance management of health workers, most importantly necessitating adequate numbers of senior staff to receive in-service management training (with a nationally approved curriculum).
The importance of improving management competence has also be substantiated by empirical evidence linking the competence of managers positively to the productivity of organisations.7,8 Improved competence of health service managers is associated with more efficient and effective health service provision.9 However, the competence of health service managers is often questionable, because management positions are not well defined in healthcare settings. In addition, health service management positions are often filled based on clinicians’ seniority and clinical leadership without adequate, prior management training.10-14 Therefore, programmes to develop the competence of health service managers are required. In Thailand, the shifting focus from ‘acute care’ in the hospital setting to ‘chronic care’ that are primarily delivered in the primary care setting, and the increasing emphasis on health promotion and disease prevention adds the urgency to the improvement of the competence of health service managers for two key reasons. Firstly, the change of management model requiring the change of management mindset which can’t be changed without appropriate training and development.12 Secondly, the evolving complex healthcare system requires manager to be equipped with modern management and leadership competencies responsive to emerging health challenges and in managing service delivery, and to confront the complex and dynamic health system.14,15
Such investment can be made through a number of mechanisms such as providing formal education in the field of management; in-service training; in-house use of mentors and study groups; offsite intensive training, and seminars and conferences.9 This emphasises the importance of the establishment of the first College of Health System Management in Thailand by Naresuan University (NUCHSM) with its Master of Science in Health Systems Management commencing in 2017.
Key steps to establish the international standing of the NUCHSM will include drawing on international expertise for teaching and research in the area of health service management; for the development of an evidence-based curriculum that addresses the management competency requirements of the Thai Health System; and developing research capacity of academic staff. The Managerial Competency Assessment Partnership (MCAP) Program led by Dr. Zhanming Liang from La Trobe University, Australia has established a Leadership and Management Competency Framework through a validated research process to guide the development of health service management curricula and, thus, the development of health service manager competence.13,16,17 This process will be introduced into Thailand as a key strategy to strengthen the Thai district health management system and staff.
MCAP is looking forward to long and fruitful partnership by contributing to the development of the current and future health service management workforce in Thailand, and also to improving the research capacity of the NUCHSM academic staff through targeted training and mentorship.
- Liang Z. Short SD, Howard PF & Brown CR. “Centralised control and devolved responsibilities: personal experiences of top-level health executives on the implementation of area health management model in NSW 1986-99”. Asia Pacific Journal of Health Management 2006, 1(2): 44-50.
- Liang Z. & Howard P. “Lesson learned from the introduction of performance management to the senior health executive levels in NSW in the 1990s”, Australian Health Review 2007, 31(3): 393-400.
- Hanvoravongchai P. (2013). Health financing reform in Thailand: toward universal cover-age under fiscal constraints. UNICO Study Series, No. 20. World Bank: Washington DC.
- United Nation (UN) http://www.un.org/en/development/desa/population/publications/manual/projection/index.shtml. Accessed on 9 September 2016.
- Hsu M, Huang X & Yupho S. (2015). The development of universal health insurance coverage in Thailand: challenges of population aging and informal economy. Social Science & Medicine, 145:227-236.
- World Health Organisation (WHO). (2010) Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. WHO: Geneva.
- Catano V & Campbell C. (2007). Performance appraisal of behavior-based competencies: a reliable and valid procedure. Personnel Psychology, 60, 201-230.
- McClelland D. (1973). Testing for competence rather than for intelligence. American Psychologist, 28, 1-14.
- Maurer J, Kimberly A, Haefner J, Stuart A. & William C. (2003). Beliefs about ‘improvability’ of career-relevant skills: relevance to job/task analysis, competency modelling, and learning orientation. Journal of Organisation Behaviour, 24, 107-131.
- Australian College of Nursing (ACN). Nursing leadership – A white paper. Canberra: CAN; 2015.
- Liang Z, Howard P & Koh L. (2013). Hey boss: are you sure they are the managers you are looking for? Managerial competency requirements for level II & III managers in community health services.
GSTF Journal of BioSciences, 2(1): 86-91.
- Taytiwat, P., Briggs, D S., Fraser, J., Minichiello, V. & Cruickshank, M. 2011 Lessons from understanding the role of community hospital director in Thailand: Clinician versus manager, International Journal of
Health Planning and Management, Vol. 26, Iss. 2, pp. e48-e67.
- Tejativaddhana, P., Briggs, D S., Fraser, J., Minichiello, V. & Cruickshank, M. 2013 Identifying challenges and barriers in the delivery of primary health care at the district level: A study in one Thai Province, I
International Journal of Health Planning and Management, Vol. 18, Iss. 1, pp 16-34.
- Briggs DS, Cruijshank M & Paliadelis P. (2012). Health managers and health reform. Journal of Management & Organisation, 18, 641-658.
- Landry A, Stowe M & Haefner J. (2012). Competency assessment and development among health-care leaders: results of a cross-sectional survey. Health Service Management Research, 25, 78-86.
- Liang Z, Leggat S, Howard, P and Koh L. “What makes a hospital manager competent at the middle and senior levels”, Australian Health Review, 2013, 37(5):566-573.
- Liang Z, Howard, P and Leggat S. “360° Management Competency Assessment: is our understanding adequate?” Asia Pacific Journal of Human Resources. (online since 12 February 2016)