The Impact Of Health System Reform On The Governance And Performance Of Primary Health Care System In Thailand

The governance and efficacy of the healthcare sector are paramount because they relate to human well-being and contribute to economic and social development.Effective primary health care system has been globally recognized as a foundation for strengthening the health system.However,the literature assessing the impact of health system reform on governance and performance of primary health care system remains scarce.Thailand is one of the few developing countries to achieve Universal Health Coverage in 2002.Although many lessons have been drawn from Thai practices to other developing countries,most literature has been focused on health financing equity while less attention is paid to how the system was governed and delivered its services.More importantly,the governance of the primary health care system after the reform and its potential impacts on the performance of the health system required further research.This study aims to answer the question of how health system reform affects the governance and performance of the primary health care system through the primary health care governance mechanisms of leadership and political commitment,policy guidelines,funding and resource allocation,and community engagement.Specifically,the governance of the primary health care system in aspects of structure and service delivery process is observed,which ultimately affects the performance of the primary health care system in terms of efficiency of resources allocation,equity to access,and resilience in times of public health crisis.To answer these questions,a mixed method of quantitative and qualitative analysis is employed.This study takes a case study of a primary health care network at the district level to showcase the impact of health system reform on the structure and service delivery of the health system through the governance mechanisms.It conducts approximately 60-90 minutes of in-depth and focus-group interviews with healthcare bureaucrats and managers of the Contracting Unit for Primary Care A during February and March 2020.To assess the performance of the primary health care system,secondary databases and a first-hand questionnaire survey were used.The international databases,governmental databases,and national surveys were used to assess the efficiency of resource allocation and the equity to access while the primary data was collected to timely evaluate the resilience of the health system during the early phase of COVID-19.The study has four important findings.Firstly,health system reform has both positive and negative impacts on the governance of the primary health care system in terms of the structure and service delivery process which ultimately leads to the varied performance of the health system through the mixed degree employment of four governance mechanisms.Secondly,despite scarce,the budget and resource allocation of the primary health care system is quite efficient in delivering corresponding healthcare services but not in regarding to health outcomes.Thirdly,the empirical evidence suggests that the effect of health system reform on the equity of access has been improved but yet insufficient,as the probability of a person experiencing the unmet outpatient care is strongly associated with age and region.However,as compared to the elderly,only the minor group has the probability to experience the unmet outpatient care where the probability has been reduced by83%,while,unexpectedly,the probability of the richer regions to experience the unmet outpatient care,as compared to the poorer regions,has been increased by 2 times.Finally,professional trust has a dual effect in facilitating policy compliance to promote legitimate institutions and build the resilience health system in times of public health crisis.Professional trust has a direct effect on policy compliance and fully mediates the relationship between public trust in government and policy compliance as the effect of trust in government on policy compliance becomes insignificant,namely from(? = 0.133,p < 0.01)to(? = 0.015,p > 0.05).Meanwhile,the health system reform and the enhanced core functions of the primary health care system have also contributed to the prevention and containment of the pandemic during its early phase.Based on these findings,the study proposes four policy recommendations and lessons learned for other countries.The findings from this study contribute to the knowledge of the governance and performance assessment of the primary health care system in two ways.It points out that health system reform did have an impact on the way the primary health care system was structured and delivered its services which ultimately lead to the varied performance of the system through four strategic mechanisms.The study also assesses the performance of the primary health care system in terms of the efficiency of resource allocation,equity to access,and resilience of the health system in times of public health crisis.However,since the primary health care system is huge and complex,further research is encouraged to continually observe the impact of health system reform on its governance and performance from a different perspective and research methodology.