Bangkok is a metropolis, administratively governed by a special form of local administration organization which has been established to take care of the entire area of the city under the supervision of the Minister of Interior, according to Bangkok Metropolitan Administration Act B.E. 2528 (1985). The existing Bangkok’s structural contexts and distribution of health resources as well as health service systems differ from other provinces of Thailand, especially in that private health facilities are outnumbering the government ones in all levels of care, whether primary, secondary or tertiary. There are many high potential private hospitals distributed around the various khets (districts) of Bangkok, but only a few choose to offer their services for any of the three government health coverage schemes, i.e. Universal Coverage (UC), Social Security (SS) and Civil Servants Medical Benefits (CS). In contrast, the total number of high potential government hospitals affiliated with either the Bangkok Metropolitan Administration (BMA) or the Ministry of Public Health (MoPH) is small with no linkage to the overall area-based integrated health service system networks and referral systems. This may result in the general public being unable to access emergency services easily and conveniently, unlike in the other regions/areas.
Acute Coronary Syndrome (ACS) is an important cause of sudden death or disability, if the patient fails to get proper reopening of the clogged vessels in time. Recently it was found that people living in Bangkok (or the 13th Health Zone of MoPH) have higher prevalence of risk factors to coronary heart diseases (i.e. overweight and obesity, Diabetes Mellitus, hypertension, and dyslipidemia), when compared to people living in other zones of the country1.
The MoPH, through Department of Medical Services, was assigned to jointly develop a service plan on heart diseases with hospitals affiliated with the BMA and other government units as well as private hospitals. This is to build a network of health service systems and heart disease patient referral systems within Bangkok area, which is effective with standard quality. However, there is still a lack in basic information on general situation and issues of medical service delivery specific for heart disease patients in the government and private hospitals within Bangkok. So the Health Insurance System Research Office (HISRO) has conducted a situational analysis on medical service delivery of government and private hospitals in Bangkok for heart diseases. This is to provide initial information for the working group concerned in the development of a service plan for heart diseases in this area. This study was aimed at analyzing the situation and issues involved in medical service delivery related to heart diseases in the government and private hospitals by focusing on acute ST elevation myocardial infarction (STEMI) in many aspects, i.e. health resources distribution, service quality and potential, pattern and structure of the organization, service system management process within and outside the hospital, and linkage or collaboration among private and government hospitals. This was to identify priority issues that should be improved and developed. The research used mixed method i.e. paper reviews, quantitative data analysis, additional survey for additional data, in-depth interviews and brainstorming sessions with experts on heart and vessel diseases.
It was found that
(1) A total of 56 government and private hospitals in Bangkok responded to the survey. Twenty nine (51.8%) have STEMI Fast Track service in place, while only 15 (26.8%) have Coronary Care Unit (CCU). However, most private hospitals which are well-equipped and having high potential in providing primary percutaneous coronary intervention (Primary PCI), i.e. having proper organizational structure and medical team, are not within the service network for government health coverage schemes.
(2) The prevalence of STEMI per 100,000 population among participants of the three government health coverage schemes, i.e. UC, SS and CS, within Bangkok showed an increasing trend when compared to other zones nationwide (i.e. among Health Zone 1-13), especially among elderly aged over 60 years. Moreover, collectively only 40% of the patients in the three government health coverage schemes have received reperfusion service, which is less than the average level of the country. Patients of UC and SS schemes could access health service networks and referral systems which are linked with private hospitals, but patients of the CS scheme still have no such systems.
(3) Discrepancy in methods and rates of payment among the existing government health coverage schemes is an important obstacle affecting the development of health service networks for heart disease patients in Bangkok where the contexts of health service system differ from other areas, especially among emergency heart patients who are in need of medical services that are convenient, timely and of standard quality to save lives and prevent disabilities.Suggestions on the service plan for heart diseases in Bangkok are as follows:
(1) There is a need to establish health service networks and referral systems for patients of heart diseases based on collaboration among government and private hospitals in each sub-zonal area. This is to ensure that every patient under every scheme can access the needed primary PCI under emergency conditions within the suggested timeframe according to technical guidelines, with support of effective information systems.
(2) Amendments on criteria, conditions, methods and rates of payment should be made to be identical or to achieve harmonization among the three government health coverage schemes. Patients of CS scheme should also be able to access the needed medical services at capable private hospitals in case of emergency.
(3) Data collection and information systems on medical and health services for heart diseases, which are integrative in nature, need to be developed. Those systems should cover government and private health facilities for continuous situation analysis, planning, and monitoring and evaluation.