Systems Challenges in Accessing Medicines among Children under Thailand’s Universal Health Coverage: A Qualitative Study of a Provincial Public Hospital Network
2. Materials and Methods
2.1. Study Design
2.2. Study Context
2.3. Selection of Participants
2.4. Data Collection
- Please explain how children’s medicines are selected, procured, distributed and used in your hospital.
- Is there a system specifically designed for children’s medicines?
- Please describe the problems encountered in accessing or using medicines for children in the current system.
- Please specify what solutions to these problems you think are possible.
2.5. Data Processing and Analysis
3.1. Children’s Medicine Selection
- Medicine selection systems are the same across all categories, including paediatric medicines.
“The overall medicine management system for children does not differ from medicine for adults and no separate or special system exists.”(FP4, staff pharmacist at a medium hospital)
- A greater number of child-appropriate medicines are available at referral hospitals.
“For instance, we need levetiracetam oral solution. Previously in our hospital, only pills were available because the oral solution is very expensive. We have to explain why the oral solution is essential. The pill is too big for young children, as young as 1 month old, and is inconvenient to break and crush. It doesn’t work. Recently, they (the PTC) allowed us to have it (oral solution).”(AD1, paediatrician at a provincial hospital)
3.2. Children’s Medicine Procurement
- Government procurement regulations in purchasing essential medicines rule over the need for children’s medicines.
“We have a limited budget and have to balance costs and benefits. The PTC board will discuss budget allocation. The problem is the fixed ratio of essential and nonessential medicines. We cannot have all that we want. The ratio must be kept as allowed.”(MP5, pharmacy department head in a large district hospital)
- Unavailable child-appropriate dosage forms on the market.
“We compound phenobarbital syrup for our paediatric patients because the formula sold in the market is in elixir form, and the percentage alcohol content is too high. So, doctors stopped using it.”(MP1, staff pharmacist in a large district hospital)
“Do we have many patients? Is the drug important? When only 10 patients are admitted for one whole year, they might not let us open an account for this order. In this case, we will refer the patients to other hospitals stocking this medicine.”(AP1, staff pharmacist at a provincial hospital)
- Compounding preparations is unavoidable.
“(In some cases, child-appropriate formulations are unavailable) so we teach the parents to crush a tablet, break a capsule, mix with water or juice, before giving it to their child. We don’t know if the drug dose is correct or not, but it’s better than nothing, better than the child not receiving medicine at all.”(UP3, staff pharmacist at a teaching hospital)
- Paediatric medicines are compounded with limited resources.
3.3. Children’s Medicine Distribution
- Short shelf-life products are burdensome for caregivers.
“We use a compounded preparation for this medicine. The problem is that its shelf-life is only for one month. Parents who cannot come back to refill the medicine have to use pills and prepare them before use by crushing and mixing the powder with water or sweet drinks by themselves.”(UP3, staff pharmacist at a teaching hospital)
- With limited resources, having something is better than nothing.
“We are unsure about the medicine’s stability. Even though the textbook states that it lasts one month, we must admit that the context is not exactly standardised as a production unit. Thus, we are comfortable with 7 days shelf-life.”(FP6, staff pharmacist at a medium district hospital)
“If you ask me how confident I am, I’m not sure. However, the children must have the medicine for their condition. That is, we have to accept it. We have no choice.”(AD1, paediatrician at a provincial hospital)
3.4. Children’s Medicine Use
- Prescribing medicines for paediatric patients remains a concern.
“I become a little tense when dispensing children’s medicines, where dosage must be well calculated. I can’t remember all. I have to open a manual or search the Internet.”(SN1, nurse at a subdistrict hospital)
“If a case is too complex, exceeding the hospital potential, it must be sent to our network district hospital. Especially in children’s cases, patients will receive close monitoring by a specialised doctor and get specialised medications.”(FP3, pharmacy department head at a medium hospital)
- A supporting system within a hospital network is being developed.
“We have a consulting system, and in some cases, we don’t have to refer every patient. In cases that they need medicines that we don’t have on our list, pharmacists, within the network, will coordinate and manage to obtain those medicines for their patients.”(FP1, pharmacy department head at a medium hospital)
“We receive excipient for preparing oseltamivir suspension from our networking provincial hospital.”(FP6, staff pharmacist at a medium district hospital)
- Educating caregivers is one way to ensure the appropriate use of medicines.
“We have to evaluate parents, first (for their readiness and competency). When they are ready, we dispense the pills for them, which is better for stability. However, we have to explain to them well.”(MP4, staff pharmacist at a large district hospital)
“It constitutes a matter of trust. A physician must be sure that the parents can prepare and administer the medication to their child. We cannot follow them home. We can only assess them based on clinical outcomes at follow-up, that’s all.”(AD1, paediatrician at a provincial hospital)
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
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|Hospital Type||Number of|
Hospitals in the Province
|Teaching hospital (1400 beds)||1||1||3|
|Provincial hospital (600 beds)||1||1||5|
|Large district hospital (90–200 beds)||4||4||9|
|Medium district hospital (30–90 beds)||18||5||8|
|Small district hospital (10 beds)||1||-||-|
|Sub-district hospital (OP case only)||267||10||10|
|Medicine||Dosage Form Prepared||Strength (mg/ mL)||Indicated Shelf-Life Stability at Room|
|Teaching Hospital||Provincial Hospital||Large|
|Medium District Hospital|
|Acetazolamide||Suspension 1||10, 50||10||7||-||-|
|Acyclovir||Suspension 1||20, 30, 40, 70, 80, 120||7||14||10||-|
|Chloroquine phosphate||Suspension||15, 20||-||30||7||-|
|Hydrochlorothiazide||Suspension 1||1, 2, 5, 10||30||30||7||-|
|Oseltamivir||Suspension||5, 10, 15||10||10||10||7|
|Phenobarbital||Suspension 1||3, 4, 5, 10||60||30||10||-|
|Prednisolone||Suspension 1||1, 5||30||7||7||7|
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Daojorn, R.; Suwannaprom, P.; Suttajit, S.; Kanjanarat, P.; Tiengket, P.; Lallemant, M. Systems Challenges in Accessing Medicines among Children under Thailand’s Universal Health Coverage: A Qualitative Study of a Provincial Public Hospital Network. Children 2022, 9, 552. https://doi.org/10.3390/children9040552
Daojorn R, Suwannaprom P, Suttajit S, Kanjanarat P, Tiengket P, Lallemant M. Systems Challenges in Accessing Medicines among Children under Thailand’s Universal Health Coverage: A Qualitative Study of a Provincial Public Hospital Network. Children. 2022; 9(4):552. https://doi.org/10.3390/children9040552Chicago/Turabian Style
Daojorn, Rangsan, Puckwipa Suwannaprom, Siritree Suttajit, Penkarn Kanjanarat, Prangtong Tiengket, and Marc Lallemant. 2022. "Systems Challenges in Accessing Medicines among Children under Thailand’s Universal Health Coverage: A Qualitative Study of a Provincial Public Hospital Network" Children 9, no. 4: 552. https://doi.org/10.3390/children9040552