The objectives of the research: by pass problems experienced by patients obtaining public health’s services in Phukhieo hospital, Phukhieo district, Chaiyaphum province, were to show the causes of this: (1) the factors of by pass problems experienced by patients obtaining public health’s services, (2) the problems occurring to the patients both inside outside of the hospital occupying when they obtained the by passed public health services and (3) to study a referral system and it’s problems for standard management of the hospital. The study focused on the qualitative research method. Data were obtained from document review, in-depth interview and focus group, and also the participant observation and non-participant observation. The study covered the period of February to September, 2003.The results of this study showed that: 	1. The factors leading to the bypassing experienced by the patients obtaining public health services were the inconvenience in transportation, inreliance of the clinical  service quality, the seriousness of the disease, the character of the servant, the contact and information obtaining from the service, service system, mode of clinical service right, the clinical referral, and the non-understanding of the card holders under the universal coverage insurance. 	2. Most of the patterns and conditional problems were described as following items: (1) an economic problem was caused of the loss of time, the cost of transportation, food, and health’s care. These charges had to be paid by the patients because the universal coverage insurance cannot be used. This was caused by unused referral system, (2) the physical problem was occurred from the inconvenience and no safety of life and (3) the mental problem was occurred because they were not satisfied of the service quality because of the non-understanding of the referral management system between the patient and the relative of the servant. 	3. The quality and standard of health care and referral system management in Phukhieo hospital were revealed that: (1) there was small amount of doctors that the ratio of doctors to patients was low score, general practice and most of them were funded and just graduated. They always move to several areas. So their knowledge and experience were not enough, and the inspiration to improve service system was lacked, (2) the strategy for the referral system management depended on the universal coverage insurance policy that the patients were commented to use the first register service. The patients with over cured disease) will be immediately and safely referred to higher efficient hospital, (3) the referral strategy always improved following the policy of referral system) of Chaiyaphum province,(4) the standard and quality of referral sys tem were shown that the patient was not treated in the referral standard from most doctors. The patients who can cure themselves were referred, while the patients with over cured disease were allowed to care themselves until they were coma and then were referred the secondary care, (5) Since running on the 30 baht policy, the referral system was limited by a payment. If it was not necessary, the patient was not referred because of the necessity to decrease the payment. This was differ from the previous service system and (6) The communication problem to refer the patient arise between general practice and specialists. Most general practice was graduated so far or funded. So they were not confident to ask the special doctor and they cannot contact to consult specialists when they have the problems. 	4. The policy suggestion was that, the alternate strategy for the persons relating to consider the policy was the patient choice for register with the health care service depending on their convenience. This was independent from the geographical or occupied dividing areas to solve the patient’s problem.  	5. The developmental suggestions indicate that: 		5.1  The patients should obtain the information from the various choices such as the community deputy meeting, the village health volunteer ’s meeting, civic groups and home health care, or the data will be obtained from family folder observation by the personnel’s health in the following mentions. (1) the patients are commented to obtain service from the specific health care and for the case of by passed patients, the charge of health care have to been paid by them, (2) the sheets describing healthcare efficiency of all hospital levels should be distributed to all personnel’s health of all department  and sub-district health. These are the data for the communication to the patients about the health care efficiency and for patient deciding, (3) There should be the communication to understand about the right of the universal coverage insurance, referral system and the rules of the health care obtaining in Phukhieo hospital for either government service right patients or life insurance patients. 		5.2  For the servants personnel’s health,  the improvement of the health personnel’s health is important. The strategies of this are that, (1) the seminar of services behavior should be always established and performances according to the patients’ rights  (2) services behavior should be used to consider progression and (3) the finding out and pronounce of the excellent personnel’s health should be done monthly or yearly. In the other case, there should be punishment when there are the complains about the improper service, and also the service system and personnel improvement should run to obtaining the patient’s trust. 		5.3  The service system revealed that, the quality and service system need to be developed, especially the out patients department (OPD.) that a lot of time was used for waiting to see doctor. Possession of nurse practitioner is a method that can help to increase the service efficiency. Case study showed that, there was the referral standard problem. The referral audit between doctors and all servants should be set up once a month or two months to improve the referral standard, communication between the referral concerned servants, and increase the occasion of communication between general practice and specialists. In addition, the quality of secondary care in the hospital has better be corrected, for example; conference, seminar, the deficient specialists to be the consultant once a week or two weeks. This is to develop the doctors’ knowledge and efficiency, inspire doctors to work in the hospital for a long time, therefore the service quality will be developed and the bypassed patients from Phukhieo hospital will be decrease.