|Year : 2010 | Volume
| Issue : 3 | Page : 457
The Thai-Australian Health Alliance: Developing Health Management Capacity and Sustainability for Primary Health Care Services
DS Briggs1, P Tejativaddhana2, M Cruickshank3, J Fraser1, S Campbell1
1 University of New England, Armidale, New South Wales, Australia
2 Naresuan University Thailand, Muang, Phitsanulok, Thailand
3 School of Health Sciences, Charles Darwin University, Darwin, Northern Territory, Australia
|Date of Submission||18-Feb-2010|
|Date of Acceptance||06-Nov-2010|
|Date of Web Publication||30-Nov-2010|
D S Briggs
& Lawrence Avenue, Tamworth, NSW 2340
Source of Support: None, Conflict of Interest: None
Context: There have been recent calls for a renewed worldwide focus on primary health care. The Thai-Australian Health Alliance addresses this call by developing health care management capability in primary health care professionals in rural Thailand.
Objectives: This paper describes the history and current activities of the Thai-Australian Health Alliance and its approaches to developing health care management capacity for primary care services through international collaborations in research, education and training over a sustained time period.
Methods: The Alliance's approach is described herein as a distributed network of practices with access to shared knowledge through collaboration. Its research and education approaches involve action research, multi-methods projects, and evaluative studies in the context of workshops and field studies. WHO principles underpin this approach, with countries sharing practical experiences and outcomes, encouraging leadership and management resource networks, creating clearing houses/knowledge centres, and harmonising and aligning partners with their country's health systems.
Findings: Various evaluations of the Alliance's activities have demonstrated that a capacity building approach that aligns researchers, educators and health practitioners in comparative and reflective activities can be effective in transferring knowledge and skills among a collaboration's partners. Project participants, including primary health care practitioners, health policy makers and academics embraced the need to acquire management skills to sustain primary care units. Participants believe that the approaches described herein were crucial to developing the management skills needed of health care professionals for rural and remote primary health care. The implementation of this initiative was challenged by pre-existing low opinions of the importance of the management role in health care, but with time the Alliance's activities highlighted for all the importance of health care management. Acceptance of its activities and goals are evidenced by the establishment of a Centre of Leadership Expertise in Health Management and the endorsement of the Phitsanulok Declaration by more than 470 primary health care practitioners, academics and policy makers.
Discussion and conclusion: Problems with the primary health care delivery system in rural Thailand continue, but the Alliance has successfully implemented a cross cultural strategic collaboration through a continuity of activities to augment practice management capacities in primary care practices.
Keywords: Primary health care, health management, health systems, collaboration, networks, developing countries, rural health, knowledge translation, cross cultural, leadership
|How to cite this article:|
Briggs D S, Tejativaddhana P, Cruickshank M, Fraser J, Campbell S. The Thai-Australian Health Alliance: Developing Health Management Capacity and Sustainability for Primary Health Care Services. Educ Health 2010;23:457
|How to cite this URL:|
Briggs D S, Tejativaddhana P, Cruickshank M, Fraser J, Campbell S. The Thai-Australian Health Alliance: Developing Health Management Capacity and Sustainability for Primary Health Care Services. Educ Health [serial online] 2010 [cited 2021 Mar 6];23:457. Available from: https://www.educationforhealth.net/text.asp?2010/23/3/457/101469
This paper is an adaptation of a paper presented at a meeting of the Thai-Australian Health Alliance during the 1st International Conference of Health Service Delivery Management, Phitsanulok, Thailand 2009.
Recent calls have been made for a renewed focus on primary health care1,2 in the midst of criticism of the overuse of “vertical programs” at the expense of “horizontal programs” of aid, research and training in health care in developing countries. Vertical programs refer to the delivery of health services through stand-alone, often disease-specific programs, in many cases managed by donor organisations and often apart from the recipient countries’ health system. In contrast, horizontal programs are generally delivered within the existing health infrastructure of the recipient country and are particularly relevant to attempts at integrated care and primary health care approaches3. The relevance of horizontal programs is expressed by the ‘15by2015’ call for quality health care for all, through primary health care4 and is more comprehensively described by De Maeseneer and colleagues5. These authors call for increased investment in horizontal care ‘to build sustainable, cost effective primary health care systems’. This paper will describe one such investment, the Thai-Australian Health Alliance, which attempts to address this call by developing health management capability.
The Thai-Australian Health Alliance has now had five years of collaborative activity focussed on policy and practice reform. The Alliance has developed health management capacity and sustainability, particularly in health professionals in rural health services, through cross cultural collaboration and knowledge transfer. This collaboration developed out of an initial engagement between the University of New England (UNE), Australia and Naresuan University (NU), Thailand, and has since expanded6. The Alliance represents a way forward for primary health care and strengthening health systems that has application in both developed and developing countries, through a collaborative research and education approach that can be described as a distributed network of practice7 or as a virtual team ‘to work collaboratively with access to shared knowledge at local, national and global levels’.
Effective management of health systems
The Thai-Australian Health Alliance recognises the importance of both public health and primary care perspectives, particularly in rural health services, and that globally most health services are organised and managed in large, health system-wide structures that are undergoing reform, integration and various levels of devolution of responsibility to provincial and district levels. The various research projects of the Alliance, described herein and conducted in rural Thailand, demonstrated that reform is systemising health care without providing the training required for effective management of health systems9. This suggests that the implementation of the reform itself is problematic because the management role, which in some health systems has traditionally been performed by health care professionals, often doctors, is either devalued or not duly recognised as vital to implementing an effective health system. Rather, management is seen by health professionals as an ‘add on’ to their existing high clinical workloads, and with typically only clinical training they often do not have adequate health management experience, qualifications or support. These health professionals also frequently exhibit a narrow, discipline-based perspective that is often not grounded in primary health care perspective or in health management capability10.
The WHO suggests that health systems require a sufficient number of managers who are properly deployed and equipped, and has indicated that existing approaches are not adequate. The WHO encourages countries to share practical experiences and their lessons, encourage leadership and management resource networks, create clearinghouses/knowledge centres, and harmonise and align partners with country health systems9,11. The Thai-Australian Health Alliance has responded to this call with predominantly ‘bottom up’ approaches and has been supported by central policy makers serving as both participants and funders of the Alliance. This approach has led to the establishment of the Centre of Expertise on Leadership in Health Management at Naresuan University, Thailand, (CE-LHM) which is currently undergoing WHO Collaborating Centre (WHO CCE) designation. This initiative of the Alliance will give a ‘generative space’ for existing and new partners to work together outside the normal constraints of, and in a separate context to, their own organisations’ usual requirements11, while engaging with others.
The principal aim of the Alliance is to work to improve the knowledge base of effective approaches to building management capacity and to improve managers’ access to knowledge, guidance and tools. The Alliance believes this can be best achieved collaboratively in cross cultural partnerships where participants together identify local needs and desired outcomes and develop local scholarly research and training capacity to begin establishing a cadre of professional health service managers9,10,12. An enabling environment also requires greater attention to ensuring a proper balance between the interests of the government, health professionals, industry, communities, patients and clients. Sound management should also recognise and value the contributions and limitations that each health profession brings to the health management role12.
Developing health management skills is often seen as merely teaching competencies, whereas contemporary research suggests that greater emphasis should be placed on teaching how to apply the principles of capacity building within health systems, which frequently operate in complex and changing environments where ability to adapt is key13,14. The Thai-Australian Health Alliance believes that all health professionals should have some health management responsibilities in their professional roles. According to Fraser et al.15 the health professional role is multi-faceted and includes that of care provider, teacher, researcher, community engager and manager. To be effective, health managers need to work closely with health professionals at the service delivery level16. Further, managing significant resources within the context of complex and often competing organisational objectives is challenging and demands focused attention; it cannot be accomplished when seen as an add-on role to a clinician-manager’s primary clinical role.
The Alliance believes that working collaboratively with a focus on health management capacity building, within health systems, is an appropriate response to meet the challenges of delivering effective primary health care to the rural poor in developing countries. This approach not only builds capacity, it also aligns researchers and research users17 in knowledge translation.
The Alliance collaboration has involved a number of partners, some formally recognised through memorandums of understanding. Other, less formal partners have contributed as requested. The Alliance partners are listed in Table 1.
Table 1: Partners, stakeholders, participants and funders of the Thai-Australian Health Alliance
There has been a number of Alliance studies reported elsewhere6,10,16,18,19, summarised in Table 2. These have included evaluations of the benefits to both Thai and Australian administrators of an international study tour of Thai community hospital directors and the use of Thai expertise to develop health management competencies and health management curriculum. This later evaluation assessed expertise contributed by the Thai Ministry of Health and the Thai National Health Security Office policy makers, senior provincial health officials from Nakhon Ratchasima (Korat) province, health professionals from primary health care and district health offices, and local government officials and village health volunteers. The findings of that study led to a curriculum plan which has now been incorporated into a new Masters of Public Health program with a health system focus at the Faculty of Public Health, Naresuan University. The University of New England has also introduced a new Masters course in International Health Management that reflects the importance of primary health care and public health in a health systems management perspective.
Current research being undertaken by the Alliance involves supporting Thai public health doctoral students and academics to adopt a health systems management perspective to their research projects which focus on the maternal and child health Millennium Development Goals. Again, the approach is collaborative, action-oriented; it uses face-to-face research workshops, site visits and video conferencing. Ilse et al.20 believes that for a given country these approaches suggest a continuous process of interpreting knowledge and experience and reconstituting to ‘create management knowledge deeply embedded in the unique social, political, cultural and economic context’21. This approach, proposed by Lavis and colleagues, is described as aligning researchers with research users. It has the dual benefit of developing the capacity of researchers, students and practising health professionals and translating knowledge into operational use17. It also has the added advantages of establishing local networks between local health service providers plus establishing the potential for a wider, international network. These connections are seldom available to health professionals and academics in rural locations in developing countries7,8.
Table 2: Thai-Australian Alliance studies and evaluations
To be effective in managing health systems and health networks, health service managers need to be trained so they can take multiple, connected approaches in their work. They need to learn how to engage in external networks that provide continuing professional development such as that provided by the Australasian College of Health Service Management, an Alliance partner and other providers and stakeholders, and have broad knowledge of local situations obtained through experience. The content and process of their education need to be aligned with the local context and to what actually occurs in the workplace and with organisational strategy around reform22. Ideally, managers will undertake formal education and gain experience that equips them with economic, technical, socio-cultural and political perspectives. Health managers need to understand and experience service delivery approaches that provide primary health care, public health, health promotion, curative and rehabilitation perspectives. To be effective, health managers also need to know how to operate as part of multi-disciplinary teams, which value and ensure the contributions of a range of health professions. An example of a successful multi-disciplinary team approach can be found in the curriculum development study undertaken in Korat province in 200619.
Increasingly, health managers work locally, regionally and globally, and this presents opportunities for them to learn from one another and from the experiences of other health systems. Again, this approach was central to Alliance activities in education and training through experiential and theoretical-focussed study tours. Evaluative studies of the Alliance approach indicate that regular comparative analysis, reflection and feedback are central to training managers. Managers returning from training also need to have authority and responsibility to disseminate what they have learned and affect change in the workplace15,18. Since the time of the initial Australian study tour mentioned earlier, there have been regular, ongoing study tour visits to Australia. For example, in 2010 three groups of some thirty senior Thai health officials visited three different state-based Australian health systems.
The challenges of engaging health professionals, providers and communities
Making progress in developing a cadre of capable, professional health managers requires commitment from government, health providers, health professionals and health management researchers and educators. The Alliance first committed to this six years ago with the enrolment of one Thai scholar in the Doctor of Health Service Management program at the University of New England, Australia. The vision and passion of this one Thai scholar was sufficient to create and help sustain the Alliance. The engagement extended to local government in Thailand and to village health volunteers in the research workshops, who learned alongside policy makers and health professionals.
The Alliance has also had to recognise clear differences between the respective health systems of the two partner countries and the importance of both national and cultural differences between collaborators23-24. Highlighting the indigenous and contemporary cultures of both Thailand and Australia through music and dance has added substantially to social interaction and increased the capacity for learning through the social network that has been established25. The Alliance is committed to establishing ‘a strategic alliance of organised interaction of considerable duration’26,27 evidenced by a range of collaborative projects over five years. The Alliance is also mindful that successful international alliances require consensus building, advocacy, cross learning and transfer of knowledge, and the production and sharing of international goods28.
The Alliance for Health Systems Research in its 2004 Report on Strengthening Health Systems recognises that developing countries use a number of successful approaches to strengthen their health care systems. Nevertheless, this group continues to recommend that ‘the health systems research community should challenge itself to explore problem-oriented alliances with other disciplinary and topic-based groups who share the same concerns of strengthening health systems’29. The Working Group on Challenges in Global Health30 as reported in a recent Health Systems Trust Report suggests that ‘in addition to looking for additional resources to meet challenges, there is also a critical need to use existing resources more efficiently and more effectively with creative thinking on ways to achieve better health outcomes with the resources we already have, and encourage stakeholders … to drive their own planning and implementation processes’31.
Proposing a way forward
The Thai-Australian Health Alliance has responded to these recommendations for change and new approaches by holding the 1st International Conference on Health Service Delivery Management in Thailand in October 2009. The main theme of this conference was the strengthening of primary health care and district health services. The focus was on health management and health systems development, management research, supporting and resourcing health professionals, innovation in health management leadership, and quality and leadership. This conference attracted 470 delegates from 17 countries. As an outcome, the delegates developed and endorsed the Phitsanulok Declaration, which calls for more resources and new policies to promote leadership, good management and governance as a way to strengthen health systems. The Alliance is now undertaking a self -evaluation to learn stakeholders’ opinions of the approaches it has taken since its inception six years ago, including perceptions of the Alliance’s strengths and weaknesses. Findings will help guide the Alliance’s way forward for its next five years. The Alliance is interested in extending the network to include other like-minded partners, both within the two existing partner countries and with colleagues in other countries. The interests of the Alliance will continue to focus on collaborative capacity building in health management situated within a context of distributed networks of practice, and in exploring appropriate approaches to knowledge translation in cross cultural settings.
This paper draws on the content of unpublished papers of the authors presented at the 1st International Conference of Health Service Delivery Management, Phitsanulok, Thailand 2009.
The Thai-Australian Health Alliance acknowledges the support and participation of Naresuan University, the University of New England, the Ministry of Health Thailand, the National Health Security Office Thailand, WHO South Eastern Regional Office, and the Australasian College of Health Service Management amongst the groups that have made the work of the Alliance possible.
The recent change in name from Prawit Taytiwat represents an honour bestowed by the King of Thailand, His Majesty King Bhumipol. This concerns the second author, whose name has been changed to Phudit Tejativaddhana (originally called Prawit Taytiwat).
1. World Health Organization. Primary Health Care, Now More Than Ever. Geneva: 2008.
2. Glasser M, Pathman D, Renewed Focus on Primary Health Care (PHC). Education for Health, 2009. 22(3): 429. Retrieved January 23rd, 2010 from: URL: http://www.educationforhealth.net/articles/subviewnew.asp?ArticleID=429
3. Oliveira-Cruz V, Kurowski C, Mills A. Delivery of Priority Health Services: Searching for Synergies within the Vertical Versus Horizontal Debate. Journal of International Development. 2003; 15:67-86.
4. 15by2015. Strengthening Primary Health Care. Retrieved January 23rd, 2010 from http://www.15by2015.org/.
5. De Maeseneer J, van Weel C, Egilman D, Mfenyana K , Kaufman A, Sewankambo N. Strengthening Primary Care: addressing the disparity between vertical and horizontal investment. British Journal of General Practice. January 2008; 3-4.
6. Briggs DS, Cruickshank M, Campbell S, Fisher K, Fraser J, Tejativaddhana P. Collaborative capacity building in applied health systems research. Proceedings of the Organisational Behaviour in Health Care Conference, Birmingham University 11-14th April, 2010.
7. Hustad, E. A Conceptual Framework for Knowledge Integration in Distributed Networks of Practice. Proceedings of the 40th Hawaii International Conference on Systems Sciences-IEEE Computer Society 2007. Retrieved January 23rd, 2010 from http://www.computer.org/portal/web/csdl/doi/10.1109/HICSS.2007.10
8. World Health Organisation. Eastern Mediterranean Regional Office. Regional strategy for knowledge management to support public health. Technical paper, EM/RC53/6, Agenda item 8(c). 2006 Retrieved January 24th 2010 from: http://www.emro.who.int/lin/media/pdf/EM_RC53_6_en.pdf.
9. World Health Organisation. Strengthening Management in Low Income Countries. Making Health systems Work: Working Paper No.1 Department of Health Systems Policies and Operations. Evidence and Information for Policy. WHO/EIP/Health Systems. 2005. Retrieved January 24th 2010 from http://www.who.int/management/working_paper_1_en_opt.pdf.
10. Taytiwat P, Briggs DS, Fraser J, Minichiello V, Cruickshank M’ Lessons from understanding the role of community hospital director in Thailand: clinician versus manager. International Journal of Health Planning Management. 2010; 25:1-20.
11. Cronin B. Managing collaborative networks. In: Suliman H, Suliman A, editors. Creating Collaborative advantage through knowledge and innovation. Singapore: World Scientific Publishers; 2007. p. 135-153.
12. Briggs DS. The lived experience of health service managers.PhD Thesis. Armidale: University of New England. 2008.
13. Dann Z, Barclay I. Complexity theory and knowledge management application. The Electronic Journal of Knowledge Management. 2006; 4(1):11-20.
14. Kernick D., Wanted – new methodologies for health service research. Is complexity theory the answer? Family Practice. 2006; 23:385-390.
15. Fraser J, Briggs DS, Taytiwat P. Thai-Australian rural health service management and medical education study tour: workplace changes after a year. Asia Pacific Journal of Health Management. 2008; 3(1):33-39.
16. Briggs DS. SHAPE declaration on the organisation and management of health services: A call for informed public debate. Asia Pacific Journal of Health Management. Feature Article. 2008; 3(2):10-13. Available from: http://www.shape.org.au/Declaration/Feature%20DBriggs.pdf
17. Lavis JN, Lomas J, Hamid M, Sewankambo NK. Assessing country – level efforts to link research into action. Bulletin of the World Health Organisation. 2006; 84(8):620-628.
18. Taytiwat P, Fraser J, Briggs DS. The Thai-Australian Health Alliance: A case study of inter-organisational collaboration. Asia Pacific Journal of Health Management. 2006; 1(1):10-16.
19. Yangratoke S, Briggs DS, Alexander C, Taytiwat P, Cruickshank M, Fraser J, Ditton M, Gaul M. The Thai-Australian Alliance: Developing a rural health management curriculum by participatory action research. World Health Population. 2010; 11(3):5-16.
20. Iles P, Ramgutty-Wong A, Yolles M. HRM and knowledge migration across cultures: Issues, limitations and Mauritian specificities. Employee Relations. 2004; 6:643-662.
21. Newell S. The transfer of management knowledge to China: building learning communities rather than translating Western textbooks, Education + Training. 1999; 41:186-293.
22. Eraut M, Alderton J, Cole G, Senker P. Development of knowledge and skills at work. In Coffield F, editor. Differing Versions of a Learning Society. The Policy Press: Bristol; 2000. p. 231-263.
23. Taytiwat P. Understanding the Role of Thai Community Hospital Directors in Implementing the Universal Health Coverage Policy in Relation to Primary Health Care. Unpublished Doctoral Thesis. University of New England. 2007.
24. Hofstede, G. Cultures and Organizations: Software of the Mind. Maidenhead: McGraw-Hill; 1991.
25. Estabrooks CA, Thompson DS, Lovely JJE, Hofmeyer A. A guide to Knowledge Translation Theory. Journal of Continuing Education in the Health Professions. 2006; 26(1):25-36.
26. Sverrisson A. Translation networks, knowledge brokers and novelty construction: Pragmatic environmentalism in Sweden. Acta Sociologica. 2001; 44(4):313-327.
27. Hagedoorn J. Strategic Technology Alliances and Modes of Cooperation in HighTechnology Industries. In: Grabher G, editor. The Embedded Firm: On the Socio-economics of Industrial Networks. London: Routledge; 1993. p.116-138.
28. Walt G. Global cooperation in international public health. In: Merson M, Black, R, Mills A, editors. International public health: diseases, programs, systems and policies. Sudbury: Jones and Bartlett; 2005. p. 667-699.
29. Alliance for Health Policy and Systems Research. Report. Strengthening health systems: the role and promise of policy and systems research. Geneva 2004. Retrieved January 25, 2010 from: http://www.hst.org.za/publications/637
30. Japan Centre for International Exchange. Global Action for Health Systems Strengthening: Policy recommendations to the G8. Report by the Task Force on Global Action for Health Systems Strengthening 2009. Retrieved January 25, 2010 from URL: http://www.jcie.org/researchpdfs/takemi/full.pdf.
31. Health Systems Trust District Management Study: A National Summary Report - A review of structures, competencies and training interventions to strengthen district management in the national health system of South Africa. Department of Health, South Africa 2008. Retrieved January 25, 2010 from URL: http://www.hst.org.za/uploads/files/dmxnatsummary.pdf.