Keywords:

Cognitive spaces; zero mile; urbanization; ethics; universal coverage; health communication

Idea:

Vulnerable people in Southeast Asia tend to have limited access to healthcare and proper services. For decades, the public investment in health systems that focused on the expansion of public health facilities and recruitment of sufficient staff to equally cover the entire population has been crucial to overcoming barriers with health scheme quality and equity of healthcare service provision. Public spending in national health services has reduced the legacy problem of “zero mile” through a provision of an easier access to better standards of treatment and new opportunities in the regional healthcare market. This physical gap is narrowing down, while a more complicated and intangible gap resulting from an implementation of those new schemes have raised an emerging new “cognitive zero mile” between the demand and supply sides through some interaction and communication.

Scenario:

The concept of “cognitive space” uses the analogy of location in three dimensional (or higher) physical space to describe and categorize mental ideas. Cognitive spaces can be understood as “workspaces of the mind” (Baars, 1998). The dimensions of this space depend on information, participating and practicing, and finally on a person’s awareness. An availability of physical space facilitates an evolution of the relationship between cognitive space and communication. This is the case for health culture and communication at the bottom-of-the-pyramid (BoP) in many nations of Southeast Asia. The observation of an emergence of a “cognitive zero mile” can be seen from perspectives of healthcare personnel, patients, and other key stakeholders (e.g. insurance sector, national security, etc.) towards an interaction within the health system, especially on their “expectations” against “realities”. In this article, two key changing elements will be elaborated as major pillars for the scenario, including health service convergence, and cognitive conflicts.

Referral Syndrome – Convergence of Urbanization and Health Reforms:

Southeast Asia is the fastest urbanizing region in the world, which can be seen from the expansion of mega-cities, the establishment of new cities, and a trend in the decentralization of public administration in some countries. Reinvestment initiatives, changing demographics, and growth in urban areas are creating changes that offer new opportunities for improving health while requiring that health systems be adapted to meet residents’ health needs.

Although this health policy is widely accepted as one of the most successful “pro-poor” policies, this policy has long been criticized for its quality, particularly the quality and equity of services such as medical treatment and medical professionals. The health scheme also has an inherent urban bias; emphasis on hospital curative medicine means that rural people must come into the cities for care and incur the extra cost and time demands. While the concept of universal health coverage (UC) is intending to lift financial burdens arising from healthcare costs, this could also be detrimental, especially for the poor. Obviously, the hospitals in rural areas with inadequacies of health personnel seem to provide lesser quality services to their clients due to the lack of medical facilities, which definitely affects the mostly poor residents.

With globalization, ensuring of accessible health services or citizens is no longer the sole responsibility of the state; healthcare in the region is rapidly becoming an industry in the world market. For example, the Department of Health Services Promotion in Thailand indicated that there has been an increase in the number of private hospitals and clinics operating in recent years.

It seems that urbanization has improved healthcare service for the poor, but the problem of inadequate service still persists. New barriers—both financial and non-financial—have been identified as significant obstacles to access in the future, and are seen as important targets for change. Transportation is a commonly identified barrier to healthcare. It can be seen that although the cost of healthcare treatment is equal regardless of the domestic economy, patients from rural areas are affected when their cases have to be referred to a provincial hospital, because it is costly for them in terms of transportation, consumption of their time, and the opportunity cost for private hospitals. There will be more patients being referred from one hospital to another, regardless of whether all people have the right for healthcare coverage. When the healthcare market belongs to supply side, the poor will suffer from a “referral syndrome”!

Cognitive Conflicts between Physicians and Patients:

More interestingly, one problem that will occur more seriously in the near future is the knowledge gap and the misunderstanding that can develop between the health service provider and beneficiaries. As the beneficiaries have more demands and expectations on their own benefits while not realizing their actual rights, they would tend not to understand the standpoint of the physicians or other service providers. There will be more lawsuits against doctors. Although there is now more protection of patient rights, the people who can sue and get protection are still the urban rich. The rural and urban poor remain largely unprotected and vulnerable to medical malpractice. Physicians currently bear a huge burden by having to take care of a large number of patients with limited time. Some unintentional errors can result and turn into big problems. The ongoing conflicts between patients and physicians are becoming more serious, even though public policies have been designed in an attempt to enhance access to health services by the poor. This is due to the fact that each government has overemphasized a populist approach while neglecting the reality of finite resources.

The tremendously miserable consequence of rising lawsuits against doctors by the demanding service users has contributed to a rise in case transfers between hospitals, especially from remote district health centers to provincial hospitals. District service providers have become increasingly reluctant to perform their duties, e.g. surgical operations, as they do not want to risk getting litigated against by patients in case something goes wrong.  Some patients have had to suffer more than before as a result, because they receive much slower treatment of their diseases. This could also in turn create an adverse turnaround effect against patients themselves in the medium to long term, as services provided to them would be more limited.

Another recent event that occurred, very clearly reflecting such a problem, was the heated debate on the drafted Protection of Damaged Users of Health Services Act (B.E.) between the service providers, e.g. doctors, versus the service users and other supporters of the law, e.g. non-governmental organizations on human rights. On the user side, they lauded the prospect that the law would enhance the quality of health services provided by the hospitals and doctors, as they would have to be certain that their services were cautiously delivered to the patients. To the contrary, the service providers were skeptical about whether the law would really solve the problems. Unnecessary expenses would be increasingly incurred by hospitals to compensate for their alleged wrongdoing, as the law would stipulate that money be paid to plaintiffs immediately once lawsuits take effect. This could cause some of them to go bankrupt and become even more incapable of delivering the services. The law could also further demoralize physicians, as they would refuse to accept more difficult cases to care for.

The UC Scheme has increased the opportunity for the poor to get access to healthcare services, though there are still limitations in terms of its benefits. However, it is a good sign of healthcare system improvement in Thailand. Nevertheless, the increased access to healthcare has led to patients using the service when it is not really necessary, causing a sometimes unbearable workload for hospital staff. Also, it has probably led to patients taking less care of themselves, as they know that they can go to hospital for free. People seem to be practicing less self-care in relation to their health after they had gained easier access to healthcare, which raises the concern of over-utilization further contributing to problems with the UC Scheme, such as increasing workloads for staff and financial difficulties that may adversely affect the quality of care and of medical facilities. There have also been some cases in which patients have requested medicine, and then sold this medicine to others.

Implications:

• Innovation in healthcare information technologies will combine and enable the collection of more health data, which in turn will give individuals more control over their healthcare. There will be more discussion on the future of self-tracking and health data rights as the conflict between health service providers and clients will continue to emerge.
• Public health insurance, containing “pro-poor” policies, is required to realign and redress unequal access to healthcare. All citizens should be entitled to and should have equal access to quality care according to their needs, regardless of their socio-economic status and religion (Jongudomsuk, 2002).
• The ongoing health reforms still have to be implemented more comprehensively. The loopholes within the scheme that could be exploited by unethical practitioners and/or consumers will have to be eliminated.  On the other hand, expectations of patients will also have to be adjusted and be based upon more accurate perceptions of what service providers are capable of accomplishing, and the providers should be allowed to have certain limitations to their responsibilities in carrying out their duties.

Early Indicators:

• Statistics show that the total number of private hospitals and clinics in Thailand rose from 18,312 in September 2009 to 18,819 in September 2010.
• Many hospitals have been unable to cope if they overspend, and many large hospitals around the country have been forced to cut back on staff and close beds amidst fears of bankruptcy. Complaints of substandard treatment are increasing. Patients may be referred to numerous different institutions as each in turn refuses to take them (Towse, 2003).
• In 2001, Thailand became the first developing country to introduce a UC scheme aiming to ensure equitable and high quality healthcare access for citizens. This was originally known as the “30 Baht treating all diseases project”. It is a means to improving the quality of life for the poor and to redress unequal access to health care.

Drivers and Inhibitors:

Drivers:

• Urbanization expanded physical spaces for the inflowing rural poor to get better access to healthcare and consequently has created their cognitive spaces in terms of rising expectations toward ideal services.
• Primary care is the first stop and is easy for the poor to access; there is a need to improve its quality and equity.
• Convenient public transportation could be the supportive infrastructure that mobilizes patients to reach more easily hospitals in different areas.
• Many hospitals focus on improving their health management systems to survive in a competitive market.
• Patents in developed countries / incubating for developing countries will create new entrants of service providers into the industry with higher value to patients.
• Decentralization to newly urbanized areas, leading to more accessibility but also more cost and redundant systems.

Inhibitors:

• The average life expectancies among the population are much higher, causing more prevalence of long term diseases and increased costs.
• There is less medical staff available than is needed to meet the needs and demands from increased accessibility of populations.
• People’s perceived needs and expectations are much higher than the system can handle.
• Governmental budget is more restricted and not enough to cover all benefits and the level of quality of care.
• Wrong policy choices with too much emphasis on populism could turn health systems to be less effective.
• A gap of knowledge sharing will create barriers to patients in comprehending new advances and things in healthcare.
• Unpredictable technologies will leave patients further behind so that it becomes tougher for them to catch up.
• Uncertainties of protection system and management system when the private sector is taking over.