A STUDY OF THE ROLES OF HEALTH UTILIZATION MANAGEMENT NURSES UNDER THE JURISDICTION OF THE OFFICE OF PERMANENT SECRETARY, MINISTRY OF PUBLIC HEALTH

Abstract

This descriptive research aimed to explore the roles of nurses in health utilization management (UM) within units under the Office of the Permanent Secretary, Ministry of Public Health, using the Delphi technique. The participants consisted of 20 experts, divided into 5 groups: 1) Three policymakers from the Ministry of Public Health and the Bureau of Nursing, 2) Four directors or financial administrators of public hospitals, 3) Five heads of health insurance departments in public hospitals, 4) Three nursing instructors with experience in teaching health utilization management, and 5) Five practicing health UM nurses from the public sector. Data collection was conducted in three rounds: In-depth interviews were conducted with experts regarding the roles and sub-roles of UM nurses in various settings in the first round, including those working in Provincial Public Health Offices, Regional/General Hospitals, and Community Hospitals. Then, in the second round, interview data were analyzed using content analysis to develop a questionnaire, which was then used to assess the perceived importance of each role. Median values and interquartile ranges were calculated. Finally, a revised questionnaire was distributed for expert validation in the third round. Responses were used to recalculate medians and interquartile ranges, leading to a consensus on the defined roles.

The results revealed six major roles of health UM nurses under the jurisdiction of the Office of the Permanent Secretary, Ministry of Public Health: 1) Advocate for patients’ rights and benefits, 2) Health insurance data manager, 3) Coordinator, 4) Health resource utilization auditor, 5) Health resource analyst, and 6) Case manager. Although health UM nurses across all levels shared these six core roles, their responsibilities varied by work setting: 1) At Provincial Public Health Offices, health UM nurses primarily function at the policy level, setting strategic directions, overseeing provincial health resource management, and conducting systems-level data analysis and inter-network coordination. 2) In Regional and General Hospitals, health UM nurses manage hospital-wide service delivery systems, oversee complex case management, act as central coordinators for health insurance data, and facilitate continuity of care across healthcare levels. 3) In Community Hospitals, health UM nurses emphasize direct patient care, ensuring efficient use of health resources, collaborating with local communities, and protecting patients’ rights and benefits at the primary care level.

These findings can inform the development of competency-based curricula and professional role guidelines for health UM nurses within the Office of the Permanent Secretary, Ministry of Public Health. They also provide useful insights for nursing and hospital administrators to better support health UM nurses in performing these designated roles effectively and consistently.