The conversation with Dr. Samrerng Yangkratoke’s Push for Three-Doctor Policy

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The conversation with Dr. Samrerng Yangkratoke’s Push for Three-Doctor Policy

Thailand is now upgrading its primary-healthcare system in terms of quality and accessibility via the initiative to assign three doctors to each family. The three-doctor policy recognizes a village health volunteer as the first doctor for providing healthcare services at community level, an official of a district health promotion hospital as the second doctor for giving healthcare at sub-district level, and a family physician as the third doctor for delivering services at district level. The policy seeks to ensure these three doctors work together systematically, making further progress from the universal coverage healthcare scheme. The Human Resources for Health Research and Development Office interviews Dr. Samrerng Yangkratoke, vice minister for Public Health, as he is the man behind this three-doctor policy.


How did the three-doctor policy start?

The formulation of this policy started because we wanted to develop the country’s healthcare system further and we took account the opinions of many. First of all, we paid attention to a goal mentioned at a World Health Organization (WHO) meeting in Astana back in 2018. Developed based on the Alma Mater Declaration on primary-healthcare development, that goal demands that every country create primary-healthcare sustainability for its people. Secondly, we paid attention to the United Nations’ moves and especially its Sustainable Development Goals (SDGs). Of the 17 SDGs, one prescribes the development of primary-healthcare system. Thirdly, the Thai constitution stipulates that family-care teams must be available to take care of people’s health. Lastly, we considered the Primary Care Act of B.E. 2562. All these four elements have provided the framework for primary-healthcare development as we strive to give the best care to people. Importantly, we have also recognized that our village health volunteers made a very good job during COVID-19 outbreak. So, when all these factors are combined with my personal experiences, I believe that the three-doctor policy will be practical.


At the heart of the three-doctor policy is coordination among healthcare workers. So, what are the differences between the three-doctor policy and the one about family-care team?

They are different. When we talk about a family-care team, we look at the concept in a legal sense. The team must consist of a doctor who is trained in family medicine, a nurse, an interprofessional-education graduate, a public-health academic, a medical technologist, a dental therapist, and a village health volunteer. The family-care team is considered in a legal sense because laws require that the state provides such team to people. But when we talk about the three-doctor policy, we focus on what Thais will get from the policy. Simply put, the family-care team concept focuses on the thing the state must provide, while the latter pays attention to what people will receive. In foreign countries, a family has just one doctor. But we are going to give Thai families three doctors, who will work together in taking care of people.


The three-doctor policy will give a clearer role for village health volunteers to play in the healthcare system. Will it require them to overwork, especially given their current pay rate?

No, they are not going to overwork. Village health volunteers have already been at work. It is just that not many people know about their work. Village health volunteers’ roles become widely known only after the COVID-19 outbreak. Today, the public recognizes that having someone who know healthcare system in their village can help people a lot. There are now three major groups of village health volunteers. The first group consists of village health volunteers who work well and have a public spirit. The second group comprises village health volunteers who work based on instructions given. The third group, meanwhile, refers to village health volunteers who do not really work but stay in the posts to get paid. So, when we introduce the three-doctor policy, village health volunteers will firstly have clearer work guidelines. Secondly, not a single village health volunteer can stay inactive. Thirdly, village health volunteers will be proud of their job because they will be recognized as doctors and given opportunities to work alongside trained physicians. Fourthly, the policy will bring healthcare-system development forward. According to the three-doctor policy, three doctors will have to work as a team. They also have to stay in touch with people. Such approach to work will drive constant development. Village health volunteers, while working, will naturally learn from the second and third doctors. The policy, in all, will develop village health volunteers further. With the implementation of the policy, village health volunteers will have to create family health volunteers. In other words, the policy will ensure at least one person in each family has health literacy.


Will village health volunteers remain volunteer based?

Yes, I think so. No one will serve as village health volunteers, if they do not have a public spirit. With the three-doctor policy, they will enjoy great dignity being a doctor, taking care of people, having clear roles to play, and working alongside family physicians and officials of district health promotion hospitals. The healthcare system will recognize village health volunteers as representatives of doctors. This is the thing village health volunteers will get from their job, on top of monetary remuneration. They will have a clearer place to stand in the healthcare system while their public spirit remains recognized. By the way, we may consider some other forms of financial remuneration for them too.

This policy seems to contradict the career path of health professionals whose scope of work has become increasingly clearer. There has been a clearer line of job responsibilities among practitioners of various professions too. 

The three-doctor policy will solve the problems related to the delegation of duties among healthcare workers. At present, human resources for health are allocated by central agencies based on health professions. Even staff working at district health promotion hospitals need clear line of professions. So, members of each profession have worked more separately. By the way, when we implement the three-doctor policy, the focus shifts. It is about doctors working at subdistrict level. We need to understand that the line between health professions is clearest at district health promotion hospitals and community hospitals. The line is indeed very clear at subdistrict health promotion hospitals. Our three-doctor policy will not divide healthcare workers by profession. We will designate everyone working at subdistrict health promotion hospitals as second-level doctors. They will be required to work together and take care of an equal number of villages. Such practice will fade the line between health professions. The second-level doctor or the second doctor in the three-doctor policy will have to wear two hats – one involving job responsibilities related to their profession and the other involving villages under his or her care. It should be noted that once you take charge of one to three villages just like others working at your hospital, your job responsibilities related to your health profession will reduce by half. Whether you are a nurse, an academic, a dental therapist or a public-health worker at subdistrict health promotion hospitals, you have to take care of villages or about 1,250 people each all the same. To do so, you will have to network, check locals’ social conditions, and their living. These tasks are not based on the health profession. On the overall, villages’ basic problems are usually pretty much the same. Solving these problems hardly requires specialized knowledge of health professions. For the second hat you wear, you use social skills and psychology. All healthcare workers who handle these tasks will have to do pretty much the same things. Profession lines thus will be blurred, as second-level doctors will naturally consult and support one another.


Will this policy cover local administrative bodies that are being engaged as key mechanisms in people’s healthcare and quality of life?

The three-doctor policy involves local administrative bodies for sure, even though we do not mention it. We believe everyone will automatically know this anyway. Normally, we use the services of local administrative bodies. So, when we implement the three-doctor policy, we will use more of their services especially at the levels of subdistricts and municipalities. At present, there have been at least two key funds in the hands of local administrative organizations namely the Health Rehabilitation Fund and the Elderly Fund (Long-Term Care). While normal funds in the healthcare system will partially support the work of second-level doctors, some funding must come from local administrative bodies. We must admit that officials at many local administrative bodies do not know how to write proposals to request budgets. So, our doctors and local administrative bodies must work together in preparing proposals so as to get funds for their work. Local administrative organizations will have to approve the proposals because such projects are designed to take care of locals. Proposal preparations will improve. Local administrative bodies at all levels will be glad, when all these moves really happen. I have heard that many local administrative organizations are so happy that subdistrict health promotion hospitals have been put under their care and they are keen about the three-doctor policy.

After all subdistrict health promotion hospitals are transferred to local administrative bodies in line with decentralization laws, will the three-doctor policy continue?

Yes, the transfer will not pose an obstacle. Three doctors, in essence, do not work for the Public Health Ministry. They work for people. So, no matter which authority subdistrict health promotion hospitals report to, the three-doctor policy can be implemented. No matter which agency the second doctor works under, he or she works for people. The first doctor, who is a village health volunteer, has to work with people all the time.


The three-doctor policy places a strong emphasis on revitalization. In your opinion, what does the current healthcare system lack? Why does it need to be revitalized?

Our system has structure and staff. But it lacks system and spirit. Still absent are continuity, attitudes, ideals, and the ideologies embraced by staff. We prescribe revitalization in the hope of revitalizing the spirit of workforce. We hope that with revitalization, our staff will be happy helping people. These days, our staff tend to work under stress. Staff at provincial hospitals are especially stressful. Our second doctor or the one working at a subdistrict health promotion hospital must key in information to claim budget reimbursement. Such task is stressful. He or she worries about whether all entries are correct and whether budget will really arrive. Those who are not in charge of data entry will naturally keep asking too as to when money will come. The recipients of data are also worried and stressed. They are worried about whether data are fabricated. What if locals do not seek services but entries are made up just to claim budget? Such cases have happened before. Stress thus spreads across the system and affects staff at all levels. Tension will ease when the three-doctor policy is in place. This is because three doctors will work in coordination. Working will be easier. Importantly, data system will have to be adjusted. We have also talked to the National Health Security Office to point out that the remuneration system must be overhauled too. You should stop counting the number of vaccine shots you have given when paying out remuneration. It will be better to count the number of visits to locals your staff make, how many family health volunteers they have created, and how many people stay healthy because of your staff’s work.


As work is the same, only indicators are changed then?

I am not sure how much workload we will be able to curb. But judging by the change in attitudes and approach, we will get a new set of indicators that better reflect staff’s work and the impacts or outcome they have achieved. The indicators will no longer focus on just numerical output like the number of persons vaccinated or the number of persons trained. We are going to focus on the good health of people. Indicators will be adjusted accordingly. Of course, it is easier said than done. But we are going to make adjustments little by little. Most important of all, we need to create trust in the system. If our members win trust, there will be no need to conduct audits all the time. When winning trust, staff usually show honesty and greater satisfaction. We hope things will turn out this way. To implement the three-doctor policy, we will need to win public trust. We will have to make sure people believe in our three doctors. To win public faith, we have to have faith in our staff first.


What is the next step to push this policy ahead?

During preparatory stage, we pursued mutual understanding of the concept and looked into rationality. Secondly, we invited experts to discussions. After we really got the mutual understanding, we focused on the third doctor. We looked into what the third doctor must do to decide which kinds of doctors we must involve and how we would be able to retain them in the system. In my opinion, the third doctor must be separated from community hospitals. If they stay with community hospitals, they may have difficulty making field trips as their hospital directors may not grant an approval. If we want to take them from community hospitals, we have to clearly define their roles and duty, and also prepare welfare. Regarding the second doctor at subdistrict level, we will have to determine how to divide villages, how to reach out to communities, and what tools we will need. We also have to think about how village health volunteers divide villages under their charges. Next, we will have to decide on whether we will need an operation center, how to create family health volunteers, and how to promote ties among three doctors. We need to ensure they can consult one another. After we go into these details, we will organize trainings for executives. Trainings will be conducted for executives of central agencies first. Then, we will talk to provincial-level agencies. Next, we will talk to operation-level staff. Now, we have already concluded that every province must implement the three-doctor policy in at least one district. The chosen district must prepare catchment areas. This means the implementation will take place in 77 districts in 77 provinces. We will cover more areas later on.


Will this policy continue if the country gets new public health minister?

I think it will continue. Look at how the Bt30-per-medical-visit scheme (now known as universal coverage healthcare scheme) has prevailed. No one can end it. Just an idea of halting the scheme is wrong, because the scheme benefits people. The three-doctor policy will work in the same way. After one or two year(s) of implementation, if all parties concerned namely staff, people, policy makers and buyers of the services agree that the policy is useful, its implementation will continue. Importantly, the constitution supports this policy. As this policy resonates with both political-office holders and permanent civil servants, it will stay. So, I am confident that three-doctor policy will keep going on the merits of rationality and methods involved.