Saturday, August 22, 2009

Exposure to National Healthcare - Thailand

Last night there was a family emergency. Duang's youngest brother was stricken with severe abdominal pain. We got the call around 5:30 PM from his girlfriend that he was in the hospital.

Thailand has a Universal National Healthcare program. The program was instituted in 2001by Shinawatra Thaksin, the Thai Prime Minister who was deposed in a 2006 military coup. He remains very popular in the rural poor districts of Thailand largely due to this program as well as other programs aimed at the poor people.

Under the Thai program, poor people can sign up to get a special ID card that they can use to obtain medical services in their health district. Typical office visits cost the member 30 baht - approximately $0.90 U S Dollars. Procedures and hospitalization costs the member 30% of the invoice with the program paying the remaining 70%.

Initially Duang was informed that her brother needed an operation and that she as a family member needed to sign a release for the operation to commence. Since we were not familiar or comfortable with driving in the city to the hospital, we called Duang's son to drive us to the hospital.

We arrived at Wattana Hospital, which is a private hospital in the center of Udonthani. Duang's brother was in a small diagnostic room in the Emergency Area of the hospital. He was on an IV and was receiving oxygen. He was in considerable pain. After awhile the situation clarified somewhat. He was stricken at his home and a neighbor brought him to the nearest hospital which happened to be the private facility. He had received emergency treatment to stabilize him and to diagnose his condition including an ultrasound scan. The cost for these services were 2,060 Baht or approximately $60.58 - very cheap by USA standards but very costly to a Lao Loum performer. His girlfriend did not have enough money to pay the bill. She borrowed 2,000 baht from me to pay the bill so that we could move on to the next step. The cost of the required operation was out of the question so he needed to go to the big public hospital in Udonthani - across the pond from the private facility.

This sounds reasonable, and easily manageable. But this involved Universal Healthcare Program and like just about any government run program in any country, things are not as they seem or should be. As I wrote above, Duang's brother had an ID which allows him to obtain medical services in his health district. A person's health district corresponds to where they are listed in "Tambien Baan" - "Blue House Book". The Blue Book for Thai residents and the Yellow Book for foreigners lists the house or apartment address and lists the names of all occupants. Since Duang's brother is listed in the Blue Book for Duang's parent's house in Tahsang Village, his health district is Kumphawapi.

Kumphawapi is approximately 60 kilometers (37 miles) from the center of Udonthani with Tahsang Village about another 12 kilometers (7.5 miles) further out. This geography lesson is important especially in regards to this family emergency. Duang's brother had moved to the center of Udonthani and had not changed either his parent's house blue book or the blue book for where he was now living. Because his medical district was Kumphawapi, he was obligated to first seek treatment at the public Kumphawapi Hospital. If after evaluation at the Kumphawapi he or any other Universal Healthcare participant from that health district is deemed to need services of a larger or more sophisticated facility, they are transported typically to Udonthani or more rarely Koen Kaen (about 90 KM, 56 miles to the south).

This seemed a little incongruous to me and I asked Duang several times about this to ensure that I understood the situation as well as requirement. I fabricated a scenario where Duang would have a accident at her parent's house and had a broken leg and arm. She said that she would have to go to the Udonthani Hospital for treatment rather than the closest hospital in Kumphawapi. I assume that in a true emergency, the patient would be treated and the paperwork sorted out later.

Thankfully we pay for our own health care using private facilities. Duang has an ID card for Universal Healthcare as a backup. Private health care is still affordable for expats in Thailand. Two weeks ago Duang went to the Doctor with a stiff neck and back - the cost for the visit, two injections and two prescriptions - $3.00 U S dollars. Some expats have had their children delivered by C-Section for $850 U S Dollars.

Last night we left Duang's brother at the private hospital around 6:30 P. M. after Duang took his health care ID with her. As we left we could hear his groans and cries of agony. We headed to Tahsang Village to obtain the Blue House Book. From Duang's parent's house we were to stop at the hospital in Kumphawapi to get a medical release or transfer document that would allow her brother to be admitted into the public hospital in Udonthani. We stopped at a small shop to get some photocopies of the necessary documents made prior to stopping at the hospital.

We arrived at Kumphawapi Hospital and went to the admission desk. Since it was past normal working hours, there was only a single administrator. Duang explained to her the situation. The clerk in typical bureaucratic fashion wanted to know why he was at a hospital in Udonthani rather than coming in to their hospital for treatment. Duang told her that he had been working in Udonthani when he got sick. The clerk said that she could not make those types of decisions regarding transfer of patients to other facilities and told Duang to come back in the morning. Duang gave her a good piece of her mind and ended up with an apology but no patient transfer paper. We headed back to Udonthani.

Through a couple of phone calls we determined that Duang's brother was now at the big public hospital in Udonthani - apparently people realized how serious his condition was and overcame the bureaucratic quagmire. The hospital is the one that we had visited several times before (11 Jan 2009 Blog "Busted Up In Isaan").

Two hours after leaving Duang's brother, we were finally back with documents and copies for his girlfriend to sort out his paperwork the next morning. We found her brother in a ward on the sixth floor of one of the many buildings of the hospital complex.

Since it was getting on in the evening, approximately 8:30 P. M., people were busy settling in for the night. People are the relatives and friends of the patients. They range in age from 2 years old to 70 years or older. Since many of them arrived from outlying villages, they spend the night at the hospital. The hospital complex is made up of several buildings interconnected with covered walkways and ramps which provide many areas that are protected from rain. The hospital has installed concrete benches and tables in many of these semi-protected areas for visitors to bed down and eat their meals.

As we walked through the hospital complex we came upon many hand washing stations. The hospital had several signs and posters encouraging people to frequently wash their hands. The stations had running cold water, soap dispenser, paper towels, and a garbage can. People were making good use of the facilities and most of them had run out of paper towels. Many of the visitors at the hospital were wearing surgical masks. The Thai government has a very extensive education and awareness program regarding Swine Flu. It is apparent that this program is having an effect on people's efforts to prevent the spread of infection. Throughout Udonthani you see people wearing masks and washing their hands in public locations.

We took the elevator up to the sixth floor and as the door opened we encountered six patient beds set up in the elevator lobby on the sixth floor. All six beds had patients hooked up to IVs. Scattered amongst the beds were woven reed mats, sahts, on the floor. Relatives were sitting on the sahts eating and socializing.

Duang's brother was located in the second ward on the floor. To reach his ward we had to walk through an open ward of 64 male patients - all the beds were filled with patients in various conditions.

Each ward is made up of three bays with 21 beds in each bay. There is no air conditioning in the wards. Cooling is provided by ceiling mounted fans with some small ventilation fans in the windows providing some air circulation. There is a balcony running along the exterior of the ward where patients, and visitors can sit on concrete benches. There is no door on the entrance to the balcony so some air circulation is provided. There is a room one one side of the ward where the nurses are stationed. I saw 5 nurses for the 64 patients in the ward. There was one orderly also available in the ward. The ward was filled with visitors to the patients - all standing around the beds since there were no chairs for visitors.

Many of the visitors were providing care to the patients. Some people were changing the patient's clothing while others were washing the patients with wet cloths. I did not see any hospital staff performing these tasks. Some of the visitors had brought pillows from home for the patients to use.

Duang's brother was in a great deal of distress. Eventually a very young man came by dressed in typical street clothing for a young college man - it turned out that he was a doctor. I asked him what was wrong with Duang's brother and he said that he believed it to be a perforated ulcer and that they would be operating on him in a couple of hours. Apparently Duang's brother was #6 in line for the operating rooms.

Around 9:00 P.M., a nurse started her rounds but seemed more occupied in announcing that everyone had to leave now because visiting hours were over. She complained to Duang's brother that he was making too much noise - which was not surprising since he was only on a saline IV without any pain medication. His chart did not indicate that he gotten any pain killers. We left hoping and wishing all the best for him.

We returned the next day to check on her brother. It was amazing- he looked so much better. He had his operation the previous night to repair what was indeed a perforated ulcer and was on some pain medication. He had a relatively small neat bandage on his abdomen. He was able to communicate well with everyone. I was amazed.

Like people the night before, his visitors took care of him. His girlfriend washed his body with a damp cloth and after completing his "bath", his mother, brother, girl friend, and sister changed his bed clothes. I noticed that his urine collection bag strapped to the side of the bed was full and close to overflowing. I meant for Duang or some one to let a nurse know so that it could be emptied. I didn't see any hospital personnel readily available but it didn't matter. Duang and her oldest brother promptly took care of the problem. Medical care here in Isaan is definitely personal and up close.

This experience with National Healthcare although initially frustrating and the standard definitely not what I am accustomed to appears to have turned out well. I guess that it is kind of like airplane landings - a good one is any landing that you can walk away from.

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