Thailand health system review

Thailand Health System Review Health Systems in Transition Vol. 13 No. 1 2024 H ealth System s in Transition Vol. 13 N o. 1 2024 Thailand Health System Review The Asia Pacific Observatory on Health Systems and Policies (the APO) is a collaborative partnership of interested governments, international agencies, foundations, and researchers that promotes evidence-informed health systems policy regionally and in all countries in the Asia Pacific region. The APO collaboratively identifies priority health system issues across the Asia Pacific region; develops and synthesizes relevant research to support and inform countries' evidence-based policy development; and builds country and regional health systems research and evidence-informed policy capacity. ISBN-13 978 92 9062 045 7

Thailand Health System Review Health Systems in Transition Vol. 13 No. 1 2024 Written by: Pongpisut Jongudomsuk, National Health Security Office, Nonthaburi, Thailand Samrit Srithamrongsawat, National Health Security Office, Nonthaburi, Thailand Walaiporn Patcharanarumol, International Health Policy Program, Nonthaburi, Thailand Supon Limwattananon, Khon Kaen University, Khon Kaen, Thailand Supasit Pannarunothai, Naresuan University, Phitsanulok, Thailand Patama Vapatanavong, Institute for Population and Social Research, Mahidol University, Nakorn Prathom, Thailand Krisada Sawaengdee, International Health Policy Program, Nonthaburi, Thailand Pinij Fahamnuaypol, Health Information Systems Development Office, Nonthaburi, Thailand Updated by: Kanitta Bundhamcharoen, International Health Policy Program, Nonthaburi, Thailand Watinee Kunpeuk, International Health Policy Program, Nonthaburi, Thailand Shaheda Viriyathorn, International Health Policy Program, Nonthaburi, Thailand Somtanuek Chotchoungchatchai, International Health Policy Program, Nonthaburi, Thailand Angkana Lekagul, International Health Policy Program, Nonthaburi, Thailand Jomkwan Yothasamut, International Health Policy Program, Nonthaburi, Thailand Edited by: Viroj Tangcharoensathien, International Health Policy Program, Nonthaburi, Thailand World Health Organization Regional Office for the Western Pacific Thailand health system review Health Systems in Transition. 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Printed in the Philippines iii Contents Preface ................................................................................................................... xi Acknowledgements ............................................................................................ xiii Abbreviations and acronyms ..............................................................................xiv Executive summary .......................................................................................... xviii 1 Introduction .................................................................................................. 1 Chapter summary ...................................................................................................1 1.1 Geography and sociodemography ................................................................2 1.2 Economic context ...........................................................................................6 1.3 Political context ..............................................................................................9 1.4 Health status ............................................................................................... 10 2 Organization and governance ................................................................... 18 Chapter summary ................................................................................................ 18 2.1 Overview of the health system ................................................................... 19 2.2 Historical background ................................................................................ 23 2.3 Organization ................................................................................................ 25 2.4 Decentralization and centralization .......................................................... 27 2.5 Planning ....................................................................................................... 31 2.6 Intersectorality ............................................................................................ 32 2.7 Health information management .............................................................. 34 2.8 Regulation .................................................................................................... 38 2.9 Patient empowerment ................................................................................ 50 3 Financing ..................................................................................................... 55 Chapter summary ................................................................................................ 55 3.1 Health expenditure ..................................................................................... 56 3.2 Sources of revenue and financial flows .................................................... 59 3.3 Overview of the statutory financing system ............................................. 62 3.4 Out-of-pocket payments ............................................................................ 75 3.5 Voluntary health insurance ........................................................................ 78 3.6 Other financing ............................................................................................ 79 3.7 Payment mechanisms ................................................................................ 79 3.8 Summary ..................................................................................................... 92 4 Physical and human resources ................................................................ 93 Chapter summary ................................................................................................ 93 4.1 Physical resources ...................................................................................... 94 4.2 Human resources ..................................................................................... 105 iv 5 Provision of services ................................................................................ 122 Chapter summary .............................................................................................. 122 5.1 Public health ............................................................................................. 124 5.2 Patient pathways ....................................................................................... 127 5.3 Primary/ambulatory care ......................................................................... 128 5.4 Specialized ambulatory care/inpatient care .......................................... 130 5.5 Emergency care ........................................................................................ 137 5.6 Pharmaceutical care ................................................................................ 141 5.7 Rehabilitation/intermediate care ............................................................ 146 5.8 Long-term care and informal care .......................................................... 154 5.9 Palliative care ............................................................................................ 160 5.10 Mental health care .................................................................................... 163 5.11 Dental care ................................................................................................ 166 5.12 Complementary and alternative medicine .............................................. 172 5.13 Health services for specific populations .................................................. 176 5.14 Disaster risk management for health (DRM-H) ...................................... 181 6. Principal health reforms .............................................................................. 191 Chapter summary ............................................................................................. 191 6.1 Analysis of recent reforms ...................................................................... 192 6.2 Future developments ............................................................................... 201 7 Assessment of health systems ............................................................... 202 Chapter summary .............................................................................................. 202 7.1 Objectives of the health systems ............................................................. 203 7.2 Financial protection and equity in financing .......................................... 206 7.3 User experience and equity of access..................................................... 212 7.4 Health outcomes, health service outcomes and quality of care .......... 217 7.5 Health system efficiency .......................................................................... 228 7.6 Transparency and accountability ............................................................ 231 8 Conclusions ............................................................................................... 233 8.1 Key findings ............................................................................................... 233 8.2 Remaining challenges ............................................................................ 236 8.3 Future prospects ....................................................................................... 237 Chapter 9: Appendices ...................................................................................... 239 9.1 References ................................................................................................. 239 9.2 Useful websites ......................................................................................... 291 9.3 HiT methodology and production ........................................................... 291 9.4 About the authors ..................................................................................... 293 Asia Pacific Observatory on Health Systems and Policies (APO) publications to date.................................................................................. 298 vList of figures Fig. 1.1 Map of Thailand .................................................................................4 Fig. 1.2 Trends in life expectancy at birth (years), adult mortality (probability of dying between 15 and 60 years of age per 1000 population), by sex, 1995–2020 .............................................11 Fig. 1.3 Adult smoking prevalence by gender, 1991–2021 ........................15 Fig. 2.1 Linkages of governance mechanisms in the national health system ..............................................................................................21 Fig. 2.2 Evolution of the Ministry of Public Health and related health agencies ...............................................................................24 Fig. 2.3 Organizational structure and interlinkages between the MoPH and NHSO .............................................................................26 Fig. 2.4 Local government budget: fiscal year 2006–2021 ........................29 Fig. 2.5 Progress of health-care decentralization and related policy interventions ....................................................................................30 Fig. 3.2 Health financing and service provision in Thailand after achieving universal coverage in 2019 ............................................61 Fig. 3.4 Scheme beneficiaries by income quintile, 2021 ...........................64 Fig. 3.6 Flows of funds to pooling or management agencies ...................73 Fig. 3.7 The structure of OOP payments, 2019 ...........................................76 Fig. 3.8 CSMBS expenditure, 1995–2019, nominal price...........................82 Fig. 3.9 Health spending per capita by the three public health insurance schemes, 2019, nominal price .....................................82 Fig. 4.1 Capital investment budget, 2002–2019 .........................................96 Fig. 4.2 Infrastructure under the MoPH (2023) ..........................................96 Fig. 4.3 Proportion of hospital beds by agency, 2003–2021 ......................97 Fig. 4.4 Hospital beds per 10 000 population across regions, 2014–2022 .......................................................................................98 Fig. 4.5 Bed occupancy rate by agency, 2011–2021 ...................................99 Fig. 4.6 National average length of stay, all hospitals, 2011–2021 ........100 Fig. 4.7 Hospital beds per 10 000 population, Thailand and countries in various regions and global average, 2017 ............101 Fig. 4.8 Hospital beds per 10 000 population, countries in the WHO South-East Asia Region, 2017 ......................................................101 Fig. 4.9 Proportions of generalist and specialist doctors, 2011–2021 ...108 Fig. 4.10 Trends in the production of generalist and specialist doctors, 2000–2022 .......................................................................109 vi Fig. 4.11 Number of dental nurses in health centres or subdistrict health-promoting hospitals ..........................................................110 Fig. 4.12 Doctors, dentists, pharmacists, and professional nurses, 2001–2020 ......................................................................................112 Fig. 4.13 Medical graduates gaining licenses from public and private domestic and foreign medical schools, 2000 and 2022, Thailand ..........................................................................................116 Fig. 5.1 Organization of public health services in Thailand ....................125 Fig. 5.2 Number of hospitals under the UCS being accredited under the Hospital Accreditation Programme 2004–2020 ........135 Fig. 5.3 Effectiveness of treatment of patients with chronic conditions 2008, 2014 and 2019–2021 ........................................136 Fig. 5.4 Number of cases receiving prehospital services, 2017–2022 ...138 Fig. 5.5 Thailand’s emergency medical operation ...................................139 Fig. 5.6 EM operation units (percentage) in Thailand ..............................140 Fig. 5.7 Value of imported and domestic production medicines, 1987–2020 ......................................................................................142 Fig. 5.8 Average number of physiotherapists by hospital affiliation, 2021 ................................................................................................148 Fig. 5.9 Number and percentage of UCS-registered persons with disabilities, 2022 ............................................................................150 Fig. 5.10 Rehabilitation service use as persons and visits by region, 2021 and 2022 ................................................................................151 Fig. 5.11 Number of visits by type of rehabilitation services, 2020 and 2022 .........................................................................................152 Fig. 5.12 Accessibility to dental care services by region, 2017–2021 .......167 Fig. 5.13 Percentage of dental care institutes, 2021 .................................168 Fig. 5.14 Types of dental care services, 2021 ............................................168 Fig. 7.1 Population coverage by different health insurance schemes and the remaining uninsured, 2001–2021 ...................................205 Fig. 7.2 Public financing of health as a ratio of GDP, Thailand and selected regions, 2000–2019 ........................................................206 Fig. 7.3 Share of current health expenditure by private and public financing, 1995–2019 ....................................................................207 Fig. 7.4 Direct payment for health as a percentage of total household expenditure, overall and by richest and poorest expenditure deciles, 1996–2020 ...................................................207 Fig. 7.5 Reduction in the incidence of catastrophic health expenditure and health-impoverished households in 1988–2020 ......................................................................................208 vii Fig. 7.6 Changes in coverage of essential health services in Member States of the WHO SE Asia Region, 2010–2020 ...........209 Fig. 7.7 Comparison of health service coverage and financial protection in Member States of the WHO SE Asia Region by income level, 2021 .........................................................................210 Fig. 7.8 Progressivity of major sources of health financing as measured by Kakwani Index, 2000–2019, reflecting the relative contributions by four sources of health financing ........211 Fig. 7.9 Annual outpatient visits and inpatient admissions per capita among UCS members, 2003–2020 ...................................212 Fig. 7.10 Overall average rating of satisfaction with UCS (on 1–10 Likert scale, 2003–2022) ..............................................................213 Fig. 7.11 Distribution of UCS, SHI, and CSMBS members according to national quintiles of household wealth, 2005–2021 ...............214 Fig. 7.12 Proportions of outpatient visits and inpatient admissions, compared with the number of beneficiaries of UCS by the poorest and richest household wealth quintiles, 2004–2021 ....215 Fig. 7.13 Proportions of government subsidy for out- and inpatient services, compared with the number of beneficiaries of the UCS by the poorest and richest quintiles of household asset index, 2004–2021 .................................................................216 Fig. 7.14 Annual prevalence of unmet need by three types of services, 2011–2019 .....................................................................217 Fig. 7.15 Maternal mortality ratio (modeled estimate, per 100 000 live births) in Thailand, world and selected world regions, 2000–2017 ......................................................................................218 Fig. 7.16 Mortality rate of under-5 children (per 1000 live births) in Thailand, world and selected world regions, 2000–2021 ..........219 Fig. 7.17A Adult female mortality in Thailand and selected world regions, 2000–2020 .......................................................................219 Fig. 7.17B Adult male mortality in Thailand and selected world regions, 2000–2020 .......................................................................220 Fig. 7.18A Incidence of breast cancer in Thailand, globally and selected world regions, 2000–2019 ............................................220 Fig. 7.18B Incidence of cervical cancer in Thailand, global, and selected world regions, 2000–2019 .............................................221 Fig. 7.19A Overall survival of UCS patients admitted with breast cancer, 2005–2020 .........................................................................221 Fig. 7.19B Overall survival of UCS patients admitted with cervical cancer, 2005–2020 .........................................................................222 viii Fig. 7.19C Overall survival of UCS patients admitted with colorectal cancer, 2005–2020 .........................................................................222 Fig. 7.20 Achievement of universal access to child immunization in Thailand, 2000–2021 .....................................................................224 Fig. 7.21 Under-five mortality and domestic general government health expenditure per capita (current US$) in Thailand and selected world regions, 2019 ................................................229 Fig. 8.1 Scatter plot between per capita current health expenditure, US$ and U5MR among upper-middle-income countries, latest year 2020 .............................................................................233 Fig. 8.2 Scatter plot between per capita current health expenditure, US$ and life expectancy among upper-middle-income countries, latest year 2020 ..........................................................234 ix List of tables Table 1.1 Trends in population/demographic indicators, selected years ....5 Table 1.2 Macroeconomic indicators, selected years ...................................7 Table 1.3 Mortality and health indicators, selected years ..........................10 Table 1.4 Main causes of death, 1980–2019, selected years (age- standardized death rates per 100 000 population) ......................12 Table 1.5 Top ten causes of disability-adjusted life year (DALY) loss among Thai men and women, 2019, Thailand .............................14 Table 1.6 Maternal, child and adolescent health indicators, selected years ................................................................................................16 Table 2.1 Characteristics of governance and management structures of the three public health insurance schemes .........39 Table 3.1 Current health expenditure and selected indicators on health spending, 1995–2019, current year prices .......................56 Fig. 3.1 Government health spending and out-of-pocket payment as a proportion of current health expenditure among ASEAN countries, 2019 ..................................................................58 Table 3.2 Health-care spending profile, percentage of current health expenditure, 1995 to 2019 ..............................................................59 Table 3.3 Health-care spending by source of fund, percentage of current health expenditure, 1995 to 2019 ....................................60 Table 3.4 Characteristics of public and private health insurance schemes ..........................................................................................63 Table 3.6 Different components of the approved budget per UCS member, 2003–2020 .......................................................................80 Table 3.7 Paying for health services .............................................................84 Table 3.8 Payment of health personnel .......................................................89 Table 3.9 Source of payment for health personnel .....................................92 Table 4.1 Ratio of high-cost medical devices per 1 million population by region, 2021 ..............................................................................102 Table 4.2 Numbers of the four cadres of health-care professionals and their density per 10 000 population .....................................105 Table 4.3 Density of the four cadres of health-care professionals (number of professionals per population) by region, in 2001 and 2021 ...............................................................................106 Table 4.4 Study years, regulatory bodies and degrees .............................115 Table 5.1 Number (and percentage) of private hospitals providing services under different health insurance schemes, 2010–2021 .....................................................................................131 xTable 5.2 Number of centres of excellence by category and level ...........132 Table 5.3 Utilization of specialized hospital services within the UCS, 2011–2021 .....................................................................................134 Table 5.4 Number of PWDs receiving assistive devices and number of devices by region, 2020–2022 ..................................................153 Table 5.5 Projection of the number of various dependent levels of older people, 2004–2024 (millions) .............................................154 Table 5.6 Available welfare services and care assistance for Thai elderly persons .............................................................................156 Table 5.7 Number of psychiatric patients, 2017–2022 ..............................164 Table 5.8 Oral health benefits package within the three main public health insurance schemes .........................................................170 Table 5.9 TTM budget used in two public insurance schemes, 2020–2022 .....................................................................................174 Table 5.10 Mode of TTM utilized by members of all schemes, 2021 and 2022 ........................................................................................174 Table 5.11 Number of different kinds of TTM practitioners and other CAM licences ................................................................................175 Table 5.12 Overview of migrant workers in Thailand by characteristics and types of employment in 2019 ...............................................177 Table 6.1 Inclusion of new interventions into the UCS benefit package, 2017–2023 .....................................................................194 Table 6.2 Expansion of options in health facilities to improve access to UCS members .........................................................................195 Table 6.3 Inclusion of new medicines in the NLEM ..................................195 Table 6.4 Loan for COVID-19 responses: allocation to three programmes, Cabinet approval and disbursement as of May 2023 ......................................................................................196 Table 6.5 Ad valorem tax structure according to Excise Tax Act B.E. 2560 (2017) ....................................................................................200 Table 6.6 Specific tax structure according to the Excise Tax Act B.E. 2560 (2017) ....................................................................................200 Table 7.21 Overall coverage and extremal quotients of child immunization between the highest and lowest socioeconomic groups, 2006–2019 .............................................227 Table 7.22 Overall coverage and extremal quotients of child health between the highest and lowest socioeconomic groups, 2006–2019 .....................................................................................227 xi Preface The Health Systems in Transition (HiT) profiles are country-based reports that provide a detailed description of a health system and of reform and policy initiatives in progress or under development in a specific country. Each profile is produced by country experts in collaboration with an international editor and the staff of the Asia Pacific Observatory on Health Systems and Policies. In order to facilitate comparisons between countries, the profiles are based on a template, which is revised periodically. The template provides detailed guidelines and specific questions, definitions and examples needed to compile a profile.  HiT profiles seek to provide relevant information to support policy-makers and analysts in the development of health systems in Asia and the Pacific. They are building blocks that can be used:  • to learn in detail about different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems; • to describe the institutional framework, the process, content and implementation of health-care reform programmes; • to highlight challenges and areas that require more in-depth analysis; • to provide a tool for the dissemination of information on health systems and the exchange of experiences of reform strategies between policy-makers and analysts in different countries; • to assist other researchers in more in-depth comparative health policy analysis. Compiling the profiles poses a number of methodological problems. In many countries, there is relatively little information available on the health system and the impact of reforms. Due to the lack of a uniform data source, quantitative data on health services are based on a number of different sources, including the World Health Organization (WHO) Western Pacific Country Health Information Profiles, national statistical offices, the International Monetary Fund (IMF), the Organisation for Economic Co- operation and Development (OECD) Health Data, The World Bank, and other relevant sources considered useful. Data collection methods and definitions xii are adapted to best reflect each country’s health system, but typically are consistent within each separate HiT profile.  A standardized profile has certain disadvantages because the financing and delivery of health care differs across countries. However, it also offers advantages because it raises similar issues and questions. The HiT profiles can be used to inform policy-makers about experiences in other countries that may be relevant to their own national situation. They can also be used to inform comparative analysis of health systems. This series is an ongoing initiative and material is updated at regular intervals.  Comments and suggestions for the further development and improvement of the HiT series are most welcome and can be sent to apobservatory@wpro. who.int and info@obs.euro.who.int.  HiT profiles and HiT summaries are available on the Asia Pacific and European Observatories’ websites at http://apo.who.int and http:// eurohealthobservatory.who.int xiii Acknowledgements This second edition of the Health Systems in Transition (HiT) profile on Thailand was updated by a team of Thai authors from the International Health Policy Program and edited by Dr Viroj Tangcharoensathien. This HiT draws upon the previous editions from 2015, also edited by Dr Viroj Tangcharoensathien but written by Pongpisut Jongudomsuk, Samrit Srithamrongsawat, Walaiporn Patcharanarumol, Supon Limwattananon, Supasit Pannarunothai, Patama Vapatanavong, Krisada Sawaengdee, and Pinij Fahamnuaypol. The authors are grateful to Nima Asgari-Jirhandeh for supporting this work. They also thank the peer-reviewers, staff at the Ministry of Public Health, the National Health Security Office and others at a wide range of Thai agencies for their assistance in providing information and for their invaluable comments on drafts of this report. xiv Abbreviations and acronyms A-SDR age-standardized death rate AHB Area Health Board AMR antimicrobial resistance APN advanced practice nurse ART antiretroviral treatment ASEAN Association of Southeast Asian Nations BMI body mass index CAM complementary and alternative medicine CCSA Center for COVID-19 Situation Administration CG caregiver CGD Comptroller-General Department CHE current health expenditure CNEU Continuing Nursing Education Unit CNS clinical nurse specialist CRVS civil registration and vital statistics CSMBS Civil Servant Medical Benefit Scheme CSO civil society organization CUP contracting unit for primary care DALY disability-adjusted life year DDC Department of Disease Control DMH Department of Mental Health DMSc Department of Medical Sciences DPMA Disaster Prevention and Mitigation Act DRG diagnosis-related group DRM-H disaster risk management for health DTAM Department of Thai Traditional and Alternative Medicine ECIM Effective Communication and Infodemics Management (Task Force) EM emergency medical (unit) EMS emergency medical services EOC Emergency Operations Centre EPI Expanded Programme on Immunization FDA Food and Drug Administration xv GCM Global Compact on Migration GDP gross domestic product GGE general government expenditure GGHE-D domestic general government health expenditure GMP Good Manufacturing Practice GNI gross national income HA Hospital Accreditation (programme) HAI Healthcare Accreditation Institute HHC home health care HICS Health Insurance Card Scheme HIS health information system HITAP Health Intervention and Technology Assessment Program HPV human papillomavirus HRH human resources for health HSQCB Health Service Standard and Quality Control Board HSRI Health System Research Institute HTA health technology assessment ICD-10 International Classification of Diseases, version 10 ICER incremental cost–effectiveness ratio ICF International Classification of Functioning, Disability and Health IHME Institute of Heath Metrics and Evaluation IHPP International Health Policy Program IHR International Health Regulations, 2005 IMR infant mortality rate IOM International Organization for Migration IPD inpatient department JEE joint external evaluation KI Kakwani Index LAO PDR Lao People’s Democratic Republic LGO local government organization LHF Local Health Security Fund LOINC Logical Observation Identifiers Names and Codes LTC long-term care MCH maternal and child health MHV migrant health volunteer MHW migrant health worker MICS Multiple Indicator Cluster Survey MMR maternal mortality ratio xvi MoI Ministry of Interior MoPH Ministry of Public Health MoU memorandum of understanding MSDHS Ministry of Social Development and Human Security NCD noncommunicable disease NCDA National Communicable Disease Act NCDC National Communicable Disease Committee NESDC National Economic and Social Development Council NGO nongovernmental organization NHA National Health Assembly NHC National Health Commission NHCO National Health Commission Office NHSO National Health Security Office NIEM National Institute for Emergency Medicine NLEM National List of Essential Medicines NSO National Statistical Office NV national verification NVC National Vaccine Committee NVI National Vaccine Institute NVSA National Vaccine Security Act OECD Organisation for Economic Co-operation and Development OOP out of pocket OPD outpatient department OPS Office of the Permanent Secretary OSS One Stop Service OTC over-the-counter (drugs) PAO Provincial Administration Organization PC position classification (system) PHC primary health care PHO Provincial Health Office PP health promotion and disease prevention PPE personal protective equipment PRF Provincial Rehabilitation Fund PVT-D domestic private health expenditure PWD people with disability QALY quality-adjusted life year R&D research and development RT-PCR reverse transcriptase polymerase chain reaction SARS-CoV-2 severe acute respiratory syndrome coronavirus-2 xvii SDGs Sustainable Development Goals SHI Social Health Insurance Scheme SSB sugar-sweetened beverage SSO Social Security Office STEMI ST segment-elevated myocardial infarction TAO Tambon Administration Organization ThaiHealth Thai Health Promotion Foundation THB Thai Baht TRIPS Agreement on Trade-Related Aspects of Intellectual Property Rights TTM Thai traditional medicine U5MR under-five mortality rate UCEP Universal Coverage for Emergency Patients UCS Universal Coverage Scheme UDHR Universal Declaration of Human Rights UHC universal health coverage UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund VHV village health volunteer WCF Workmen’s Compensation Fund WHO World Health Organization WTO World Trade Organization xviii Executive summary Background Thailand has gone through demographic and epidemiological transitions, evolving from high fertility, high mortality to low fertility and low mortality. The below-replacement-level fertility rate and low crude mortality rate have had profound impacts on health- and social-service development and financing, which need to respond to a rapidly greying society. The health systems context and achievement Since 1999, the major causes of death are noncommunicable diseases (NCDs); the total disability-adjusted life years (DALY) loss from NCDs was 58.5%, 64.6% and 73.0% in 1999, 2004 and 2019, respectively, while communicable diseases contributed to 27.7%, 21.2% and 9.0%, respectively, in the same years. Despite the reduction in DALY loss from communicable diseases, HIV/AIDS was still an outstanding public health problem until universal antiretroviral treatment became available in 2004, when mortality from HIV/AIDS was displaced from the top position. The burden from a few preventable causes is still high and challenging, such as traffic injuries, ischaemic heart disease, diabetes, and self-harm. Adult mortality has been declining over time for both males and females, though with a large gender gap; females have a lower adult mortality rate than males. The decline in adult, infant and under-five mortality rates indicate improved life expectancy at birth for both males and females. One major health risk is adult smoking. The prevalence has declined over 20 years; the overall prevalence (both genders) was 25.5% in 2001 and 20.7% and 17.4% in 2009 and 2021, respectively. Reduction in the prevalence of tobacco use has become slower in recent years, for which the retail price should be increased to keep pace with the increase in disposable income. Commercial determinants of NCDs demand rigorous implementation of WHO-recommended “best buy” interventions, including increased taxes on tobacco and alcohol, plain packaging, and advertising bans. Despite the high level of contraceptive prevalence and equitable access to reproductive health services, a few challenges remain such as unmet xix contraceptive needs among unmarried young couples and unprotected sex among young adolescents, resulting in HIV/AIDS and unplanned pregnancies, especially among teenagers. However, progress has been made in reducing adolescent (15–19 years) birth rates from 51 births per 1000 women in 2015 to 23 births per 1000 women in 2019. The Ministry of Public Health (MoPH) is the national health authority responsible for formulating and implementing health policy. However, its role has changed as several autonomous health agencies have been established through legislation, notably the Health Systems Research Institute (1992), the Thai Health Promotion Foundation (2001), National Health Security Office (2002), National Health Commission Office (2007), National Institute for Emergency Medicine (2008), Healthcare Accreditation Institute (2009), and National Vaccine Institute (2018). The MoPH and these independent agencies form a complex interdependent governing structure where non-State actors and civic groups also play an increasing role. The National Health Commission Office is mandated to convene the annual National Health Assembly (NHA), ensuring participatory engagement by all government and non-State actors in formulating health policy through NHA resolutions; where a number of resolutions are further endorsed by the Cabinet Resolution, strengthening the resolutions’ legality and enforcement. The advent of the National Health Security Office (NHSO) has had a major impact on transforming the integrated model where the MoPH played the role of both purchaser and service provider, to one where the NHSO is the purchaser and MoPH is a major service provider. Thailand has a long history of de-concentration of management decisions to the Provincial Health Office (PHO) and all public hospitals, such as delegating financial power to generate, retain and use revenue according to regulations, subject to regular audits by the Auditor-General. The PHO also holds regulatory power, such as licensing and relicensing private pharmacies and clinics, and consumer protection on food, drugs and cosmetics. The Decentralization Act 1999 requested the MoPH to devolve all public health-care facilities to the local elected government units, health centres to tambon administration organizations (TAOs), district hospitals to municipalities and provincial hospitals to provincial administration organizations. Progress in implementing the Decentralization Act has been slow, both in terms of devolving functions and transferring budget from the central government to local governments. In 2021, there were 84 MoPH health centres that were devolved (0.8%) out of a total of 9759, as TAOs lacked readiness, capacities and funding, and could not fulfil the criteria for assuming responsibility for health centres. In 2021, guidelines were xx established for transferring health centres or subdistrict health-promoting hospitals to PAOs, to implement the Decentralization Act based on the readiness of PAOs. Capacity in health technology assessment has gradually developed since 2007 and has contributed to the inclusion of new medicines in the National List of Essential Medicines and interventions included in the benefit package of the Universal Coverage Scheme, to which the other two schemes also refer to. When Thailand achieved universal health coverage (UHC) in 2002, public expenditure on health became the dominant financing source, accounting for 72.2% of current health expenditure (CHE) in 2019. Out-of-pocket expenditure decreased from 44.9% of CHE in 1995 to 8.5% in 2019. Additionally, domestic general government health expenditure (GGHE-D) as a proportion of general government expenditure (GGE) rose from 12.0% in 1995 to 15.5% in 2019. Curative expenditure dominates total health spending, accounting for about 70–80% of the total. Thailand legislated an earmarked sin tax for health promotion, using 2% additional surcharge on the tobacco and alcohol excise tax to be managed by the ThaiHealth Foundation, an autonomous public agency, for campaigning on various key health risks. By 2002, the entire population was covered by three public health insurance schemes – civil servants and their dependents by the Civil Servant Medical Benefit Scheme (CSMBS), private sector employees by the Social Health Insurance Scheme (SHI) and the rest of the population by the Universal Coverage Scheme (UCS). This resulted in three main public purchasers where the split in purchaser–provider roles was fully implemented; and supply-side financing through annual budget allocation to health facilities was fully replaced by demand-side financing. Thailand applied a mix of provider payment methods, though closed-ended payment plays a dominant role. Notably, capitation for outpatient services is applied by SHI and UCS while fee for service is used for CSMBS outpatient payment. Diagnosis- related group inpatient payment has been widely applied by the three schemes with some variations. As a result of strong political commitment to the health of the population, during the 1980s there was heavy investment in government health-care delivery systems: health centres, district and provincial hospitals provided full geographical coverage in all subdistricts, districts and provinces. xxi Health delivery systems are dominated by the public sector, for which the MoPH has the majority share; local government organizations play an increasingly important role in health service provision due to decentralization. Almost all hospitals are designed for acute care. The MoPH accounted for 67.2% of the total hospital beds in 2021, with private hospitals comprising 19.5%. Large private hospitals located in Bangkok include some hospital chains registered on the stock market, and offer services to mostly international patients. Private non-profit charity-run hospitals account for a negligible share of beds. The extensive geographical coverage of MoPH primary health care (PHC) and public hospital services is the foundation for successful implementation of UHC, especially pro-poor health service utilization and public subsidies. The health-care workforce density per 1000 population was 4.10 in 2020, which is below the indicative WHO benchmark of 4.45 per 1000 population for doctors, nurses and midwives in 2016. To ensure that rural populations are served by an adequate health-care workforce, continued efforts were made through multiple interventions, such as education strategy by recruiting students from a rural background, a curriculum that reflected rural health problems, mandatory rural services by all doctors, nurses, pharmacists and dentists graduated since 1972, and financial and non-financial incentives such as social recognition. Task-shifting has also been applied throughout, such as nurse practitioners and other specialized nurses, dental health officers and pharmacist assistants. Thailand is self-reliant in producing a health-care workforce of a high quality and standard. Quality is ensured through national licensing examinations for all cadres of the health-care workforce by professional councils. Additionally, professional nurses are relicensed every five years. Health worker mobility in Thailand is influenced by economic trends and government policies; internal migration from rural to urban areas and between public and private sectors is notable, with the government’s focus on positioning Thailand as a medical hub contributing to internal brain drain. Despite government measures to enhance capacity during the COVID-19 outbreak, the health workforce is experiencing high resignation rates, especially among nurses and new doctors, due to heavy workloads and inadequate compensation. Strong institutional capacity in strategic purchasing by the NHSO resulted in improved equitable access to certain high-cost interventions, such as cataract surgery, open-heart surgery, renal replacement therapy, and antiretroviral therapy. Improvement in the quality of hospital care is indicated by an increase in the number of hospitals that meet the standard xxii requirement of hospital accreditation and a reduction in hospital standardized mortality among networks with accredited hospitals. Health systems reforms Thailand’s health system has witnessed limited major reforms since the first publication of the Health Systems in Transition (HiT) report in 2015. However, noteworthy developments include the devolution of subdistrict health centres from the MoPH to locally elected governments at the provincial level, specifically the Provincial Administration Office. The impact of this ongoing transition, launched in 2022, awaits further evidence of its positive or negative effects on population access to services. In terms of legislative changes, a constitutional challenge resulted in the partial upholding of provisions in the Criminal Code criminalizing abortion. Subsequent amendments in 2021 legalized abortion for gestation periods of less than 12 weeks, with cases between 12 and 20 weeks requiring examination and counselling by a physician, governed by rules and regulations from the Medical Council. Incremental reforms have included the NHSO’s expansion of the benefit package, guided by evidence of cost–effectiveness, long-term budget sustainability, and health system capacity. This expansion has contributed to enhanced financial risk protection for the population, ensuring that new benefit packages are fully funded without unfunded mandates. The COVID-19 pandemic, spanning 2020 to 2022, prompted substantial resource consumption, notably through domestic loans, especially during the peak of the Delta strain in the third quarter of 2021. Innovative adaptations, though not major health reforms, emerged to alleviate overcrowding in hospital-based outpatient services. Telemedicine, teleconsultation, and medication dispatch via post were among the strategies employed. Legislation introduced in 2019, known as the Primary Health Care System Act, advocates for a family doctor care team, potentially positively impacting access to quality primary care. However, being in the early stages of implementation, future assessments are necessary to gauge its impact fully. Furthermore, the introduction of a progressive tax rate for sugar-sweetened beverages (SSBs) in 2017, aimed at addressing obesity and NCDs, has demonstrated positive outcomes. The current SSB tax rate, however, holds potential for further increase to achieve public health goals related to reduced body mass index (BMI) and obesity. xxiii Health systems performance Assessments of the Thailand health systems performance against financial risk protection, responsiveness, health outcomes, and efficiency have found favourable outcomes, although a few challenges remain. Health-care financing is dominated by general tax revenue and is progressive with respect to population incomes. Direct payment by households has consistently declined while the government has significantly increased spending from tax revenues on public insurance schemes, especially after the implementation of UCS. Achievement of financial risk protection is evident by a noticeable reduction in the number of non-poor households being impoverished by health-care payment. Use of the UCS entitlement when using health services has gradually increased and is higher for inpatient than outpatient care. The net public budget subsidy to outpatient and inpatient services for the poorest UCS members was relatively higher than for the richest members. This pro- poor subsidy was driven by service utilization that was disproportionately concentrated among the economically worse-off, probably because of easy access to various levels of health delivery mechanism withn the districts. Thailand has performed better in terms of maternal and child health as compared with other low- and middle-income countries. The country also experienced a steady decline in the under-five mortality rate even before achieving UHC. Adult mortality rates were also lower than the global average and other regions. However, the country has been facing challenges related to hospitalizations for chronic conditions like chronic obstructive pulmonary disease (COPD), diabetes, and coronary heart disease. Effective coverage for diabetes and hypertension has been low, but is improving, particularly among men and younger populations. The remaining challenges Despite notable progress in Thailand’s health system, the prevalence of NCDs remains a significant challenge, with NCDs contributing to a majority of deaths and DALYs. The country faces specific challenges in road injuries, stroke, and ischaemic heart disease compared to nations with a similar sociodemographic index. Addressing the commercial determinants of NCDs, such as tobacco and alcohol, requires robust implementation of WHO-recommended interventions, necessitating collaboration between government entities, including the MoPH and the Excise Department. xxiv Multiple interventions such as increased tobacco tax reduced the prevalence of adult smoking from 23% in 2004 to 17.4% in 2021. Despite the decreasing prevalence, the reductions are projected to be insufficient to achieve a 30% reduction in the prevalence of tobacco smoking by 2025. While interventions like the SSB tax have shown promise, achieving effective coverage for diabetes and hypertension remains a critical issue. Additionally, challenges persist in promoting exclusive breastfeeding, tackling childhood malnutrition, and ensuring optimal early childhood development. Exclusive breastfeeding rates in Thailand fluctuated from 12.3% (2012) to 23.1% (2015) but fell to 14% in 2019 due to aggressive marketing by breast milk substitute industries. Early breastfeeding initiation decreased from 49.6% (2006) to 34% (2019), impeding the 2030 global targets. Thailand’s 2019 Multi-Indicator Cluster Survey revealed disparities in child nutrition: 13% stunting, 8% wasting, and 8% overweight, with regional variations and maternal education. Furthermore, the threat of antimicrobial resistance, the need for rehabilitation care for the ageing population, and the evolving landscape of chronic health conditions pose ongoing challenges that demand focused research and policy attention. 11 Introduction Chapter summary Thailand, a South-East Asian nation, was one of the five founding members of the Association of Southeast Asian Nations (ASEAN) in August 1967. Siam was renamed Thailand in 1949; and the absolute monarchy was transformed into a constitutional monarchy after the 1932 democracy revolution. See map of Thailand (Fig. 1.1) for its geographical location and neighbours in South-East Asia. Thailand has gone through demographic and epidemiological transitions. In terms of demographics, it has evolved from a high fertility/high mortality country to a low fertility/low mortality one. Thailand’s fertility level in 2020 was below replacement level at 1.3 child(ren) per woman, and its crude mortality rate in the same year was 7.3 per 1000 population. This has had profound impacts on health and social service development and financing, which need to respond to a rapidly greying society. Epidemiological transition took place well before the evidence on burden of diseases was available. Since 1999, noncommunicable diseases (NCDs) have become the major cause of death; the total loss of disability-adjusted life years (DALY) from NCDs was 58.5% in 1999, rising to 64.6% in 2004 and 73.0% in 2019, which meant an increase of 14.2 percentage points in 20 years. DALY loss from communicable diseases contributed to 27.7%, 21.2%, and 9% in the same years; this was a reduction of 18.7 percentage points in the same period. Despite the reduction in DALY loss from communicable diseases, HIV/AIDS was still an outstanding public health problem until universal antiretroviral treatment (ART) became available in 2004, when mortality from HIV/AIDS was dislodged from the top position. The burden from a few preventable causes, such as traffic injuries, ischaemic heart disease, diabetes and alcohol dependence/harmful use, is still high and challenging. Along with the improvement in maternal and child health outcomes, a decline in adult mortality has also been observed; greater decline for females than males. There have also been advancements in the Tobacco Products Control Act B.E. 2560 (2017) in Thailand. Since 2019, the tobacco industry in Thailand has been required by law to provide information, including its production, 2marketing expenditure and revenue (Assunta, 2020). The prevalence of tobacco use reduced from 19.9% in 2015 to 19.1% and 17.4% in 2017 and 2021, respectively (National Statistical Office, 2021b). Additionally, Thailand was ranked 11th on the Global Tobacco Index in 2021 for governments responding to the tobacco industry’s interference and protecting their public health policies from the tobacco industry’s commercial and vested interests (Global Center for Good Governance in Tobacco Control, 2021). Even with the high level of contraceptive prevalence and equitable access to reproductive health services, a few challenges remain, such as unmet contraceptive needs among unmarried young couples and unprotected sex among young adolescents, resulting in HIV/AIDS and unplanned pregnancies, especially among teenagers. Teen pregnancies are an outcome of inequitable social structure and have negative impact on the health of the teens and their babies. Progress has been made in reducing adolescent (15–19 years) birth rates from 51 births per 1000 women in 2015 to 23 births per 1000 births in 2019 (National Statistical Office et al., 2016, 2020). However, in 2019, adolescent girls in vulnerable situations still had a high birth rate, especially those living in rural areas, as did non-Thai girls, girls in primary school, and those belonging to the poorest wealth quintiles. 1.1 Geography and sociodemography Thailand is in the centre of mainland South-East Asia at latitude 5°30’ N to 20°30’ N and longitude 97°30’ E to 105°30’ E. Its shape looks like an ancient axe. Thailand is bordered on the west and north-west by Myanmar; on the north-east and east by Lao People’s Democratic Republic (Lao PDR) and Cambodia; and on the south by the Gulf of Thailand, Peninsular Malaysia, the Andaman Sea and the Strait of Malacca. In total, the borders extend to about 8031 km (4990 miles) (Fig. 1.1). The country covers an area of 513 115 km2 (198 115 square miles), making it the world’s 51st-largest country in terms of total area. It is slightly smaller than Yemen and slightly larger than Spain. It is the third-largest country in South-East Asia, after Indonesia and Myanmar. The capital city of Thailand is Bangkok or “Krung Thep”. In terms of geographical area, Thailand has four distinct regions: Central, Northern, Southern and North-eastern. The Northern region is the mountainous area, including the ranges of Daen Lao, Luang Phra Bang and Phetchabun in the east, and Thanon Thongchai in the west. The Southern region, which looks like the shaft of an ancient axe, covers the narrow Kra Isthmus and Andaman Sea and Gulf of Thailand where natural resources and the tourism sectors are dominant. The North-eastern region occupies the highland area called the Korat Plateau and the plains along the Mun and 3Chi rivers. It is bordered to the east by the Mekong River. The Central, most populous region consists of the fertile plains surrounding the Chao Phraya River (basins of the Chao Phraya River) and is the country’s rice basket. There are three climate zones in Thailand – tropical rain, tropical monsoon, and seasonal tropical grassland or savannah. The tropical rain climate covers the coastal areas of the east (including some of the Central region) and the south with heavy rainfall and there is tropical rainforest. The tropical monsoon climate is found in the south-western and south-eastern coastal areas. These areas are hit by the monsoons and have very high average annual rainfall. The seasonal tropical grassland or savannah is the typical climate found in most regions of Thailand, especially the Central, Northern and North-eastern regions. Heavy rains in the south-west monsoon season and dryness in the cold season are common in this type of climate. Both temperature and humidity are high in Thailand, with the average temperature in the range of 24–33°C (75–92°F). According to the 2021 Notre Dame Global Adaption Initiative (ND-GAIN) index, which ranks 185 countries by their vulnerability to climate change impacts, Thailand ranked 71st out of 185 countries (University of Notre Dame, 2021); (World Bank Group et al., 2021). A wide range of climate change impacts on health outcomes include air quality: exposure to increased concentrations of PM2.5 is associated with an increased risk of lung cancer, cardiopulmonary and all-cause mortality, while O3 is associated with an increased incidence of cardiovascular, respiratory, and all-cause mortality (Department of Health, 2016b). Peak 24-hour concentrations of PM10 in Bangkok are consistently above the permissible level of 120 μg/m3 (Department of Health, 2016b). The location and activity of vectors are at least partially determined by temperature and having sufficient water for breeding sites. Pathogen replication rates are generally temperature dependent, although the relationship is typically nonlinear. Climate-sensitive vector-borne diseases of importance for Thailand include malaria, dengue, chikungunya and leptospirosis. The Thai population is homogeneous. An overwhelmingly large majority of population (96%) is of Thai ethnicity. The rest are Chinese, Malay, Khmer, Mons, and other minorities, including hill tribes. The country’s official language is Thai. Buddhism is the main religion (93%). There were an estimated 3.9 million migrant workers (including both documented and undocumented migrant workers) in Thailand in 2019 (United Nations Women et al., 2020). 4Fig. 1.1 Map of Thailand Source: (United Nations Geospatial, 2009) 5Table 1.1 Trends in population/demographic indicators, selected years   1970 1980 1990 2000 2010 2020 2021 Total population (millions)a 35.79 45.74 55.23 63.07 68.27 71.48 71.60 Population, female (% of total)a 49.8 49.9 50.0 50.7 50.9 51.4 51.4 Population age 0–14 years (% of total population)a 45.0 39.0 30.0 24.0 19.0 16.0 16.0 Population age 65 years and above (% of total population)a 3.0 3.0 4.0 6.0 9.0 14.0 15.0 Population age 80 years and above (% of total)a 0.5 0.6 0.7 1.0 1.6 2.7 2.7 Population growth (average annual growth rate, %)a 2.8 2.2 1.7 1.0 0.7 0.2 0.2 Population density (people per sq. km of land area)a 70.1 89.5 108.1 123.4 133.6 139.9 .. Fertility rate, total (births per woman)a 5.6 3.4 2.1 1.6 1.6 1.3 .. Birth rate, crude (per 1000 people)a 37.4 26.8 19.7 13.5 11.9 9.2 .. Death rate, crude (per 1000 people)a 10.3 7.3 5.6 6.0 6.3 7.3 .. Age dependency ratio (population 0–14 & 65+:population 15–64 years)a 91.2 72.7 52.1 43.2 39.1 42.7 43.5 Distribution of population (rural/urban, %)a 79.1/ 20.9 73.2/ 26.8 70.6/ 29.4 68.6/ 31.4 56.1/ 43.9 48.6/ 51.4 47.8/ 52.2 Proportion of single-person households (%)b .. 3.5 5.1 9.4 18.4 23.5 25.5 Adult literacy rate (%)a .. 88.0 .. 92.6 96.4 93.7c 94.0 Sources: a (World Bank, 2021g) b (National Statistical Office, 2010a, 2021a) c data from 2018 The population growth rate slowed down from 2.8% in 1970 (population 35.79 million) to 0.2% in 2021 (population 71.60 million) (Table 1.1) as a result of an effective and high coverage of the family planning programme since the 1970s. With a constant 2.8% annual population growth, the population would have reached more than 100 million by 2010. Demographically, there were slightly more females than males (51% versus 49%) since the 2000s. The percentage of the population aged 0–14 years decreased from 45.0% to 19.0% during 1970–2010 and to 16.0% in 2021, while the percentage of people aged 65 years and over increased continuously, 6increasing by five times from 3.0% in 1970 to 9.0% in 2010, and to 15.0% in 2021. The oldest population (80 years old and above) also quintupled over the 50 years, from 0.5% in 1970 to 2.7% in 2021. It can be noted that the population of Thailand has been ageing rapidly over the past century due to declines in both fertility and mortality. The total fertility rate declined from 5.6 births per woman in 1970 to 1.6 in 2000–2010 and to 1.3 births per woman in 2020, along with a decline in the birth rate. As a result of population growth, the population density increased from 70.1 people/km2 in 1970 to 133.6, and 139.9 people/km2 in 2010 and 2020, respectively. The proportion of the rural population that resides in non- municipality areas decreased from 79.1% in 1970 to 47.8% in 2021. Rapid urbanization was noted, from 20.9% in 1970 to 52.2% in 2021, due to the reclassification of all sanitary districts (once categorized as rural areas) as municipality areas in 1998 by the Ministry of Interior. Though the overall age dependency ratio has been declining (Table 1.1), the old-age dependency ratio has been increasing while the child dependency ratio has been decreasing. As Thailand became a rapidly ageing society (United Nations Population Fund, 2011), the change in the dependency ratio from child dependants to elderly dependants has shifted the burden on the working age population: they have fewer children to support, but the number of older people who need support has increased. Therefore, the number of older people requiring support from the working age population will continue to increase in the future. The adult literacy rate in 2021 was high (94.0%) with a small gender gap (male 96% and female 93%) (World Bank, 2021c) and a high status of females in the society measured by labour force participation rate among women (59.2% in 2021, compared with an average 45% among women in middle- income countries), contributing to a high child health status (World Bank, 2019a). Thailand youth literacy (15–24 years old) was 99% in 2021, on a par with 98% in upper-middle-income countries in 2020 (World Bank, 2021f). Finally, Internet use by the Thai population increased from 22% in 2010 to 85% in 2021; compared with 35% and 76% among upper-middle-income countries during the same period (World Bank, 2021f). 1.2 Economic context Thailand had been one of the fastest-growing economies in Asia and in South-East Asia in particular, experiencing rapid growth between 1985 and 1996; it was a newly industrialized country and a major exporter. Negative economic growth was observed after the 1997 Asian financial crisis. Thailand 7took 10 years to recover from the crisis; gross national income (GNI) per capita in 2005 was the same as that in 1996. Thailand has made remarkable progress in social and economic development, moving from a low-income to an upper-middle-income country in 2011 (World Bank, 2021b). As such, Thailand has been a widely cited development success story, with sustained strong growth and impressive poverty reduction. However, the growth prospects from the export-led model that not long ago powered so much of Thailand’s economic growth seem to have diminished significantly, owing to a stagnation in productivity. Average growth in total factor productivity (TFP) stagnated from a high of 3.6% per annum during the early 2000s to just 1.3% during 2009–2017. Additionally, the COVID-19 pandemic has dealt a blow to the economy, aggravating the structural challenges. In 2020, the economy was estimated to have contracted by 6.1% (World Bank, 2023c). The slowing external environment, domestic price pressures, and raised household debt pose downside risks. However, Thailand’s economic recovery continued to lag behind that of ASEAN peers; falling goods exports have clouded the outlook. Economic growth decelerated more than expected in 2022Q4 to 1.4% (year on year) following weakening goods trade despite resurgent private consumption and strong tourism inflows. Overall, in 2022, gross domestic product (GDP) grew 2.6%, up from 1.6% the previous year (World Bank, 2022b) (Table 1.2). Table 1.2 Macroeconomic indicators, selected years 1980 1990 2000 2010 2020 2021 GDP per capita (US$)a 707 1 545 2 004 4 996 6 991 7 066 GDP per capita, PPP (current international $)a .. 4 411 7 281 12 989 17 771 18 761 GDP average annual growth rate for the past 10 years (%)a 5.2 11.2 4.5 7.5 (6.2) 1.5 Tax revenue (% of GDP)a 13.1 16.9 13.0 14.9 14.5 .. Central government debt, total (% of GDP)a .. 18.4 22.0 26.9 50.4 .. Value added in industry (% of GDP)a 28.7 37.2 36.7 39.9 33.2 34.8 Value added in agriculture (% of GDP)a 23.2 12.5 8.5 10.5 8.7 8.5 Value added in services (% of GDP)a .. 55.1 b 54.8 49.6 58.1 56.7 Labour force (total, thousands)a .. 29 032 34 801 39 447 40 207 40 333 Unemployment, total (% of labour force)a 0.9 2.2 2.4 0.6 1.1 1.2 Gini coefficienta .. 45.3 42.8 39.4 35 .. Source: a (World Bank, 2021g) 8The size of the labour force in Thailand has been increasing over time. The number of registered unemployed reduced from 2.2% of the total labour force in 1990 to 1.2% in 2021. Although the labour force engaged in the agricultural sector is large, its contribution to the GDP has been decreasing. In 2021, it accounted for only 8.5% of the GDP, which is about one third of the 1980 contribution. The decreasing contribution of the agricultural sector to GDP was replaced by increasing export of manufactured products, from 28.7% in 1980 to 34.8% in 2021, while the service sector contributed around 50–60% of the GDP over the three decades 1990–2020 (Table 1.2). Many services in Thailand such as wholesale and retail trade, transportation, and tourism and travel-related activities are the largest contributors to GDP and maintain significant shares in employment (Koonnathamdee, 2013). Thailand’s economy suffered a significant blow due to the COVID-19 pandemic, with its GDP plummeting by over 6% in 2020. The pandemic resulted in widespread job losses, particularly affecting workers in the tourism sector (International Monetary Fund, 2021). The main manufacturing industries in Thailand are industrial goods, accounting for 75% of total export value, including automobiles and their assembly, computers and their components and accessories, chemical products, plastic resin, rubber products, and jewellery. Thailand has been a centre for automobile manufacturing for the ASEAN market. Manufacturing facilities are mostly located in Bangkok and on the eastern seaboard, which was designated in 1977 as the long-term site for large-scale small, medium and heavy industries. Due to the favourable economic growth, the Gini index has significantly decreased from 45.3 in 1990 to 35.0 in 2020; the index was lower than China (38.2) and Malaysia (41.2) in 2020, but still high when compared to high- income countries such as Austria (29.8), France (30.7), and the Netherlands (26.0) (World Bank, 2021a). The fiscal space – measured by tax revenue of 13–16.9% of GDP, though not high compared to countries belonging to the Organisation for Economic Co-operation and Development (OECD), is slightly higher than the average of middle-income countries – it facilitates government spending on health and education. Given the limited fiscal spaces, investment in health infrastructure in the 1980s and 1990s was possible only as a result of political commitment and prioritized investment in district health systems, and temporary slowing down of investment in provincial health infrastructure (Patcharanarumol et al., 2011). 91.3 Political context Thailand is a constitutional monarchy with a history of 20 constitutions, the most recent one ratified in 2017. The government structure includes a National Assembly with a prime minister heading the executive branch. The National Assembly, Council of Ministers, and courts collectively exercise power in accordance with constitutional provisions and laws. The 2017 Constitution, approved by 61.4% of voters with 59.4% public participation, grants authority to the National Council for Peace and Order (NCPO) to appoint a panel of eight to ten individuals who select senators. Notably, six Senate seats are reserved for top military figures, including the heads of the Army, Navy, Air Force, Police, the military’s supreme commander, and the defence permanent secretary. Additionally, the bicameral Parliament can choose a Prime Minister from outside its ranks or even a non-politician (Detwattanayotin, 2022). In May 2014, a military coup led to the suspension of the 2007 Constitution (except monarchy-related provisions), with military leaders forming a council to assume power. They appointed a 200-member interim legislature and an interim prime minister. In early 2018, it was announced that parliamentary elections would take place in 2019, leading to the Palang Pracharath Party’s emergence and Prayuth’s appointment as prime minister. In March 2023, the House of Representatives was dissolved, and elections were set for May. Initially, Pita’s Move Forward formed a coalition with pro- democracy parties but could not form a government due to Senate allies. Pheu Thai then aligned with conservative, pro-military parties and nominated Srettha Thavisin, who was elected as prime minister on 22 August 2023. Thailand’s governance is led by an elected prime minister and Cabinet, chosen by members of the House of Representatives. The country features a two-chamber legislature and an independent judiciary. Throughout its history, Thailand has consistently pursued a path towards a multi-party democracy, emphasizing values like accountability, transparency, good governance, human rights, and the rule of law. In Thailand, government is primarily managed through centrally appointed officials at the local level, including provinces and districts. Over the years, there has been a discernible shift towards decentralization of power since the 1980s. Major cities like Bangkok, Chiang Mai, and Pattaya have their own significant local governing bodies. While locally elected provincial assemblies have limited authority, they offer a launchpad for emerging local politicians who may eventually enter the National Assembly. In 1997, communes (Tambon) were empowered to elect Tambon administrative organization 10 (TAO) members, elevating them to crucial local democratic entities with administrative and financial responsibilities. Village leaders are elected but have limited authority due to oversight by centrally appointed district officers and TAOs. Over the past decades, Thailand has maintained policy continuity, offering a stable environment for investors and businesses. Key principles include good relations with neighbours, responsible foreign policy, an open-market economy, foreign investment and tourism friendliness, prudent fiscal and monetary policies, and infrastructure development for competitiveness and sustainability. These policies are supported by a robust private sector and a dependable civil service responsible for policy implementation and law enforcement (Baker et al., 2009). 1.4 Health status Thailand is on track with the Sustainable Development Goals (SDGs) (Sachs et al., 2022). Demographic transition started in the early 1980s, life expectancy at birth increased gradually, reaching 75.0 years for males and 83.7 years for females in the mid-2020s with a period of stagnation due to the HIV/AIDS epidemics in the 1990s. Life expectancy of females exceeds that of males due to higher mortality rate among men attributable to accidents, risk-carrying work and unhealthy behaviour, though women live longer with disability. The improvement in life expectancy is partly a result of successful HIV/AIDS prevention, which started to reverse the epidemic around the late 1990s (see Table 1.3) (United Nations Population Fund, 2011). Table 1.3 Mortality and health indicators, selected years 1980 1990 1995 2000 2005 2010 2015 2020 Life expectancy at birth (years) Male 60.2 66.8 66.5 68.4 70.0 72.1 73.5 75.0 Female 68.0 74.2 75.7 76.4 77.8 80.4 82.0 83.7 Total mortality rate, adult (per 1000) Male 315.2 239.4 255.3 239.8 228.6 208.0 192.3 174.2 Female 204.6 143.3 129.8 124.3 113.5 93.1 81.7 70.7 Source: (World Bank, 2021g) The adult mortality rate is the probability of dying between the ages of 15 and 59 years per 1000 population; it has been declining over time for both males and females though with a large gender gap (Fig. 1.2). For adult males, the rate declined from 239.8 per 1000 in 2000 to 208.0 and 174.2 in 2010 and 2020, respectively. The adult mortality rate among females decreased from 124.3 per 1000 in 2000 to 93.1 and 70.7 in 2010 and 2020, respectively, though 11 stagnation was observed from 1997 to 2003, probably due to HIV/AIDS (this is consistent with the findings by (Rajaratnam et al., 2010)). The decline in adult, infant and under-five mortality rates indicate improved life expectancy at birth for both males and females. Fig. 1.2 Trends in life expectancy at birth (years), adult mortality (probability of dying between 15 and 60 years of age per 1000 population), by sex, 1995–2020 30 60 90 50 100 150 200 250 300 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17 20 18 20 19 20 20 Li fe e xp ec ta nc y at b irt h, y ea rs ! Ad ul t m or ta lit y pe r 1 00 0 po pu la tio n! 60q15 Male 60q15 Female Life expectancy Male Life expectancy Female Source: (World Bank, 2021g) 1.4.1 Main causes of death Table 1.4 shows age-standardized death rates (A-SDRs) per 100 000 by major causes of death in Thailand during 1980–2019. A U-shape of the A-SDRs of all infectious and parasitic diseases during 1980–2019 has been observed: from the high A-SDR in 1980 (61.3 per 100 000), the rates came down to 37.9 and 28.9 per 100 000 in 1985 and 1990, respectively. The A-SDRs of this cause subsequently went up again after 1995 (54.5, 63.7, 63.6 and 56.1 per 100 000 in 2000, 2005, 2010 and 2010, respectively) and the rates came down to 56.1 and 40.5 per 100 000 in 2015 and 2019. However, a closer look shows that HIV/AIDS was the major contributor to this reverse trend in mortality from infectious diseases. 12 Table 1.4 Main causes of death, 1980–2019, selected years (age- standardized death rates per 100 000 population) Causes of death (ICD-10 classification) 1980 1990 2000 2005 2010 2015 2019 Communicable diseases a Infectious and parasitic diseases (A00–B99, G00–G04, G14, N70–N73, P37.3, P37.4) 61.3 28.9 54.5 63.7 63.6 56.1 40.5 Tuberculosis (A15–A19, B90) 15.0 7.0 9.9 8.5 7.0 9.4 7.0 STDs excluding HIV (A50–A64, N70– N73) 0.1 0.1 0 0 0 0 0.1 HIV/AIDS (B20–B24) ND 0 12.4 10.8 4.9 7.4 5.6 Noncommunicable diseases b Malignant neoplasms (C00–C97) 40.6 53.9 68.1 76.1 85.4 91.1 89.8 Colon and rectum cancers (C18– C21) 1.3 1.8 3.4 2.4 3.5 5.0 5.9 Trachea, bronchus, lung cancers (C33–C34) 4.2 4.5 9.7 12.3 14.0 16.2 15.7 Breast cancer (C50) 0.7 0.6 1.9 2.7 3.5 4.6 5.2 Cervix uteri cancer (C53) 0.7 0.3 1.5 2.1 2.4 2.7 2.5 Diabetes mellitus (E10–E14) 5.6 7.2 13.9 11.4 10.4 15.6 21.2 Neuropsychiatric conditions (F01– F99, G06–G98 (minus G14), U07.0, X41, X42, X44, X45) 16.2 13.4 16.5 7.9 6.0 11.3 19.9 Cardiovascular diseases (I00–I99) 80.5 99.9 58.5 57.3 59.4 75.7 79.5 Ischaemic heart disease (I20–I25) 2.1 1.9 11.8 18.4 19.8 23.7 21.9 Cerebrovascular disease (I60–I69) 18.1 14.5 15.2 24.3 26.1 34.5 37.3 Respiratory diseases (J30–J98) 7.1 8.1 21.9 19.6 22.5 15.4 13.5 Digestive diseases (K20–K92) 34.8 24.6 15.5 19.2 19.3 22.7 23.5 External causesc Road traffic accidents (V01–V04, V06 (.1–.9), V09 (.2–.3), V10–V14 (.3–.9), V15–V19 (.4–.9), V20–V28 (.3–.9), V29–V79 (.4–.9), V80 (.3–.5), V81.1, V82 (.1, .8–.9), V83–V86 (.0–.3), V87 (.0–.9), V89 (.2–.3, .9), V99, Y85.0) 15.8 14.5 19.4 15.4 20.5 21.0 28.4 Self-inflicted injuries (X60–X84, Y870) 8.2 6.8 7.9 5.6 5.4 5.6 7.7 Ill-defined diseases (R00–R94, R96– R99)d 519.5 328.3 304.5 256 242.8 135.3 115.1 ND: not determined Sources: a (World Health Organization, 2020a), b (World Health Organization, 2020d), c (World Health Organization, 2020c), d (World Health Organization, 2020b) 13 After 2000, it is not surprising that cardiovascular disease (I00–I99) mortality rates declined, because of the change in coding practice – unspecified heart failure was moved from cerebrovascular diseases to the Ill-defined group in an attempt to improve the accuracy of cause of death. Similar to high- and middle-income countries, NCDs have become the main causes of death. Certain causes, such as malignant neoplasms or circulatory diseases, have A-SDRs higher than for all infectious diseases combined (Table 1.4). Among malignancy, increased trends were observed among cancers of the colon and rectum, trachea, bronchus and lung, breast, and cervix uteri during 1980–2019. The A-SDR of cancer of the trachea, bronchus and lung was 4.2 per 100 000 population in 1980, but increased to 4.5, 9.7, 14.0, and 15.7 per 100 000 in 1990, 2000, 2010, and 2019, respectively. Diabetes, ischaemic heart disease, cerebrovascular disease, and chronic respiratory disease all also increased. Despite active policies to reduce traffic injuries and mortality – such as the “Don’t Drink and Drive” campaign, Decade of Action for Road Safety, and Year of 100% Helmet Wearing – Table 1.4 shows an erratic trend, peaking in 2019, the latest year that data are available. Mortality from road traffic accidents was double the suicide rate in 1980 but had quadrupled by 2019. The number of registered vehicles increased from 28.4 million in 2010 to 36.7 million and 41.4 million in 2015 and 2020, respectively (Department of Land Transport, 2020). In contrast, the total length of the main and secondary roads underwent a gradual increase (Ministry of Transport, 2022). Perhaps better statistics and reporting of traffic-related injuries, erratic or ineffective interventions, poor law enforcement may explain this erratic mortality trend. Closer monitoring and effective interventions are on the national policy agenda. Although the epidemiological transition of diseases in Thailand has changed from the stage of infectious diseases to NCDs, the burden of infectious disease still exists. In 2019, the Thai Working Group on Burden of Disease conducted a Burden of Disease Study (Table 1.5). The study found road injuries and stroke to be the two leading causes of DALY loss among men, while women were more likely to be affected by diabetes and stroke (Burden of Disease Research Program Thailand, 2021). The results confirm that the DALY loss from HIV/AIDS resulting from the AIDS epidemic in the 1990s remained fairly high, with up to 209 900 years of DALY loss. 14 Table 1.5 Top ten causes of disability-adjusted life year (DALY) loss among Thai men and women, 2019, Thailand Top ten ranking in men Top ten ranking in women Cause/ disease YLL (x 1000) YLD (x 1000) DALY (x 1000) Cause/ disease YLL (x 1000) YLD (x 1000) DALY (x 1000) 1 Road injuries 1 140.1 195.9 1 335.9 Diabetes mellitus 721.9 113.6 835.5 2 Stroke 855.9 27.3 883.1 Stroke 586.2 22.6 608.9 3 Diabetes mellitus 725.7 88.6 814.3 Road injuries 380.5 108.3 488.8 4 Ischaemic heart disease 705.7 21.8 727.4 Ischaemic heart disease 274.5 24.2 298.7 5 Liver cancer 464.0 4.0 468.0 Breast cancer 223.2 10.7 233.8 6 Cirrhosis and other chronic liver diseases 434.8 29.8 464.6 Chronic kidney disease 170.9 52.3 223.2 7 HIV/AIDS 305.1 37.0 342.1 Oral disorders - 209.9 209.9 8 Self-harm 314.3 0.5 314.8 HIV/AIDS 152.2 30.9 183.1 9 Tracheal, bronchus, and lung cancer 283.6 3.9 287.4 Tracheal, bronchus, and lung cancer 161.7 2.3 164.0 10 Tuberculosis 245.1 30.1 275.2 Alzheimer disease and other dementias 154.0 4.8 158.7 Note YLL: years of life lost (non-discount rate 3%, non-age weights) YLD: years lost due to disability (non-discount rate 3%, non-age weights) DALY: disability-adjusted life year (non-discount rate 3%, non-age weights) Source: (Burden of Disease Research Program Thailand, 2021) On major health risks, adult smoking prevalence declined by 8 percentage points over 20 years, the overall prevalence (both genders) was 25.5% in 2001 and 20.7% and 17.4 % in 2009 and 2021, respectively (Fig. 1.3). This may reflect the effectiveness of interventions, though almost all the best buy interventions recommended by WHO were implemented. The WHO report shows that cigarettes are not less affordable by smokers, which reflects a need to further increase the tobacco excise rate (World Health Organization, 2021c). 15 In 2022 and 2023, there were efforts led by some politicians to revoke the current total ban of importation and use of electronic nicotine delivery systems (ENDS). It was supported by the End Cigarette Smoke Thailand (ECST), which actively promotes e-cigarettes. ECST works closely with other organizations that have industry connections, such as the International Network of Nicotine Consumer Organisations, which is a grantee of the Foundation for a Smoke-Free World (FSFW). The FSFW in turn is funded by Philip Morris International (Southeast Asia Tobacco Control Alliance, 2020). Fig. 1.3 Adult smoking prevalence by gender, 1991–2021 0 10 20 30 40 50 60 70 1991 1996 2001 2004 2007 2009 2011 2013 2014 2015 2017 2019 2021 % a du lt po pu la tio n Male Female Total Sources: (Kongsakon et al., 2020); (Aekplakorn et al., 2021); (National Statistical Office, 2021b) In relation to other significant health risks, the findings from the National Health Examination Survey 2019–2020 (NHES) VI reveal that the prevalence of physical inactivity among Thais aged 15 years and above was 30.9% (28.9% in males and 32.7% in females). The percentage of physical inactivity is highest among the elderly and has increased to 27.9% in males and 31.7% in females compared to the data from NHES V in 2014. Furthermore, the prevalence of a body mass index (BMI) greater than or equal to 25 kg/m2 is now at 42.2% (37.8% in males and 46.4% in females), showing a notable increase from the NHES V data when it was 36.8% in males and 45.4% in females. Additionally, for alcohol consumption within the past 12 months, the prevalence is recorded at 44.6% (59.0% in males and 31.0% in females), indicating an increase from the NHES V data when it was 58% in males and 30% in females (Aekplakorn et al., 2021; Aekplakorn et al., 2014). 16 1.4.2 Maternal, child and adolescent health While Thailand has achieved success in reducing the fertility of the population and sustained a high level of contraceptive prevalence and equitable access to reproductive health services (Kongsri et al., 2011), new challenges have emerged. These include increased infertility due to delayed marriage, lower- than-replacement fertility rate, increasing sexual activity among teenagers and young adolescents and unmarried adults, and higher unmet need for contraception than that found in the typical fertility survey (United Nations Population Fund, 2011). Table 1.6 shows some indicators of the reproductive health situation during 1980–2021 in Thailand. Table 1.6 Maternal, child and adolescent health indicators, selected years Indicator 1980 1990 2000 2010 2015 2020 2021 Adolescent birth rate (per 1000 women aged 15–19 years)a 59.4 51.1 34.5 50.8 45.9 33.2 .. Infant mortality rate (per 1000 live births)a 46.9 30.3 18.7 11.7 9.3 7.4 7.1 Under-five mortality rate (per 1000 live births)a 60.9 37.1 21.9 13.6 10.8 8.6 8.3 Maternal mortality ratio (per 100 000 live births)a .. .. 48.0 35.0 30.0 29.0 .. Source: a (World Bank, 2021g) From the mortality rates, the improvement in the reproductive health situation in Thailand is based on three indicators – infant mortality rate (IMR), under-five mortality rate (U5MR), and maternal mortality ratio (MMR). In 1980, the IMR was nearly 46.9 per 1000 live births, while U5MR was 60.9. These rates significantly reduced to 7.1 for IMR and 8.3 for U5MR in 2021. This meant that Thailand had achieved the SDG 3.2 target – by 2030 reduce under-5 mortality to at least as low as 25 per 1000 live births. There were many improvements in maternal and child health (MCH) services during this period, including an increase in vaccine coverage. Thailand has achieved good health at a relatively low cost due to comprehensive geographical coverage of primary health care (PHC), and expansion of financial risk protection to the population, reaching universal coverage by 2002 (Patcharanarumol et al., 2011; Rohde et al., 2008). Studies suggest that health systems development, well-functioning PHC and female literacy are the main contributing factors to the health of the population (Balabanova et al., 2013; Tangcharoensathien et al., 2018). 17 Over the same time period, the MMR also reduced, from 48.0 per 100 000 live births in 2000 to 30.0 in 2015 and 29 in 2020. Looking back to the early 1960s, the MMR reported in the Public Health Statistics was around 400 per 100 000 live births. This is a tremendous improvement in reproductive health in Thailand in a few decades, though more needs to be done to further reduce the MMR. In terms of adolescent health, there was a decline in adolescent birth rates during 1980–2000, followed by an increase in 2010, and then another decline in 2020 (Table 1.6). The trend in adolescent birth rates, as with the results of the Multiple Indicator Cluster Survey (MICS), decreased from 51 births per 1000 women in 2015 to 23 births per 1000 births in 2019 (National Statistical Office et al., 2020). However, the survey found adolescent birth rates that were lower than what the World Bank reported. The survey was conducted by the NSO of Thailand. It collected and analysed data of children and women in over 40 660 households across Thailand from May to September 2019 through face-to-face interviews with families. Since teenage pregnancies affect both the mother and the quality of life of their baby throughout its life, the emerging challenges of increased early unprotected sexual activity, and large unmet need for family planning services (in particular, among unmarried couples since 2000) should be priority policy interventions. The high level of unsafe abortions is also a major concern. 18 2 Organization and governance Chapter summary The Ministry of Public Health (MoPH) is the national health authority responsible for formulating and implementing health policy. However, its role has changed as several autonomous public health agencies have been established recently through legislations, notably the Health Systems Research Institute (1992), the Thai Health Promotion Foundation (2001), the National Health Security Office (NHSO) (2002), the National Health Commission Office (NHCO) (2007), the National Institute for Emergency Medicine (NIEM) (2008), the National Vaccine Institute (NVI) (2018) and the Healthcare Accreditation Institute (HAI) (2009), which is an exception as it was established by a Royal Decree according to the Public Organization Act 1999. The MoPH and these independent agencies form a complex interdependent relationship and governing structure, while non-State actors and civil society groups also play increasing roles. The NHCO is mandated to convene the annual National Health Assembly (NHA), ensuring participatory engagement by all government and non-State actors in formulating health policy through NHA resolutions where some of the NHA resolutions are endorsed by a Cabinet resolution ensuring effective multisectoral implementation. The advent of the NHSO has had a major impact on transforming the integrated model of the MoPH as a purchaser and service provider to NHSO as the purchaser and MoPH as one of the major service providers in Thailand. Thailand has a long history of de-concentration of health management to the Provincial Health Office (PHO) and all public hospitals under the MoPH, especially the financial power to retain and use revenue according to regulations, subject to regular audit by the Auditor-General. The PHO also holds regulatory power, such as new licence or annual licence renewal of private pharmacies and clinics, and consumer protection on food, drugs and cosmetics in the respective province. The Decentralization Act 1999 requested the MoPH to devolve all public health-care facilities to local elected government units: health centres to tambon administration organizations (TAOs), district hospitals to municipalities, and provincial hospitals to provincial administration organizations (PAOs). Progress in implementing the Decentralization Act has been slow, both in terms of devolving functions and transferring budget from central to local 19 governments. In 2021, 84 MoPH health centres out of a total of 9759 (0.8%) had devolved, as TAOs lacked readiness, capacities and funding, and could not fulfil the criteria for assuming responsibility for health centres. In 2021, the guidelines were established for transferring health centres or subdistrict health-promoting hospitals to PAOs to implement the Decentralization Act, based on the readiness of PAOs. Capacity in health technology assessment has been gradually developed since 2007 and has contributed to the inclusion of new medicines on the National List of Essential Medicines (NLEM) and interventions to be included in the benefit package of the Universal Coverage Scheme (UCS). Medicines are regulated by the Food and Drug Administration, which handles market approval and post-marketing control. However, with the exception of essential medicines sold to government bodies, prices are governed by market forces. Medical appliances are regulated, but their social, economic and ethical impacts are assessed only if they cost more than Thai Baht (THB) 100 million (US$ 3.3 million). Patients have the right to choose their preferred provider from those approved by their insurance scheme, and most have access to a complaint procedure. The public is involved in policy formulation. 2.1 Overview of the health system The 2007 Constitution and subsequent versions of the Constitution of Thailand guarantee the equal rights of citizens: (1) to receive standard public health services; (2) to survive and receive physical, mental and intellectual development (the latter particularly among children and youth); (3) to access and use with dignity public welfare, public utilities, and other appropriate support from the State; (4) to receive information and explanation and to express their opinions on any government project or activity that may affect their environment, health or well-being; and (5) to participate with the State and communities in the preservation of natural resources and biological diversity and in the protection of an environment that minimizes hazards to health. In 2002, Parliament passed the National Health Security Act B.E. 2545 (2002), which aimed to set up a health system that provided essential good-quality health services for the people using the universal health coverage (UHC) approach. As mandated by the Act, the NHSO was established to manage and ensure health security for the rest of the people who were not covered 20 by the Civil Servant Medical Benefit Scheme (CSMBS) and the Social Health Insurance Scheme (SHI) scheme. The year 2007 was a major turning point in the history of the health system, when the National Health Act, B.E. 2550 was adopted by Parliament. As described in this Act, health means the state of complete well-being in multiple dimensions, including physical, mental, intellectual and social, all of which are considered in a holistic and interconnected way. As mandated by the National Health Act, the National Health Commission (NHC) and the National Health Commission Office (NHCO) were established as the implementing body of the Act and secretariat, respectively. The NHC is mandated to submit recommendations in respective National Health Assembly (NHA) resolutions to the government through a Cabinet Resolution on health policies and strategies for the government and all sectors in society (Rasanathan et al., 2012). Once an NHA resolution is endorsed by the Cabinet, it becomes legally binding for line agencies in the government to implement and report back to the Assembly. Non-Cabinet-endorsed resolutions are used to build social pressure so that line agencies may enact them on a voluntary basis (National Health Commission Office, 2022a). The multiple governance mechanisms of the national health system are illustrated in Fig. 2.1. Increasingly, there are legally established players and foundations, civil society, and the private sector, which are active in shaping health policies and agendas in Thailand. However, the MoPH, as a national health authority, is the principal agency, although its focus is on the largest health-care delivery systems under its jurisdiction. Other ministries also play a role in health-related activities in various dimensions. Local government gradually played a significant role in primary health care, in particular, the transfer of subdistrict health-promoting hospitals to provincial administration organizations (PAOs) in the fiscal year 2023. For the health security system, three major agencies cover the whole population: the NHSO manages the Universal Coverage Scheme (UCS), the Comptroller-General Department (CGD) of the Ministry of Finance manages the CSMBS, and the Social Security Office (SSO) of the Ministry of Labour manages the SHI. 21 Fig. 2.1 Linkages of governance mechanisms in the national health system NHC & NHCO• Making recommendations on health policies and strategies • Statute on national health system • Health assembly Other networks • Generating system • Networks of health, civil society and partners • Managing health promotion fund • Managing health security fund • Implementing health Networks of the mass media Local administration organiations Academic and professional networks Provincial administration agencies Parliament Ministry of Public Health and other ministries working on health NESAC NESDB Cabinet HSRI HAI EMIT NHSO ThaiHealth NESAC: National Economic and Social Advisory Council; NESDB: National Economic and Social Development Board; NHSO: National Health Security Office; NHC: National Health Commission; NHCO: National Health Commission Office; ThaiHealth: Thai Health Promotion Foundation; HAI: Healthcare Accreditation Institute; HSRI: Health System Research Institute; NIEM: National Institute for Emergency Medicine; NVI: National Vaccine Institute Note: solid lines refer to the line of command, reporting and direct accountability, while dotted lines depict intersectoral coordination. Source: modified from (Wibulpolprasert et al., 2011b). In 1992, the Health System Research Institute (HSRI) was founded by the Health System Research Institute Act 2535B.E. (1992). The aim of the HSRI is to manage and support health system research and development. In 2001, the Thai Health Promotion Foundation (ThaiHealth) was established by the Thai Health Promotion Foundation Act, 2001. The aim of ThaiHealth is to manage the Health Promotion Fund, financed by 2% additional surcharges from excise tax levied on tobacco and alcohol. Between 2010 and 2021, it received an average annual revenue of US$ 131 million, of which 32% was from tobacco and 68% from alcohol. This revenue is equivalent to US$ 2 per capita Thai population (analysis from Thai Health annual report between 2010 and 2021). The Fund supports all relevant 22 sectors, including public, private and civil society, through things like catalytic funding for model development and policy development to carry out active health-promoting activities. The National Institute for Emergency Medicine (NIEM) (2008), the Healthcare Accreditation Institute (HAI) (2009), and the National Vaccine Institute (NVI) (2018) were established by a Royal Decree according to the Public Organization Act, 1999. The NIEM was founded by the Emergency Medical Act B.E. 2551 (2008). It aims to regulate and strengthen the emergency medical service system of Thailand. The NIEM is also assigned as a juristic person under the supervision of the MoPH and the Secretary General. The HAI was established by a Royal Decree in 2552B.E. (2009) as mandated by the Public Organization Act, 2542B.E. (1999). The mission of the HAI is to promote and support health-service quality development and accredit all public and private hospitals and other health-care facilities (such as health centres). In 2018, the NVI (public organization) was established by a Royal Decree in 2555B.E. (2012) as mandated by the Public Organization Act 2542B.E. (1999). The NVI is a public autonomous authority that manages and coordinates vaccine affairs with domestic and international stakeholders throughout the vaccine-making process, including vaccine research and development, production, and distribution (National Vaccine Institute, 2023; Royal Thai Government Gazette, 2018 ). In light of these multiple actors, most established by laws, the MoPH has adjusted its strategy to better coordinate and orchestrate the contributions by these public agencies to achieve national health goals in a synergistic manner (Tantivess, 2008). Once decision-making has been made by the State authorities with control of power, there is a process to turn such decisions to non-State actors with diverse backgrounds and professions. These include people from civil society, nongovernmental organizations (NGOs), health professionals in public hospitals, family and community members, community leaders and representatives and community volunteers, with similar concerns regarding health policy issues. 23 2.2 Historical background The MoPH is the core agency in the Thai public health system. The development of the MoPH began in 1888 as the Department of Nursing under the Ministry of Education. In 1918, it became the Public Health Department under the Ministry of Interior. The Ministry of Public Health was established in 1942 according to the Reorganization of Ministries, Sub-Ministries and Departments Act, B.E. 2485 (1942). Since then, there have been several reorganizations, first in 1972, a second in 1974, a third in 1992, and a fourth in 2002. In 2006, the MoPH prepared a proposal on its mission and structure, and the formal ministerial regulation on MoPH reorganization was issued in 2009, whereby a number of new departments were established, and the government was downsized – including the health sector, where the posts of retired persons were terminated (see Fig. 2.2). In 1999, the Decentralization Act was adopted by Parliament to transfer various activities held by central ministries, including education and health services, to local government organizations (LGOs). However, in late 2002, all health-care decentralization movements were suspended because of changes in government policy. In 2002, the advent of the NHSO responsible for UCS resulted in a major shift of financial power from the MoPH to the NHSO. The conventional supply-side financing through annual recurrent budget allocation to the MoPH-owned health-care facilities ended, with the service-related budget transferred to the NHSO; allocation is now based on catchment population for outpatient services and service load for inpatient services. The MoPH still retains a regulatory function, consumer protection, implementation of related public health laws, and health service provision. This shift, splitting the role of purchaser (NHSO) and provider (MoPH), has had major ramifications on the MoPH and its relationship with the NHSO. In 2009, there was a major public-sector reform to improve the efficiency of the government sector, including delegation of tasks and budget to LGOs, downsizing and restructuring; posts were terminated after retirement across all government sectors. As a result, the MoPH, especially at central administration level, has become smaller and plays more stewardship functions such as goal-, policy-, strategy- and standard-setting, regulatory and public health functions, monitoring and evaluation, and coordinating with other health and non-health sectors to improve the health of the population. The competence and skill mix in the central MoPH administration needs to be reoriented in response to potential future evolution. 24 Fi g. 2 .2 Ev ol ut io n of th e M in is tr y of P ub lic H ea lth a nd re la te d he al th a ge nc ie s De pa rt m en t o f L oc al Ad m in is tr at io n, M in is tr y of In te rio r 1s t, 2n d an d 3r d re or ga ni za tio n of M oP H 4t h re or ga ni za tio n of M oP H Tr an sf er o f s om e he al th ce nt re s to T am bo n Ad m in is tr at iv e Or ga ni za tio ns (T AO s) o r M un ic ip al iti es Tr an sf er o f s om e su b- di st ric t he al th p ro m ot io n ho sp ita ls to Pr ov in ci al A dm in is tr at iv e Or ga ni za tio ns (P AO s) Pr op os iti on o n re or ga ni za tio n an d re st ru ct ur in g of M oP H H ea lth s ys te m re fo rm De pa rt m en t o f Pu bl ic H ea lth , M in is tr y of In te rio r De pa rt m en t o f N ur si ng , M in is tr y of E du ca tio n De pa rt m en t o f Pu bl ic P ro te ct io n, M in is tr y of In te rio r H ea lth S ys te m s Re se ar ch In st itu te (H SR I) N at io na l H ea lth S ec ur ity Of fic e (N H SO ) Un iv er sa l H ea lth C ov er ag e (U H C) N at io na l I ns tit ut e fo r Em er ge nc y M ed ic in e (N IE M ) N at io na l V ac ci ne In st itu te (N VI ) M in is tr y of P ub lic H ea lth (M oP H ) Th ai H ea lth P ro m ot io n Fo un da tio n (T ha iH ea lth ) N at io na l H ea lth Co m m is si on O ffi ce (N H CO ) H ea lth ca re A cc re di ta tio n In st itu te (H AI ) M in is te ria l r eg ul at io n on M oP H re or ga ni za tio n 18 88 19 16 19 42 19 92 20 01 20 02 20 07 20 08 20 09 20 18 19 08 19 18 19 72 19 74 19 92 20 00 20 02 20 06 20 07 20 09 20 22 So ur ce : m od ifi ed fr om (W ib ul po lp ra se rt e t a l., 2 01 1b ). 25 2.3 Organization The MoPH is the main organization responsible for health promotion, prevention, disease control, treatment and rehabilitation, as well as other official functions, as dictated by laws. Other ministries also have health-care provision roles, albeit limited – including the Ministry of Social Development and Human Security responsible for other health-related social services for people with disability (PWD) and older persons; the Ministry of Justice for special populations such as prisoners; local governments such as municipalities and Tambon administration organizations (TAOs). The MoPH administrative structure is divided into two levels – central and provincial. The central administration consists of the Office of the Permanent Secretary and three clusters of technical departments: Cluster of Medical Services Development, Cluster of Public Health Development, and Cluster of Public Health Service Support (Wibulpolprasert, 2005). The Office of the Permanent Secretary (OPS) is responsible for developing strategies, translating Ministry policies into operational plans, managing and distributing resources, monitoring and evaluating the implementation of programmes by agencies under the Ministry, developing information technology systems, public relations, international cooperation, and making amendments to relevant laws (Wibulpolprasert, 2005). The OPS consists of agencies at both central and provincial levels. In 2020, at the central level, there were 15 agencies such as Strategy and Planning Division, Health Administration Division, Inspection Division (Office of Permanent Secretary, 2020; Royal Thai Government Gazette, 2017b). At the provincial level, there were 76 PHOs, 878 district health offices, and 9759 health centres or subdistrict health-promoting hospitals (Rojanapithayakorn et al., 2019; Strategy and Planning Division, 2021c). The central ministry also delegates functions to regional health offices and regional technical centres under technical departments to monitor and support the work of PHOs. The regional health offices are coordination bodies across provinces within a geographical region, responsible for the integration of planning and mobilization of resources within a region. More administrative and resource allocation is also a part of the responsibility of the regional health office (Fig. 2.3). 26 Fig. 2.3 Organizational structure and interlinkages between the MoPH and NHSO Ministry of Public Health Office of the Permanent Secretary 15 divisions and agencies Regional Health Office Regional Branch of National Health Security Office Provincial Public Health Office Other Public Health Facility Private Health Facility District Health Office Health Centre or Sub-district Health Promoting Hospital National Health Security Office Department of Medical Services Regional Technical Centre Regional / General Hospital District Hospital (Community Hospital) Department of Health Department of Disease Control Department of Mental Health Department of Traditional Medicine Department of Medical Science Department of Service Support Food and Drug Administration Cluster of Public Health Service Support Cluster of Public Health Development Cluster of Medical Services Development Ce nt ra l Re gi on al Pr ov in ci al Command Coordination Purchasing Di st ri ct Su bd is tr ic t Source: Synthesis by the author The PHO in each province reports to the provincial governor and plays a role in addressing health issues at the local level. It serves as one of the provincial administrators, receiving technical support from the MoPH. The PHO oversees and supports the regional or general hospitals, district hospitals and district health offices within each province. The district health office oversees all health centres in the district and coordinates with the district hospital for managing the district health system. 27 In terms of level of care, health centres offer primary health care (PHC) services, while district hospitals provide PHC and secondary care (all district hospitals have the clinical capacity to provide admission services, the number of beds ranges from 10 to 120) and regional/general hospitals provide tertiary and other specialized care, depending on their size and capacity. There are also other public health-care facilities under other ministries and local governments, but these make up a very small proportion. Private clinics and hospitals also play a role in providing mostly curative services to match the demand among the better-off who opt to pay despite being covered by CSMBS, SHI or UCS. Note that private hospitals with more than 100 beds are the main contractors for SHI members through registration and annual capitation payment. The private sector has more than 60% of the total 10 million registered SHI members (see Chapter 3 for more details). The NHSO also established regional branches for purchase of services within regions, covering providers under the MoPH, other public organizations and the private sector (see organizational relationship between the MoPH and NHSO in Fig. 2.3) (National Health Security Office, 2019). There are also regional committees that coordinate multiple stakeholders in the region: the Regional Health Security Board and the Regional Standard and Quality Control Board. These two committees are responsible for addressing policy and controlling the quality and standard of the health security system, respectively. 2.4 Decentralization and centralization Thailand’s administrative system comprises three major administrative categories: central administration, provincial administration, and local administration, according to the State Administrative Act, B.E. 2534 (1991) as amended by No. 8 of B.E.2553 (2010). The MoPH, as a part of central administration, has a long history of de- concentration of health management, devolving mobilization and use of revenue to the PHO and all hospitals, as a part of provincial administration, since 1975, along with a certain degree of decision-making power and financial autonomy. The Decentralization Act 1999 was promulgated as mandated by Chapter 284 of the 1997 Constitution. The Act mandates that all public services held by central ministries, including health and education, as well as their associated budgets, should be gradually devolved to the LGO as a part of local administration. LGOs include PAOs, municipalities and TAOs. The councils that oversee TAOs are elected members. The First Decentralization 28 Action Plan focused on the establishment of area health boards (AHBs) at the provincial level and transferred all public health-care facilities to AHBs. This was intended to maintain integration of the health system, instead of fragmenting it to PAOs, municipalities and TAOs. The MoPH actively implemented functional AHBs in 10 pilot provinces in 2002 with some success (Leerapan et al., 2005) and there was a plan to institutionalize AHBs by law in 2005. All health devolution was suspended in late 2002 since there were changes in leadership of the MoPH and government policy (Taearrak et al., 2008). Between 2001 and 2006, Prime Minister Thaksin’s administration initiated several policies affecting devolution – Village Fund and Urban Community Funds, UHC and provincial integrated administration policies through the function of the provincial Chief Executive Officer (CEO). Slow progress of decentralization was noted not only in health but also in education. More than 500 000 staff needed to be transferred to the LGO. As a result of the delays, the LGO budget share was only 29.50% in 2022 against the mandated target by Law of 35% (Fig. 2.4). Given the implementation problems, the Decentralization Act was amended in 2006 to set the minimum share of LGO-to-total government budget at 25%, with a target of 35%. Not only did this change the target of the devolved budget, but the model of health-care decentralization as proposed in the Second Decentralization Action Plan (2008 onwards) was also amended. It seems that keeping all health-care facilities together as a network was less of a concern and devolution of health centres to TAOs was clearly defined as a target for health-care decentralization, while district and provincial hospitals had more flexible options (formerly they were to be devolved to the municipalities or PAOs). Establishment of a comprehensive integrated model of AHB was not referred to in this plan (Royal Thai Government Gazette, 2008b) and previous pilot implementations of AHBs were terminated. In 2010, the Thai government upgraded and improved the health centres to subdistrict health-promoting hospitals, to increase convenience and accessibility to health-care services for people residing in remote areas, with a focus on promoting health (Strategy and planning Division, 2012a). Slow progress was again noted during the Second Decentralization Action Plan. As of 2021, only 84 subdistrict health centres out of the total 9759 were devolved to TAOs, because of the stringent criteria of readiness for TAOs to 29 assume health responsibilities. Positive results among the devolved health centres were reported, such as increased management flexibility, greater responsiveness to the community and patients, and increased community participation (Hawkins et al., 2009). In 2009, there was an attempt of the Association of PAOs to demand transfer of the remaining health centres to the PAOs, as indicated in the Action Plan, and provincial committees in 27 pilot provinces were appointed by the Office of Prime Minister to explore a feasible model to be fitted to the individual provincial context. There was no progress from this effort. The draft of the Third Decentralization Action Plan was developed in 2012 without major changes from the Second Action Plan except for the proposal again of a model of transfer of a network of provincial health-care providers to PAOs in provinces with large populations as an alternative. Progress of health-care decentralization and related policy interventions since 1999 are summarized in Fig. 2.5. The criticism is that Thailand runs a risk of defragmentation of a well-functioning provincial–district–subdistrict health system to individual PAOs, municipalities and TAOs. Fig. 2.4 Local government budget: fiscal year 2006–2021 0 1 2 3 4 5 6 7 8 9 10 0 5 10 15 20 25 30 35 40 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 16 20 17 20 18 20 19 20 20 20 21 GD P Go ve rn m en t r ev en ue % as compared to government revenue % as compared to GDP Source: (Office of the Decentralization to the Local Government Organization Committee, 2021) 30 Fi g. 2 .5 Pr og re ss o f h ea lth -c ar e de ce nt ra liz at io n an d re la te d po lic y in te rv en tio ns DecentralizationAct 1999 Es ta bl is hm en t o f A H B in p ilo t 1 0 pr ov in ce s Es ta bl is hm en t o f co m m un ity h ea lth fu nd s un de r T AO s & m un ic ip al iti es Fi rs t D ec en tr al iz at io n Ac tio n Pl an Se co nd D ec en tr al iz at io n Ac tio n Pl an (D ra ft) T hi rd De ce nt ra liz at io n Ac tio n Pl an Im pl em en ta tio n of U H C po lic y, pr ov in ci al in te gr at ed ad m in is tr at io n an d vi lla ge fu nd s Co up d ’e ta t De vo lu tio n of 2 8 H Cs to TA Os a nd m un ic ip al iti es Th ai C on st itu tio n of 2 00 7 Up gr ad e H Cs to su b- di st ric t h ea lth pr om ot in g ho sp ita ls an d pa yi ng in ce nt iv es fo r V H V Es ta bl is hm en t o n th e co m m itt ee s on tr an sf er o f s ub -d is tr ic t h ea lth pr om ot io n ho sp ita ls to P AO s Tr an sf er o f s ub -d is tr ic t h ea lth pr om ot io n ho sp ita ls to P AO s Tr an sf er o f t he e m er ge nc y m ed ic al se rv ic e ho tli ne c en te r u nd er N IE M to P AO s. - Tr an sf er o f H Cs to T AO s/ m un ic ip al iti es - Tr an sf er o f H Cs to P AO - Fl ex ib le m od el s fo r de vo lu tio n of d is tr ic t a nd pr ov in ci al h os pi ta ls - Sh ar e of L GB / GG B >2 5% in 2 00 7 w ith a ta rg et o f 3 5% - Es ta bl is hm en t o f A H B in e ac h pr ov in ce a nd a tr an sf er o f a n et w or k of p ro vi nc ia l h ea lth ca re p ro vi de rs to A H B - Sh ar e of L GB /C GB > 20 % in 2 00 1 an d >3 5% in 2 00 6 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 20 20 22 A H B : A re a H ea lt h B oa rd ; C G B : c en tr al g ov er nm en t b ud ge t; G G B : g en er al g ov er nm en t b ud ge t; H C : h ea lt h ce nt re ; L G B : l oc al g ov er nm en t b ud ge t; P AO : p ro vi nc ia l ad m in is tr at io n or ga ni za tio n; T AO : t am bo n ad m in is tr at io n or ga ni za tio n; U H C : u ni ve rs al h ea lt h co ve ra ge ; V H V: v ill ag e he al th v ol un te er (s ). So ur ce : S yn th es is b y th e au th or 31 The Decentralization Action Plan also indicated that 34 public health functions needed to be transferred from the MoPH to LGOs. These public health functions were mainly under the responsibility of the Department of Health, Department of Disease Control, and Food and Drug Administration. In 2010, there were only seven public health functions under the responsibility of the Department of Health that had been transferred to LGOs (Wibulpolprasert et al., 2011b). • In 2020–2022, guidelines were established for transferring subdistrict health-promoting hospitals to PAOs to implement the Action Plan based on the guidelines and the readiness of PAOs (Decentralization to the Local Government Organization Committees, 2021). The NIEM Office also coordinated and supported PAOs in providing emergency medical services in accordance with the guidelines and criteria developed by the NIEM; the process of implementation has been delayed by the COVID-19 pandemic. 2.5 Planning Health and well-being were integrated into the 3rd and 4th National Development Plans (1972–1981) when inequity increased significantly. Public health programmes needed to be improved along with national economic development to address this challenge. However, from the 5th to 7th National Development Plans, economic development was not central to all targets of national strategies. Rather, the sustainability of economic development should be focused on poverty reduction and income distribution. During the last phase, the 8th–10th plan, a human-centred approach has become central to all development. This includes multisectoral collaboration across sectors to ensure community involvement at all levels in response to new threats and dynamics in the society. The 10th National Health Development Plan established a sufficiency health system in a green and happiness- creating health culture, a medical and health service system that was satisfactory to both clients and health-care providers, and an immunization system for minimizing the impact of illnesses and health threats (Wibulpolprasert et al., 2011b). The National Public Health Strategic Plan was created with the aim of serving as an operational framework for health agencies, in response to the context of current environments. The latest plan is the 20-year National Strategic Plan 2017–2036, which is in line with the 12th National Economic and Social Development Plan (2017–2021), Thailand 4.0 Agenda, the United Nations’ SDGs, and the National Reform Policy toward “Security, Prosperity, Sustainability” (Strategy and Planning Division, 2018b). 32 The implementation plan is divided into four five-year phases with each having a separate focus, as follows: Phase 1: 2017–2021 Health system reform Phase 2: 2022–2026 System strengthening efforts Phase 3: 2027–2031 Moving toward sustainability Phase 4: 2032–2036 Becoming one of the top three countries in Asia The MoPH Plan of Action for 2023–2028 is aligned with the SDGs, the National 20-year Strategic Plan, the master plan under the National Strategy, the 13th National Economic and Social Development Plan, the National Reform Plan for public health, government policies, philosophy of a sufficiency economy, and the 20-year National Strategic Plan for Public Health (Committee for National Reform on Public Health, 2020; Ministry of Public Health, 2022a; Royal Thai Government Gazette, 2017c, 2022a, 2023; Strategy and Planning Division, 2018b). This 5-year Action Plan comprises four main targets: (1) Promotion, prevention, and protection excellence (PP&P Excellence) in promoting health, disease prevention, and consumer protection; (2) Service excellence; (3) People excellence in human resources; and (4) Governance excellence with ethical administration. The Plan consisted of 277 projects, with a total budget of THB 1804 billion (US$ 51.54 billion at 2022 exchange rate) (Ministry of Public Health, 2022a). 2.6 Intersectorality Intersectorality in the health system is demonstrated by the public participatory engagement for policy formulation. The implementation of various public policies might have negative impacts on health and well- being – for example, promoting livestock products might increase the use of antimicrobials. However, since 2015, the Department of Livestock has restricted the use of pesticides, and the use of antibiotics as a growth promoter has been banned entirely (Department of Livestock Development, 2015). Conversely, the implementation of public policy that has a positive impact on health and well-being is termed “healthy public policy”, emphasizing the creation of health security – for example, the public policy on road safety, and pesticide-free agriculture and green movement are health-enabling frameworks. Furthermore, given that the risk factors that drive noncommunicable diseases (NCDs) are primarily outside of the health system, the Health Ministry alone cannot address them successfully. Effective public policies such as marketing restrictions, increased taxes and retail prices of unhealthy products and a shared vision of safeguarding the health of the population 33 are foundations for effective multisectoral collaboration across government sectors, including ministries of finance, trade, digital economy and society, local government, and health. Most importantly, it should be guided by good governance and effective measures against conflicts of interest and regulatory capture. Key NCD legislations include the Road Traffic Act 2522 B.E. (1979), the Alcohol Control Act 2551 B.E. (2008), the Tobacco Products Control Act 2560 B.E. (2017), the Excise Tax Act 2560 B.E. (2017) (including alcohol, tobacco, and sugar-sweetened beverages taxes), and the Town Planning Act 2562 B.E. (2019). NGOs also play crucial roles in surveillance systems that accelerate the enforcement of these NCD policies. In 2021, the MoPH, ThaiHealth, NSO and other partners jointly invested in the “Health Behaviour of Population Survey 2021” where all key NCD risk factors were fully captured by the survey (National Statistical Office, 2021b). The outcomes are used by all actors to improve implementation of NCD policies. The creation of healthy public policy should be a participatory public policy process with participation by all sectors, including the technical and professional sectors, popular and social sectors, and political and civil service sectors. In this process, each sector can exert its support of the policy development initiative (Rasanathan et al., 2012). The National Health Act, B.E. 2550 (2007) was regarded as the first law in Thailand to foster public participation in agenda-setting and policy formulation. The Act provides an innovation platform for stakeholders from all sectors to formulate public policies conducive to the health of the people, such as the Statute on the National Health System, the annual NHA, Local Health Assembly, the use of health impact assessment as a mandatory tool prior to decisions on major public and private investment projects that may have negative impacts on the health of the people (Wibulpolprasert et al., 2011b). The NHA was officially convened in 2008. The consensus-based resolutions of the NHA are submitted to the National Health Commission and further to the Cabinet. Until 2022, 93 resolutions from 15 assemblies have been implemented (National Health Commission Office, 2022b). For example, the NHA has been successful in the resolution on control of marketing promotion of infant and young child foods to become legally binding, and to enable local communities to reimburse expenses and provide compensation to road safety volunteers (National Health Commission Office, 2022a). The NHA is the vehicle for policy dialogue, especially on complex health problems, including asbestos-induced illnesses, medical tourism, antimicrobial resistance linked to antibiotic use in food-producing animals, 34 access to basic care for Stateless people, illegal advertisement of drugs and health products, waste management, and more (Rajan et al., 2017). The progress report of the implementation of various resolutions of the NHA was mixed; some showed good progress, while others showed stagnation – even when an NHA resolution was endorsed by the Cabinet and therefore legally binding on government agencies, such as the total ban on chrysotile asbestos. 2.7 Health information management 2.7.1 Information systems The health information system (HIS) can be categorized into two subsystems: population based and facility based. Population-based HIS includes household surveys regularly conducted by the NSO, and civil registration. Facility-based HIS includes clinical, health and management information systems. The population-based HIS conducted by the NSO aims to provide national public health data as a representation of the country. This includes the Census data with information disaggregated by age, sex, place, and life expectancy (National Statistical Office, 2010b). Regarding public health data collected by civil registration, it is managed by the Department of Local Administration, Ministry of Interior. The primary goal of this data collection is to provide records of vital events in accordance with the regulations and instructions issued by the Civil Registration Division. It represents the social and health data at the municipal and district levels. For example, birth and death registration, the information on personal identity card, and household registration book are recorded within this database. However, there are challenges, especially in the quality of cause-of-death information as 60–70% of deaths occur outside hospitals and then it is often reported by the head of the village and civil registration officers. As such, misclassification of death registration is possible during the data collection and recording process (Tangcharoensathien et al., 2006). Some initiatives have been created to mitigate this problem. These are a manual of medical certification of cause of death based on the International Classification of Diseases-10 (ICD-10), and the use of verbal autopsy to verify the cause of death (Kijsanayotin, 2011). In 2019, the accuracy of cause-of-death certificates for both in-hospital and non-hospital deaths was 53.4% and 29.7%, respectively (Burden of Disease Research Program Thailand, 2021). In 2020, the implementation of civil registration and vital statistics (CRVS) was achieved to improve the process and quality of data collection and reporting with the establishment of guidelines and a working group (Strategy and Planning Division, 2021a; World Health Organization, 2021b). 35 Another source of population-based data is the NSO. These include the Household Socioeconomic Survey (SES), Health and Welfare Survey (HWS), elderly survey, and disability survey. These surveys are undertaken with the aim of monitoring social policy impacts at the household level. After the country implemented the Universal Coverage Policy in 2001, the MoPH requested the NSO to conduct the HWS every two years since 2007 (National Statistical Office, 2009). All NSO surveys contain a module to assess household ownership of durable goods, which facilitates computation of the wealth index and quintiles to monitor equity on a regular basis with a very long time trend (Tangcharoensathien et al., 2007). In 2021, the 22nd HWS survey included information related to health insurance, illness, access to health care and antimicrobial utilization (National Statistical Office, 2021a). The MoPH also conducted the first National Health Examination Survey in 1991–1992 through the collective efforts of the National Epidemiological Board of Thailand and academia. Though costly, the survey contributed to an in-depth understanding of the health status of the Thai population. Subsequent surveys have been conducted every five years financed by the MoPH (1996–1997, 2003–2004,2008–2009, 2013–2014 and 2019–2020), with the active leadership and funding availability of the HSRI and the MoPH (Jongudomsuk et al., 2012). The sixth survey was conducted in 2019–2020. The survey included information on health behaviours, and measurable health conditions such as weight, height, blood pressure, blood sugar level and blood lipid profile, with different age groups (Aekplakorn et al., 2021). Moreover, the national HIV sentinel surveillance survey was also funded by the MoPH. The survey began in 1989 and has been consistently conducted up to the 39th round in 2021 (Division of Epidemiology, 2021; UNAIDS, 2004). The HIV infection situation was continuously monitored and documented in reports and dashboards (Division of Epidemiology, 2019, 2023). The AIDS surveillance system was linked to the HIV data system established by the MoPH in collaboration with its partners (Bureau of AIDS TB and STIs, 2023). At the facility-based level, clinical and health information systems were established. These include all information systems related to health services, medical records, pharmacy information, radiology and laboratory information, health promotion, disease prevention, and sanitation. However, there is a need to develop disease registries to cope with the increasing trends in NCDs, as there were only a few registries maintained by university hospitals and some tertiary hospitals within the MoPH. There was an attempt to link these registries together for research purposes, as well as to improve the quality of patient care. The NHSO requests all contracted health-care providers to register NCD patients as part of the disease management system. 36 Moreover, public health data at the facility-based level are available from management information systems. This type of the data includes administrative data at the operational, management and executive levels. Health insurance coverage of patients, claim data, management of resources such as payrolls and medicines inventory are also reported in this system. The MoPH has developed health minimum standard datasets of facility-based HIS; these are the “12-files” and “18-files”. The 12-files standard data were developed as a standard dataset for health insurance management; it covers demographic data of individual inpatients, as well as their clinical data, treatments and resources used. Case-based provider payment for inpatient care such as Thai diagnosis-related group (Thai DRG) has been developed based on the 12-files data. The 18-files standard data were developed in 2002 to be used by PHC facilities. The data cover demographic data, as well as insurance coverage of its catchment population, disease prevention, health promotion and sanitation activities. Facilities within the MoPH have access to both 12-files and 18-files standard data with different software. Exchange of data between health-care facilities is limited and can be done only for administrative data because of the lack of standardization of the HIS. Recently, there was an attempt to develop a standard medicine code, the so-called 24-digit system, which was implemented with some limitations. Development of standards for laboratory data is beginning by using the Logical Observation Identifiers Names and Codes (LOINC) system with the support of the HSRI to increase the interoperability (Kijsanayotin, 2016). In 2012, the Thai Health Information Standards Development Center (THIS) was established under the HSRI with the purpose of creating health data standards that adhere to international standards and proposed the data standards development plan (Kijsanayotin, 2016; Thai Health Information Standards Development Center, 2023). In 2022, the THIS provided resources of the selected data standards, including the Systematized Nomenclature of Medicine-Clinical Term (SNOMED CT), Thai Medicines Terminology (TMT), Thai Medical Laboratory Terminology (TMLT), Health Level 7 Fast Health Interoperability Resources (HL7 FHIR) (Thai Health Information Standards Development Center, 2022a, 2022b, 2022c, 2022d). 2.7.2 Health technology assessment Health technology assessment (HTA) in Thailand is defined as a form of policy research that measures short- and long-term health, economic, social and ethical consequences of the application or use of health technologies (Teerawattananon et al., 2009). Since 2012, there has been no legal requirement to apply HTA in market authorization by the Thai 37 Food and Drug Administration for diffusion and reimbursement of health technologies, including medicines and biological products, except a few medical devices. The draft of revised Medical Device Act B.E.2551 (2008) requires assessment of the social and economic consequences of medical devices with a cost higher than THB 100 million (US$ 3.3 million) before their market authorization. According to the draft, the Minister of Public Health can designate relevant HTA bodies in and outside the country to conduct the assessment, the cost of which is met by the industry. However, due to a delayed process of issuing a subordinate law, the HTA of medical devices has not been implemented since 2008. In Thailand, HTA has become increasingly popular in recent years, especially after the establishment of the Health Intervention and Technology Assessment Program (HITAP), which is a research arm of the Bureau of Health Policy and Strategy, MoPH (Tantivess et al., 2009). In early 2007, HITAP was set up with the aim of generating the evidence necessary for priority-setting and resource allocation of health technologies and initiatives, including health-promoting and disease-preventing interventions. In December 2007, the first national methodological HTA guidelines (mainly focusing on health economic evaluation) were developed by local scholars with extensive consultations among stakeholders. The guidelines were eventually adopted by the National List of Essential Medicines (NLEM) Subcommittee and, since then, pharmacoeconomics evidence – including the assessment of cost–utility and budget impact analysis – has been requested by the Subcommittee for assessment of new and high-cost medications. For instance, the NLEM Subcommittee used pharmacoeconomic evidence to support the inclusion of tenofovir for the treatment of chronic hepatitis B, pegylated interferon alfa-2a and pegylated interferon alfa-2b for the treatment of chronic hepatitis C, oxaliplatin for the treatment of colon cancer in the pharmaceutical reimbursement list (Mohara et al., 2012), and to reject the inclusion of drugs for the treatment of osteoporosis in the list (Kingkaew et al., 2012). The national methodological HTA guideline was regularly updated for the second edition in 2014 and the third edition in 2019 (Working group on developing the national methodological HTA guidelines (edition 2019), 2021). In 2010, the NHSO endorsed the HTA guidelines and HTA has been used for the development of the NHSO health benefit package under the UCS. The International Health Policy Program (IHPP) and HITAP have been designated to act as programme coordinators, responsible for systematically prioritizing and assessing health interventions in cooperation with several groups of stakeholders, including policy-makers, health-care professionals, civil society, patient groups, academics, industry and lay people (Mohara et al., 38 2012). At least 10 HTA studies are conducted annually by IHPP and HITAP, and the results are considered by the NHSO Subcommittee. Although the NHSO Subcommittee does not always make decisions in line with HTA results, HTA information is very useful and has increased the robustness of its decisions (Youngkong et al., 2012). In 2021–2022, the findings of HTA studies were considered and some new interventions were added into the benefit package (National Health Security Office, 2023c) such as thalassaemia screening for all pregnant women and their spouses in the whole population (Chaikledkaew et al., 2022), hearing screening for high-risk newborns (Chinnacom et al., 2022), and the economic evaluation of liver transplantation (Prakongsai et al., 2020). Tantivess et al. (2009) analysed key strategies contributing to the recent success of using HTA to inform policy decisions in Thailand. These include: (i) promoting effective communications between HTA agencies and key stakeholders; (ii) enhancing the image of HTA agencies by, for example, promoting transparent HTA processes and strengthening technical capacity; (iii) ensuring the validity of research; (iv) ensuring policy relevance of HTA topics and research; and (v) establishing appropriate and effective programme management. HTA in Thailand is now recognized as a role model for other low- and middle-income countries (Glassman et al., 2012; Yang, 2009). and HITAP is the host of the regional HTA network, namely HTAsiaLink. In 2022, the HTA conference at the regional level gathered 300 academics from 20 countries (Health Intervention and Technology Assessment Program, 2022). 2.8 Regulation 2.8.1 Regulation and governance of third-party payers There are three public health-financing schemes covering the entire population. The SHI covers private-sector employees (without dependants, except maternity benefits); the CSMBS covers civil servants, pensioners and their dependents (including spouses, children under 20 years and parents); and the remaining population is covered by the UCS. All schemes have been established by specific laws (Office of Insurance Commission, 2007). • SHI is a part of the comprehensive social security system, as mandated by the Social Security Act 1990 for non-work-related conditions; and Workmen’s Compensation Act 1972 (amended 1974) for work-related injuries, disabilities and mortality. The SHI is administered by the Social Security Office (SSO) of the Ministry of Labour. 39 • CSMBS is mandated by the Royal Decree on Medical Benefits of Civil Servants 1980 and its major amendment in 2010. The CSMBS is administered by the Comptroller-General’s Department (CGD) of the Ministry of Finance. • UCS is mandated by the National Health Security Act, 2002. By law, the UCS is administered by the National Health Security Office (NHSO). The characteristics of the governance and management structures of three public health insurance schemes are shown in Table 2.1. Note that they are public agencies and use public funds and are all therefore subjected to financial audit by an internal auditor and external audit by the Auditor General. Private health insurance in Thailand is regulated by the Office of Insurance Commission (OIC), which is established under the Insurance Commission Act B.E. 2550. The OIC is responsible for setting policies, regulating, promoting, and developing the insurance business in Thailand. Table 2.1 Characteristics of governance and management structures of the three public health insurance schemes UCS SHI CSMBS Legal framework National Health Security Act 2002 Social Security Act 1990 Royal Decree 1980 and recent amendment 2010 Type of organization Autonomous public agency A department in Ministry of Labour (MoL) A Bureau of the Comptroller- General Department of the Ministry of Finance (MoF) Governing board 31 members chaired by the Public Health Minister 15 members chaired by Permanent Secretary of the MoL Advisory board (19 members) chaired by the Permanent Secretary of the MoF Branch offices 13 regional offices with 13 regional advisory committees 12 branch offices in Bangkok 76 provincial offices and 50 branch provincial officesc – 40 UCS SHI CSMBS Roles of branch offices Beneficiary registration, contract provision and consumer protection Managing collection of payroll tax contribution through wire transfer of employers’ and employees’ shares, managing benefit disbursement, consumer protection and public education – Admin budgeta 0.8% of total UCS annual budget 10% of total expenditure Negligible 0.00000008% Private provider contractual agreements and contracting modalitiesb Providers submit applications at NHSO regional offices following an annual call by the NHSO. All contracts between the SHI and private hospitals are annual agreements. Every year, the SSO calls for new applications and renewal of incumbents between April and May through its official website and invitation letters. - Provider payment mechanisms b Blended methods, mainly age-adjusted capitation for outpatient services and DRG with global budget for inpatient services, capitation and block grants for health promotion and disease prevention. High-cost interventions are paid for by fixed-rate fees. Capitation for outpatient and lower-resource inpatient services. Additional capitation rate for outpatient management of chronic diseases. DRG with global budget for inpatient services with relative weight >2. - Accreditation and monitoring systems b The Health Service Standard and Quality Control Board (HSQCB), one of the two governing bodies of the NHSO, sets and monitors the standards, adequacy and quality of health-care providers. Annual quality assessment for private providers and every 2–3 years for public providers is carried out by a consultant team. - Notes: a 2009 data b (Sakamoto et al., 2023), c (Royal Thai Government Gazette, 2017a; Social Security Office, 2020) Source: (Jongudomsuk et al., 2012) Table 2.1 Characteristics of governance and management structures of the three public health insurance schemes (contd) 41 2.8.2 Regulation and governance of providers In 2021, public hospitals accounted for 76% of all hospitals and 80% of beds, the majority owned by the MoPH, a few by other ministries, State enterprises and local governments. Private hospitals make up the remainder (24% and 20%, respectively) (Strategy and Planning Division, 2021c). There were 11 959 public health facilities and 31 286 private facilities. For public facilities, there were 2054 public hospitals, 9905 community health centres and 961 outpatient clinics. For private facilities, there were 382 private hospitals and 30 904 private clinics (Sakamoto et al., 2023). In Bangkok, there are only 69 public primary care centres, in contrast to the 6296 private clinics providing primary care services (Marshall et al., 2023). Each ministry and local government has their own regulation mechanisms for their own hospitals. The MoPH enforces various regulations, including the Health Facility Act BE 2559 (AD 2016), the Healing Arts Practices Act BE 2556 (AD 2013), and other related regulations. The Department of Health Service Support, MoPH, holds legal responsibility for regulating the health service system. Private health medical institutions are licensed and relicensed annually under the Sanatorium Act 1998 (Medical Premises License Act) in line with the stipulated quality and standards. Historically, the Medical Premises Act applies only to the private sector; all public providers are exempt from licensing. The NHSO and the SSO have their own rules and regulations established through contractual agreements with health facilities (Marshall et al., 2023). The Healthcare Accreditation Institute (HAI), a public organization, is responsible for voluntary accreditation of both public and private health facilities and promotes the improvement of health-care quality. The Department of Internal Trade, Ministry of Commerce, enforces the Notification of Central Committee on the Price of Goods and Services No. 52 BE 2562 (AD 2019) under the Price of Goods and Services Act BE 2542 (AD 1999) to regulate the prices of medicines, medical supplies, and other health- care services (Sakamoto et al., 2023). Health professionals, including physicians, nurses, pharmacists, dentists, medical technologists, physical therapists, and Thai traditional medicine practitioners, are subject to various regulations that govern their practice and ensure ethical standards. There are the Medical Profession Act BE 2525 (AD 1982) for physicians, the Nursing and Midwifery Profession Act BE 2528 (AD 1985) and the revised second version in BE 2540 (AD 1997) for nurses, the Pharmaceutical Profession Act BE 2537 (AD 1994) and the revised second version in BE 2558 (AD 2015) for pharmacists, the Dental Profession Act BE 2537 (AD 1994) and the revised second version in BE 2559 (AD 2016) for dentists, the Medical Technology Profession Act, BE 2547 (AD 2004) 42 for medical therapists, the Physical Therapy Profession Act BE 2547 (AD 2004) for physical therapists, and the Thai Traditional Medical Professions Act, B.E. 2556 (AD 2013) for Thai traditional medicine practitioners and applied Thai traditional medicine practitioners. These regulations involve obtaining licenses and being monitored for professional conduct. In addition, individuals in professions like occupational therapy, speech–language pathology, cardiothoracic technology, radiological technology, clinical psychology, orthotics and traditional Chinese medicine, who do not have their own professional councils, are included under the Healing Art Practices Act BE 2556 (AD 2013). This Act sets guidelines for their qualifications and professional behaviour, applicable to both public and private practitioners. Before they graduate, aspiring professionals must pass national licensing exams administered by their respective professional councils to obtain their licenses. All professionals, except physicians, are required to renew their licenses every five years by completing the necessary credits for continued professional development. 2.8.3 Registration and planning of human resources Several agencies are involved in the planning and management of human resources for health (HRH): the MoPH, the main employer of the health-care workforce; the Ministry of Education, overseeing training institutions, the National Economic and Social Development Board for macroeconomic policy, the Civil Service Commission on public-sector employment and postgraduate training; the Bureau of Budget, overseeing the annual budget proposal; and the professional councils responsible for licensing and/or relicensing of professionals. However, all these organizations work in isolation, lacking coordination and synergies (Jindawatana et al., 1996). In 2006, the MoPH led the development of the National Strategic Plan for HRH 2007–2016 in consultation with partners. The Plan was discussed in the National Health Assembly, from where a resolution was submitted and endorsed by the Cabinet in April 2007. A National HRH Committee, comprising representatives of all HRH-related organizations, was established to facilitate the implementation of this National Strategic Plan. It also serves an advisory role to the Cabinet on HRH (Ministry of Public Health, 2009). The First National Medical Education Forum (NMEF) was convened in 1956. Since then, the Forum has been held every seven years to review progress and redirect medical education in line with country health and health system needs and the requirements for medical curriculum reforms. All training institutions, public and private, must be accredited by the Ministry of Education, while curricula are accredited by the concerned professional 43 councils before student recruitment. The number of training institutions in 2022 are summarized below (Leerapan et al., 2005): • Medical doctors: 25 medical schools – 21 public, 4 private (Medical Council of Thailand, 2021). • Dentists: 17 dental schools – 14 public, 3 private (Dental Council of Thailand, 2022). • Pharmacists: 18 pharmacy schools – 14 public, 4 private (Pharmacy Council of Thailand, 2022). • Nurses: 97 nursing schools – 71 public, 26 private (Thailand Nursing and Midwifery Council, 2022a, 2022b). The professional councils – Medical, Dental, Pharmacy and Nursing and Midwifery – are responsible for their particular national licencing examination. All students are required to obtain licences for professional practice to ensure similar qualifications and professional standards, regardless of their training institutions. 2.8.4 Regulation and governance of pharmaceuticals The Thai Food and Drug Administration (FDA) of the MoPH is a national regulatory agency of pharmaceutical products which, according to Thai laws, include modern and traditional medicines and biological preparations such as vaccines, toxoids and blood derivatives (Drug Act B.E. 2510 (1967)). Regulation of psychotropic substances and narcotics with therapeutic uses is also the responsibility of the FDA. To undertake pre- and post-marketing control of all categories of pharmaceuticals, the FDA works closely with the Department of Medical Sciences (DMSc) of the MoPH, which is the national laboratory agency. Furthermore, the FDA serves as a secretariat for the National Committees for Drugs, Psychotropic Substances, and Narcotics, the missions of which are to determine national policies and guidance in relation to regulation of these products. Entry to the market Market authorization is required for all pharmaceuticals, either locally manufactured or imported. Exemptions have been given to importation and production managed by public agencies, including MoPH departments, the Government Pharmaceutical Organization (GPO), the Defence Pharmaceutical Factory and the Thai Red Cross Society. Production of medicines in hospitals and freshly prepared products for individual patients are also exempt from regulation as stated in the Drug Act (Drug Act B.E. 2510 [1967]). However, the production of psychotropic substances and narcotics for any purpose has to follow the provisions in the respective laws. It should 44 be noted that despite the exception, the GPO – the MoPH-controlled state enterprise – voluntarily follows the market authorization requirements. Market approval of pharmaceutical products generally involves assessments of their safety, efficacy, effectiveness and quality (Teerawattananon et al., 2003). Importers or manufacturers of particular products are required to submit an application for registration, together with the content of container labels and package leaflets, drug formula (active and non-active ingredients and their amounts), and dossiers showing that the products meet legal requirements. For new drug products, i.e. products containing new chemical entities, new combinations or those with new routes of administration, submission of evidence from preclinical and clinical studies are mandatory. Modern medicines are classified into three categories, over-the-counter (OTC) drugs, dangerous drugs, and specially controlled drugs. OTC products can be distributed through any of the premises, without requiring the qualifications of the seller (Teerawattananon et al., 2003). Dangerous and specially controlled medicines are available only in pharmacies, clinics and hospitals, and may be dispensed only by pharmacists or medical doctors. Dispensing of specially controlled drugs requires a physician’s prescription. The sale and dispensing of traditional medicines are allowed by traditional drug stores under the supervision of licensed traditional doctors or pharmacists. Advertisement of pharmaceutical products of all categories is regulated by the FDA (Teerawattananon et al., 2003). Advertising medicines requires FDA approval of the materials, sounds and related scripts. Only OTC and traditional drugs can be advertised to the general public. Quality of medicines Registration of all locally produced or imported medicines requires information on their specifications, including quality standards, and submission to the FDA of the protocol for quality assurance and testing. Bioequivalence data are required in case of generic drugs whose original products have obtained approval in the country since 1991. Product samples submitted with registration files are sent to the DMSc laboratory for testing of their quality and analysis. The quality of pharmaceutical products manufactured in Thailand is ensured through the enforcement of Good Manufacturing Practice (GMP); this is a legal requirement for manufacturing premises, including the infrastructure, personnel, manufacturing and quality-assurance processes. FDA officials inspect for compliance with GMP standards among local drug producers. Regarding manufacturers in foreign countries, the Thai authority requests GMP certificates issued by national regulatory agencies in the country 45 of origin. At the post-marketing phase, FDA inspectors and pharmacists in PHOs, in collaboration with DMSc scientists, monitor the quality of pharmaceutical products on the market through testing of samples from the shelves. Container labels, leaflets, expiration dates, registration status and storage conditions are also inspected during official visits to drug stores. Pharmacovigilance as recommended by the World Health Organization (WHO) is overseen by the FDA as an integral part of post-marketing control of medicines. Major sources of information on adverse drug reactions (ADRs) are mandatory reports by all health-care professionals in hospitals, clinics and pharmacies. At the same time, global evidence generated by the Uppsala Monitoring Centre contributes significantly to effective risk management measures such as product withdrawal and revision of warnings/precautions illustrated on product leaflets. The FDA works closely with the MoPH Bureau of Epidemiology to conduct case investigation of all reportedly severe ADRs and determine their causal relationship with specific products, and provide the evidence and recommendations to the appropriate subcommittee and the Drug Committee for appropriate action (Health Product Vigilance Center, 2021). For new drugs, the manufacturers and importers are responsible for safety monitoring and reporting for at least two years after market approval (Jirawattanapisal et al., 2009). The monitoring period is extended in cases where questions arise. Pricing and market access Price regulation of pharmaceutical products is not well established in Thailand (Jirawattanapisal et al., 2009). As a laissez-faire market, there was no mechanism in place to control retail and wholesale prices and margins; however, price negotiations are conducted daily at different levels, such as the Subcommittee for the Development of the National List of Essential Medicines (NLEM), the NHSO responsible for UCS as a strategic purchaser, and Pharmacy and Therapeutics Committee in individual hospitals. The reference pricing scheme for drugs on the NLEM is promulgated by the appropriate subcommittee under the Committee for National Drug System Development. However, reference prices recommended by this scheme are effective only for drugs purchased by government hospitals and health programmes. The NLEM is referred to as the pharmaceutical benefit package by all three health insurance schemes (CSMBS, UCS and SHI). The formulation of this List is undertaken by a subcommittee under the Committee for National Drug System Development. The drugs to be listed must have market approval by FDA. The subcommittee reviews the safety, effectiveness and some elements concerning the quality of the products, in comparison with drugs 46 of the same category. Prices, health needs and burden of disease are also taken into account. Cost–effectiveness and budget impacts are analysed for expensive drugs. In practice, beneficiaries of the CSMBS are privileged, as drugs outside the List – nonessential medicines (NEMs) – can be fully reimbursed if their physicians consider them necessary. Patients covered by UCS and SHI are unlikely to obtain expensive NEMs, owing to incentives for cost containment. It is evident that medicines prescribed to members of CSMBS differ from, and are more expensive than, those acquired by beneficiaries covered by UCS and SHI. At the national level, there is no regulation regarding generic substitution. Although guidelines on this practice exist in public and private hospitals, significant variation occurs across settings. It has been argued that capitation payment applied by SHI and UCS and its consequence on budget constraints encourage the use of generic drugs, especially in hospitals; generic substitution is de facto applied extensively for beneficiaries covered by SHI and UCS (Tarn et al., 2008). In most settings, generic substitution is not allowed for particular drugs, such as life-saving ones and drugs with a narrow therapeutic index. Increased problems have been noted with direct sale, mail-order and Internet pharmacies. Although selling medicines through these channels is prohibited by law, there is no effective solution to contain such practices. As a member of the World Trade Organization (WTO), Thailand has adopted a patent policy as suggested in the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPs). The Patent Act provides 20-year protection for both product and process innovations, including pharmaceuticals. Although TRIPs flexibilities such as government-use licences are legalized according to Thai law, policy-makers are reluctant to introduce these measures to improve access to essential medicines, as the country has experienced strong protests from patent holders, associations of transnational pharmaceutical companies, including threatening trade sanctions by governments of industrialized countries (Wibulpolprasert et al., 2011a). To improve access to these patent products in public health emergencies, the government had successfully introduced TRIPS flexibilities on government use for a few antiretroviral medicines. Intellectual property protection beyond TRIPs, which will result in extension of the period of market exclusivity and delayed market entry of generic products, has been sought by some countries through bilateral trade negotiations. Extension of 47 market exclusivity beyond those agreed in the TRIPs has negative impacts on access to essential medicines (Akaleephan et al., 2009). Rational use of medicines (RUM) has long been a point of concern at country level, as efforts to combat irrational use first appeared in the National Drug Policy of 1981. Since then, several measures have been developed and introduced with the aim of changing professional practice and consumer behaviour. Such efforts involve the introduction of regulatory, management, education and information measures. Despite this, inappropriate use of pharmaceutical products is prevalent in communities and health-care facilities. Only a few measures, especially those connected to health-care provider payments, have proved effective (Tantivess et al., 2009). Pilots such as Antibiotic Smart Use have been successful but still need to be scaled up nationwide (Sumpradit et al., 2012). Drug-use evaluation (DUE) and preprescription authorization are recommended and enforced in hospitals as conditions for prescribing a number of very expensive medicines on the NLEM. The measures are successful in preventing irrational use of these drugs among UCS beneficiaries. Sponsoring medical professionals for domestic and international medical conferences and other unethical market promotion activities by the pharmaceutical industry has been regularly reported (Layton et al., 2005). These unethical practices and involvement by some practitioners – violating trust in and integrity of health-care professionals – led to the National Health Assembly adopting a resolution in 2009 to terminate the unethical practices of drug market promotion, and subsequent establishment of ethical criteria for drug promotion in Thailand (National Drug System Development Committee, 2016) with reference to the WHO ethical criteria (World Health Organization, 1998). The Code of Conduct applies to all concerned parties such as prescribers, dispensers, the pharmaceutical industry, who are all obliged to observe and implement the Code. The National Health Assembly is responsible for monitoring the progress of implementation of the Code, especially on its effectiveness and responses from all stakeholders. 2.8.5 Regulation of medical devices The Medical Device Control Division of the FDA is responsible for regulating, controlling and monitoring the use of medical devices in Thailand (Teerawattananon et al., 2003). By law, a device is licensed in the market if it achieves the performance intended by the manufacturer and meets standards for personal safety. Unlike pharmaceutical products, there is no requirement for clinical efficacy evaluation from randomized controlled trials before market approval. The Medical Device Control Division also 48 controls post marketing, such as inspection of the manufacturing factory and implementation of appropriate measures when unsafe medical devices are reported. The Medical Device Act B.E.2551 (2008) was updated from the Medical Device Act B.E.2531 (1988)(Royal Thai Government Gazette, 2008a). In 2019, Thailand amended the Medical Device Act B.E. 2562 to comply with the ASEAN Medical Device Directive (AMDD) (Food and Drug Administration, 2022; Royal Thai Government Gazette, 2019d). This update aims to address the rapidly evolving landscape of medical technology and innovations in the country. The revised Act categorizes medical devices based on their risk levels, offering more comprehensive guidance for medical device assessments, civil liabilities, and adjustments to penalties and fees. The new regulatory framework includes three tiers of control for risk-based classification of medical devices: licensed medical devices, notified medical devices, and listing medical devices, in descending order of risk. Medical devices are divided into two categories: in vitro diagnostic medical devices (IVD) and non-in vitro diagnostic medical devices (non-IVD). They are further classified into risk classes: Class 1 (low risk), Class 2 (low-to-moderate risk), Class 3 (moderate-to-high risk), and Class 4 (high risk) (Wong et al., 2022). The coverage of use of medical devices was harmonized across the three public health insurance schemes. The CSMBS scheme covers almost all medical devices using a fixed-rate fee-for-service payment. The UCS schemes operate the systematic HTA for new procedures, medicines and devices and avoid under provision of services by unbundling certain high- cost services from the capitation and DRG systems and replacing them with fee-for-service according to an established schedule (Patcharanarumol et al., 2018). The SHI scheme keeps updating the coverage of medical devices and payment (Central office for Healthcare Information, 2023). 2.8.6 Regulation of capital investment During the early phase of health-care infrastructure development in Thailand, the National Economic and Social Development Board and the MoPH played a pivotal role in planning for capital investment through the use of the 5-year National Economic and Social Development Plan. As a result, Thailand rapidly built up good geographical coverage of rural health-care infrastructure within the 25 years from the first Plan (1961–1966) to the fifth Plan (1982–1986) (Wibulpolprasert, 2002). A capital investment plan was developed later based on the demand of public hospital managers, or local resources mobilized by reputable monks, with reference to criteria such as standards of hospitals at different levels. During the past two decades, 49 the government has established specific policies to improve health-care infrastructure and these have led to a substantial increase in the capital investment budget. These policies included: • Decade of Health-centre Development (1992–2001); • Health-care Infrastructure Investment Plan under the economic stimulus policy (2010–2013) (National Economic and Social Development Office, 2009). Before the implementation of the UCS in 2002, the highest proportion of the capital investment budget to the total health budget was 34.0% in 1997 and the average proportion of the capital investment budget to the total health budget during 1994–2001 was 21.16% (NaRanong et al., 2005). The UCS totally changed planning and capital budget allocation. Budget for the UCS was calculated on a per-capita basis (capitation rate). Part of the capitation budget covers capital replacement or depreciation cost, calculated as 10% of the budget for ambulatory and inpatient care (Prakongsai et al., 2002) and this was intentionally misinterpreted by the Bureau of Budget as a capital investment budget and bar for new capital investment in MoPH hospitals for some years. The NHSO managed this capital-replacement budget by transferring part of it directly to their contracted health-care providers and keeping some to manage at the central level to strengthen health-care infrastructure at the PHC level and some excellent centres such as trauma, cardiac and cancer centres in consultation with the MoPH. This capital replacement budget was reduced from 10% of the curative budget to 6% in 2012 (Health Insurance Information Service Centre, 2012). The MoPH complained that the new system that operated after the establishment of the UCS substantially decreased its total capital investment budget. The Bureau of Budget then allowed the MoPH to request a capital investment budget directly from the government. Private-sector investment in infrastructure is usually focused in urban provincial areas where people have high purchasing power. The government has a policy to support private investment in poorer areas where there are inadequate health-care facilities through corporate income tax incentives for eight years and import duty exemption for major medical devices (Thailand Board of Investment, 2021). 50 2.9 Patient empowerment 2.9.1 Patient information Thai people can obtain health information through various media. In 2005, the most popular media for rural people were television (29.7%), newspapers (17.7%), radio (16.3%), personal contacts (8.8%), magazines (8.2%), village broadcasting service (7.7%), leaflets (6.1%) and posters (2.8%). When people are sick, they seek advice from health personnel (90.6%) and friends/ relatives (28.5%). People’s opinions on the accuracy of health information varies according to its source, with health personnel as the most trusted (85.3%) followed by television/radio (10.7%), journals (3.5%) and village broadcasting service (0.5%) (Uphayokin et al., 2005). At that time, the majority of Thai people could not access health information and were not aware of their rights, and health-care providers provided limited information to their patients since they were afraid of being sued by the patients using that information (Wongchai et al., 2008). The situation totally changed after 14 years due to health literacy improvement, development of communication technology, and behaviour change. In 2019, approximately 19% of the Thai population had inadequate health literacy. Most individuals with insufficient health literacy were found in specific demographic groups. Among individuals aged 60 years and older, 39.8% had inadequate health literacy, followed by individuals aged 45–59 years at 21.74%. Other factors contributing to insufficient health literacy included not completing formal education, which accounted for 64.68% of all education profiles. Additionally, having a low income represented 36.0% of all income profiles. Individuals who lacked community involvement made up 20.68% compared to those who had a community role. Furthermore, not receiving health information affected 28.86% of the population, while obtaining health information primarily through television or community announcements accounted for 17.81% and relying on family members or friends for health information accounted for 17.34% (Roma et al., 2019). The literacy rate of Thai youth and adults in 2021 was 99% and 94%, respectively (World Bank, 2021d, 2021e). As a result of the COVID-19 pandemic, there has been a notable increase in the percentage of individuals using the Internet. From 2020 to 2022, the overall Internet usage rate rose from 77.8% to 85.0%. Among different regions, Bangkok exhibited the highest level of Internet utilization, with rates increasing from 91.4% in 2020 to 94.5% in 2022. Regarding mobile phone usage, there was a slight decrease in the percentage of individuals using mobile phones. From 2020 to 2022, the mobile phone usage rate declined from 94.8% to 94.6% (National Statistical Office, 2022c). 51 2.9.2 Patient choice Patients can go to any health-care facility if they pay the cost of health services from their own pocket. The PHC gatekeeping system started in the low-income Medical Welfare Scheme (MWS) in 1975 and was extended to the Health Card Scheme (HCS) in 1984 (Health Systems Research Institute, 2002) and the UCS in 2002. The SHI requires its insured persons to register with hospitals with more than 100 beds as their main contractor. SHI members have to use the contractors they are registered with as first-contact health- care providers, except in case of accidents and emergency. However, they can choose any health facility for high-cost care when the DRG is more than two. This exception is also applied to beneficiaries of the UCS. Members of the CSMBS can use health services in any public health-care facility and in private health-care facilities under certain conditions. The government adopted a policy “Universal Coverage for Emergency Patients” or UCEP to allow every Thai citizen to access emergency medical services at any health- care facility, both public and private hospitals, from 1 April 2017 (National Health Security Office, 2020g). In 2023, a new initiative “Cancer Anyway” was implemented to allow UCS patients to choose any health facility registered with the NHSO for cancer treatment (National Health Security Office, 2023b). 2.9.3 Patient rights Patient rights have been guaranteed by several mechanisms. Access to essential health services has been considered as a basic right since the promulgation of the Thai Constitution in 1997. Professional organizations, including the Medical Council, the Nursing and Midwifery Council, the Pharmacy Council and the Dental Council have adopted the Declaration of Patient’s Rights since 1998 and requested all health-care providers to ensure that patient rights are fully observed in their clinical and professional practices (Faculty of Medicine Ramathibodi Hospital, 2015). The National Health Act 2007 provided a legal framework to guarantee patient rights in many sections of Chapter 1. In summary, patient rights include: • the right to use essential health services without discrimination by social status, race, nationality, religion or other factors; • the right to get adequate information before obtaining health services and the right to consent to or refuse treatment except in the case of emergency life-threatening situations; • the right to get urgent attention and immediate relief in case of critical conditions or near death regardless of whether the patient requests assistance; • the right to know the full name and speciality of the health-care provider who provides health services to them; 52 • the right to request a second opinion and opt for another health-care provider; • personal health information shall be kept confidential – the only exceptions being with the consent of the patient or due to legal obligation; • the right to demand complete information regarding their role as subjects in research and the associated risks, in order to make an informed decision to participate in, or withdraw from, research carried out by a health-care provider; • the right to know and demand full and current information about their medical treatment as in the medical record; • the father/mother or legal representative may use their rights on behalf of a child under the age of 18 years or who is physically or mentally handicapped, whereby they cannot exercise their rights; • the right to live in a healthy environment; • the right to appropriate promotion and protection of the health of women, children, disabled persons and older people; • the right to request for an assessment and participate in the assessment of health impact resulting from a public policy; and • the right to make a living will in writing to refuse a health service that is provided merely to prolong life at a terminal stage or to stop severe suffering from illness. 2.9.4 Complaints procedures (mediation, claims) If patients are harmed, injured or suffer adverse outcomes from iatrogenic medical services, they or their relatives can complain to the Medical Council and request an investigation. The Medical Council can initiate the investigation process by itself without any request from the victim or publicity in the media. This mechanism aims to protect patients by ensuring medical and ethical standards of physicians. Among the three public health insurance schemes, the UCS has a clear legal framework, well-established complaint-handling mechanisms and enforcement by the NHSO. UCS beneficiaries can complain through various means such as a call centre with a 24-hour hotline number, email, letter, facsimile or contact the office directly. From 2010 to 2022, the number of complaints remained relatively stable, with 4186 complaints in 2010 and 4210 complaints in 2022. However, there were notable changes in the issues raised in these complaints. The main issue reported in both 2010 and 2022 was related to health-care facilities not providing treatment in accordance with individuals’ rights, accounting for 41.6% in 2010 and increasing to 44.87% in 2022. There was a significant increase in complaints related to 53 inconvenience experienced while using health-care services, which rose from 21.72% in 2010 to 36.01% in 2022. Conversely, issues regarding health- care units charging fees without authority decreased from 21.33% in 2010 to 15.80% in 2022. Another noteworthy change observed was the issue of health-care units failing to meet the prescribed service standards. This issue decreased substantially from 41.61% in 2010 to 3.33% in 2022 the law, all complaints must be investigated and settled. In 2010, 95.36% of the complaints were successfully addressed within a 30-day time frame. However, the performance in terms of timely resolution decreased in 2022, with only 76.03% of the complaints being resolved within 25 days. Some of these complaints needed to be investigated by the Health Service and Quality Standards Committee, a national committee established by the National Health Security Act 2002, and health-care providers may be penalized if they violate the law. However, the Social Security Office (SSO) sets up a complaint-handling system for SHI members under the Social Security Act with a specific committee. If the committee decides that the provider is at fault, it will also recommend the penalty, range from warning, probation, reducing the ceiling number of insured patients, to termination of contact (NaRanong et al., 2004). SHI members can seek information and complain through a call centre hotline or direct phone number, letter, email, website, webchat, facsimile or contact the office directly (Social Security Office, 2021a). While civil servants and their dependents have a generous benefit package, there is no effective system for handling complaints (Hawkins et al., 2009). 2.9.5 Public participation Public participation is an essential component of the UCS through various channels, such as engaging in the development of legislation and policies for UHC. This highlights the importance of leadership, transparency, accountability, and the establishment of a supportive legal framework (Patcharanarumol et al., 2022). There are representatives of civil society groups on both the national health security committees, on subcommittees and on regional health security committees to oversee UCS implementation. An interconnection between representatives of civil society organizations (CSOs) in these committees and various subcommittees, as well as the broader CSO networks at the grassroots level, enables the seamless transmission of problems and concerns from the local level to policy decisions. This collaborative approach ensures the effectiveness of the UCS (Kiewnin et al., 2020). In addition, there is a specific national subcommittee and a bureau within the NHSO to support public participation. One example of this is the use of public hearings, which have been successful in meeting 54 the criteria for influencing policy decisions and partially meeting the criteria for appropriate participation approaches and social learning (Kantamaturapoj et al., 2020b). Initiatives that support public participation include the establishment of health insurance-coordinating centres in 104 communities, establishment of six patient groups and their support networks, and establishment of local health security funds with matching funds from the local government budget. The participation of local government organizations in the fund significantly increased from 5508 organizations (70.8% of all local government organizations) in 2010 to 7774 organizations (99.45%) in 2022 (National Health Security Office, 2010, 2022e). There is less participation in the governance bodies of SHI and CSMBS. The Social Security Committee has a tripartite governance, consisting of 15 members, namely, five government representatives from the Ministry of Labour, Ministry of Finance, MoPH, Budget Bureau and the secretary general of the SSO; five employee representatives (all trade union representatives); and five employer representatives. The CSMBS was administered by the Comptroller-General Department (CGD) of the Ministry of Finance. As CGD is a department answerable directly to the Director-General, there is no need for a governing body; however, it has an advisory board representing government and a few CSMBS members, but neither civil society nor health- care providers are represented. In Thailand, patient groups, lay people and CSOs can be involved in the decision-making process of the NHSO, especially in its National Health Security Board and when health technology is being evaluated under the UCS. These include representatives from diverse bodies in HTA agencies who will engage in such processes, or participate in advisory panels (Slutsky et al., 2016). To ensure the right to health, Thailand’s Constitution allows Thai citizens to submit a draft bill following the legislative texts and adoption into law. The legislation mandates registration of beneficiaries, a 24/7 helpline, annual public hearings and no-fault financial assistance for patients who have experienced adverse events (Kantamaturapoj et al., 2020a). The NHSO also conducts a satisfaction survey of health-care providers and beneficiaries annually by outsourcing an independent polling agency affiliated with Assumption University. From 2003 to 2022, satisfaction of beneficiaries with the results of their treatment was very high and stable at 8.77 out of 10 in 2010 to 9.19 in 2022. Satisfaction of health-care providers with the system was lower at 7.64 out of 10 in 2010 to 7.85 in 2022 (National Health Security Office, 2010, 2022e). 55 3 Financing Chapter summary Universal health coverage (UHC) in Thailand was introduced in 2002 with the emergence of the Universal Coverage Scheme (UCS), the largest public health insurance scheme. The country has made great strides in providing coverage to the whole Thai population. By 2002, the entire population was covered by the three public health insurance schemes – civil servants and their dependents by the Civil Servant Medical Benefit Scheme (CSMBS), private-sector employees by the Social Health Insurance Scheme (SHI), and the rest of the population by the UCS. This achievement resulted in substantial changes in the health financing profile. Prior to the UHC era, private spending was greater than public spending, with more than half of national health spending financed privately. However, after UHC implementation, public expenditure on health became the dominant financing source, accounting for 72.2% of current health expenditure (CHE) in 2019. Also, domestic general government health expenditure (GGHE-D) as a proportion of general government expenditure (GGE) rose from 12.0% in 1995 to 15.5% in 2019. Out-of-pocket (OOP) expenditure decreased from 44.9% of CHE in 1995 to 8.5% in 2019. General tax was the major source of funding to support public health spending, while OOP payment and private insurance premiums were the main sources for private spending. External funds have a tiny role in Thailand’s health spending, comprising less than 0.5% of CHE during the entire period of 1995–2019. Curative expenditure, including rehabilitative care and long-term care, had the largest share of current health spending (about 70–80% of the total), of which 35% was for inpatient services and 37% for outpatient services in 2019. The NHSO, the manager of the UCS, manages funding for health promotion and disease prevention for the population (i.e. not only for UCS members). However, expenditure on prevention and public health services remained at around 7–8% of CHE during the five years prior to 2019. As a consequence, the Governing Board of the NHSO demanded that by 2022, the overall UCS budget on preventive and public health services be increased to 12% of the budget. 56 In addition, Thailand legislated an earmarked sin tax for funding health promotion programmes, using 2% additional surcharge on tobacco and alcohol excise tax for campaigning on key health risks such as tobacco and alcohol. The three main public health insurance schemes are managed by the different institutes that purchase health services for their respective members. Hence, the split in purchaser–provider roles was fully implemented; supply-side financing was fully replaced by demand-side financing. Besides this, Thailand applied a mix of provider payment methods. Although close-ended payment is dominant, capitation for outpatient payment is used by SHI and UCS, while fee-for-service is used by CSMBS outpatient payment. DRG inpatient payment has been widely applied by the three schemes with some variations. Fee-for-service reimbursement is generally applied by private voluntary health insurance. 3.1 Health expenditure During 1995–2019, the share of CHE as a proportion of GDP had not changed significantly: CHE as %GPD was 3.0–3.9%, while CHE per capita increased from US$ 85.4 in 1995 to US$ 301.6 in 2019. The share of government health spending from general government expenditure gradually climbed from 12.0% in 1995 to 15.5% in 2019, the last available year (see Table 3.1). Table 3.1 Current health expenditure and selected indicators on health spending, 1995–2019, current year prices Indicators 1995 2000 2005 2010 2015 2019 Current health expenditure (CHE), million Baht 126 557.8 157 228.0 240 594.2 366 406.9 529 438.2 651 915.5 Current health expenditure (CHE), million current US$ 5 079.5 3 919.7 5 981.9 11 563.8 15 459.1 20 997.3 Current health expenditure (CHE) per capita (Baht) 2 128.2 2 497.6 3 677.9 5 452.9 7 704.9 9 363.2 Current health expenditure (CHE) per capita (US$) 85.4 62.3 91.4 172.1 225.0 301.6 Current health expenditure (CHE) as % gross domestic product (GDP) 3.0% 3.1% 3.2% 3.4% 3.9% 3.9% 57 Indicators 1995 2000 2005 2010 2015 2019 Domestic general government health expenditure (GGHE-D) as % gross domestic product (GDP) 1.3% 1.7% 2.0% 2.5% 2.7% 2.8% Domestic general government health expenditure (GGHE-D) as % general government expenditure (GGE) 12.0% 12.7% 13.1% 14.4% 14.7% 15.5% Domestic general government health expenditure (GGHE-D) as % of CHE 43.1% 55.2% 63.7% 73.8% 71.4% 72.2% Domestic private health expenditure (PVT-D) as % of CHE 56.9% 44.8% 36.2% 26.1% 28.4% 27.7% Out-of-pocket (OOP) spending as % of CHE 44.9% 34.2% 27.6% 14.5% 11.9% 8.5% Voluntary prepayments as % of CHE 2.5% 3.2% 3.4% 5.9% 10.6% 13.6% External health expenditure (EXT) as % of CHE 0.0% 0.0% 0.1% 0.1% 0.3% 0.1% Exchange rate (Baht per US$) 24.9 40.1 40.2 31.7 34.2 31.0 Source: (National Health Accounts Working Group, 2021) The proportion between domestic government and private financing sources had significantly changed due to the Asian financial crisis in 1997 and the introduction of the UCS in 2002. The share of government spending increased considerably from 43.1% in 1995 to 72.2% in 2019; meanwhile, private health spending reduced significantly from 56.9% in 1995 to 27.7% in 2019. With this situation, OOP payments sharply declined from 44.9% in 1995 to 8.5% in 2019 of CHE. Even after the introduction of UCS in 2002, we see a continuous gradual decrease in OOP from 27.6% of CHE in 2005 to 8.5% in 2019. The Thai health system relies mainly on domestic funds; spending from donor or development partner sources is negligible (less than 0.5% of CHE). The data from ASEAN countries sheds light on the relationship between government health spending and OOP spending. The GGHE-D and OOP Table 3.1 Current health expenditure and selected indicators on health spending, 1995–2019, current year prices (contd) 58 spending as a proportion of CHE were reversed. In 2019, countries with a high share of GGHE-D such as Brunei Darussalam and Thailand experienced a low proportion of OOP spending, while countries with low government health spending such as Myanmar and Cambodia faced a higher share of OOP spending, see Fig. 3.1. Fig. 3.1 Government health spending and out-of-pocket payment as a proportion of current health expenditure among ASEAN countries, 2019 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Br un ei D ar us sa la m Ca m bo di a In do ne si a La o PD R M al ay si a M ya nm ar Ph ili pp in es Si ng ap or e Th ai la nd Vi et N am % o f C H E GGHE-D as % of CHE OOP as % of CHE Source: (World Health Organization, 2022b) Table 3.2 shows a consistent pattern of expenditure across the past 25 years, with curative services accounting for 70–80% of CHE, of which inpatient services accounted for 30–35% and outpatient services for approximately 35–50%, depending on the year. Note that these costs included any medicines prescribed by the services. Ancillary services made up less than 1% of CHE because most expenditures on ancillary services were already included in outpatient care. Medical goods that were mainly paid for by households for self-prescription in private pharmacies reduced significantly from 7.4% of CHE in 1995 to 4.5% in 2005 after implementation of UCS in 2002. In contrast, spending on health administration rose dramatically in the past five years because of the change in data collection with more inclusive scope to 59 cover all items of operational cost of private and traffic health insurances (Viriyathorn, 2021). Preventive care accounted for 5–9% of CHE during 1995–2019. The NHSO is entrusted by the government to manage prevention and health promotion programmes for the whole population, not only UCS members. The budget for prevention and health promotion was set at 10% of total personal health care at the inception of the UCS in 2001–2002; but the budget for the curative component gradually increased, leading to a decrease in the proportion of the budget used for prevention and health promotion. The decreased share of prevention and health promotion led the NHSO Board to set a clear direction to boost health promotion and public health services for the entire population. By 2022, budget allocation for prevention and health promotion managed by the NHSO had increased to 12% of the capitation budget formula (National Health Security Office, 2021b). Table 3.2 Health-care spending profile, percentage of current health expenditure, 1995 to 2019   1995 2000 2005 2010 2015 2019 Inpatient care (%)a 30.3 32.7 35.4 32.5 30.8 34.9 Outpatient care (%)a 48.7 43.3 45.3 45.1 38.2 36.6 Ancillary services (%) 0.0 0.2 0.4 0.2 0.5 0.3 Medical goods (%)b 7.4 6.7 4.5 5.6 6.0 4.9 Preventive care (%) 8.7 8.8 5.1 8.9 7.3 7.8 Health administration (%) 4.8 8.4 9.3 7.8 17.2 15.6 Other health-care services not elsewhere classified (n.e.c.) (%) 0.0 0.0 0.0 0.0 0.0 0.0 Total (%) 100.0 100.0 100.0 100.0 100.0 100.0 Note: a: Inpatient and outpatient services included long-term care and rehabilitation services; b: Expenditure on medicines and medical devices paid by households and mainly self-prescribed Source: (National Health Accounts Working Group, 2021) 3.2 Sources of revenue and financial flows 3.2.1 Sources of funds The Thai health system is mostly centralized. The system has been financed by a mixture of financing sources, namely general taxes, social insurance contributions, private insurance premiums and direct OOP payments. The trend in health spending reflects the effects of the economic crisis in 1997 that resulted in the decrease of household spending and increase in government expenditure on health. The major changes in health 60 spending were also the consequences of health policies during that time. The implementation of UCS in 2002 significantly increased the share of general government spending in CHE, while household OOP payments were notably reduced. The abolishment of copayment of THB 30 of the UCS and the approval of the direct payment measure for the Civil Servant Medical Benefit Scheme (CSMBS) outpatients in 2006 resulted in a decrease in OOP and increase in outpatient expenditure by the government (National Health Accounts Working Group, 2013). Spending on private health insurance became an important source of private expenditure in the past five years (Table 3.3). Table 3.3 Health-care spending by source of fund, percentage of current health expenditure, 1995 to 2019   1995 2000 2005 2010 2015 2019 General government (%) 39.2 49.6 55.5 65.7 62.9 63.2 Social Health Insurance (%) 3.8 5.6 8.2 8.1 8.4 9.0 Private voluntary health insurance (%) 2.5 3.2 3.4 5.9 10.6 13.6 Traffic insurance (%)* 2.8 2.8 2.4 2.5 3.0 3.0 Out-of-pocket spending (%) 44.9 34.2 27.6 14.5 11.9 8.5 Employer benefit (%) 6.2 4.2 2.4 2.2 2.2 1.9 Non-profit-making institutes (%) 0.6 0.4 0.4 1.0 0.7 0.7 Rest of the world (%) 0.0 0.0 0.1 0.1 0.3 0.1 CHE, million THB 126 557.8 157 228.0 240 594.2 366 406.9 529 438.2 651 915.5 Note: * Traffic insurance is compulsory insurance required by law for every vehicle registered with the Department of Land Transport. The insurance will cover curative care, compensation for the damage to life and body, loss of ability, disability, death, and income loss of everyone affected by car accidents. Source: (National Health Accounts Working Group, 2021) Fig. 3.2 conceptualizes the relationships among three stakeholders: (a) the population that is responsible for paying personal income tax or corporate tax (in case of employers), or indirect tax through consumption of goods and services such as 7% value-added tax, or contribution to the SHI fund if they are private-sector employees or employers (these beneficiaries may fall ill and become patients); (b) the three main public purchaser organizations that manage the three schemes; and (c) the public and private health-care providers throughout the country. After achieving population coverage in 2002, there have been three public insurance schemes for the entire population, including CSMBS for government employees and their dependents, SHI for private formal employees, and UCS for those who are not covered by CSMBS or SHI. 61 In addition to these three main public fund managers for the population, voluntary private insurance also provides insurance coverage on a competitive basis mostly to the high-income earners. People who are members of public health insurance schemes can buy private supplementary health insurance on a voluntary basis. Note that in Fig. 3.2 voluntary insurance schemes usually reimburse patients after they have paid upfront and do not directly deal with health-care providers. Fig. 3.2 Health financing and service provision in Thailand after achieving universal coverage in 2019 General tax General tax Ministry of finance CSMBS (5.0 million beneficiaries) National Health Security Office UCS (47.5 million) Social Security Office SHI (12.1 million formal employees) Voluntary private insurance Fee-for-service Fee-for-service for OP, DRGs for IP services Public & Private Contractor networks Private facilities Capitation (OP)&DRGs (OP+IP) Capitation (OP) & global budget with DRGs (IP) Standard benefit package Risk-related contributions Tripartite contributions Population Patients Payroll taxes CSMBS: Civil Servant Medical Benefit Scheme; DRGs: diagnosis-related groups; IP: inpatient; OP: outpatient; SHI: Social Health Insurance Scheme; UCS: Universal Coverage Scheme. Sources: (1) Number of health insurance members in 2019 from the National Health Security Office (2022f); (2) Synthesis by the author 3.2.2 Domestic general government health expenditure (GGHE) Between 1995 and 2019, domestic general government health expenditure (GGHE-D) – comprising health spending from: (1) the Central Government that covered the MoPH, other ministries, CSMBS and other small public government schemes and UCS, (2) local government, and (3) the Social Security Scheme (including Workmen’s Compensation Fund [WCF]) – experienced an important shift due to the emergence of the UCS in 2002. 62 Central Government expenditure contributed to the major share of GGHE-D, accounting for 77–88% of GGHE-D. The proportion of local government spending increased from 2.9% in 1995 to 10.6% in 2019, while the SHI had not changed much during the period observed. There was some fluctuation in GGHE-D within the range of 9–16% of general government expenditure (GGE). A large increase in GGHE-D was found in 2003 as Thailand implemented the UCS, and thereafter the GGHE-D as a % of GGE remained at approximately 13–16% (Fig. 3.3). Fig. 3.3 Key national health account parameters on GGHE-D, 1995–2019 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0 50 000 100 000 150 000 200 000 250 000 300 000 350 000 400 000 450 000 500 000 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17 20 18 20 19 M ill io n Ba ht Central government as % of GGHE-D Local government as % of GGHE-D Social security schemes as % of GGHE-D GGHE-D as % of GGE GGGHE-D, million Baht GGHE-D: domestic general government health expenditure Source: (National Health Accounts Working Group, 2021) 3.3 Overview of the statutory financing system 3.3.1 Coverage Population coverage Since 2002, Thailand has had three main public health insurance schemes covering the whole population. The CSMBS is a fringe benefit for government employees and their dependents to compensate for the relatively lower salary (compared to market rates) in the public sector. This is a tax-financed noncontributory scheme. Government employees, pensioners, and their dependents (parents, spouses, no more than three children less than 20 years old) are provided with a wide range of medical services. 63 The SHI protects 12 million private-sector employees (National Health Security Office, 2022f) in firms having more than one employee, for non- work-related conditions, while the Workmen’s Compensation Fund covers work-related injuries, illnesses or deaths. The SHI covers the individual worker, not their dependents, except maternity benefit, which covers the spouse of a male beneficiary. It is a mandatory tripartite payroll-tax financed scheme equally contributed to by employers, employees and the government for non-work-related illnesses and injuries, maternity and cash allowances for disability, old age pension and death compensation. The scheme started with coverage of employees in enterprises with more than 20 workers when it was launched in 1991. It was then gradually extended to cover enterprises with more than 10 employees, then more than five, and finally more than one worker in April 2003. The UCS covers the proportion of the population who are neither covered by CSMBS nor SHI. In addition to the three public health insurance schemes, private health insurance covers individuals who voluntarily purchase additional benefits from private health insurance. Table 3.4 presents the key characteristics of these schemes. Table 3.4 Characteristics of public and private health insurance schemes Insurance scheme Civil Servant Medical Benefit Scheme (CSMBS) Social Health Insurance Scheme (SHI) Universal Coverage Scheme (UCS) Private health insurance Population coverage Government employees plus dependents (parents, spouse and up to three children aged <20 years) Private-sector employees, excluding dependents The rest of the population not covered by SHI and CSMBS Additional health insurance scheme for those who can afford premiums 7% 18% 71% NA Financing source General tax Tripartite contributions, equally shared by employer, employee, and the government General tax Health insurance premiums paid by individuals or households Mode of provider payment OP: fee-for-service; IP: diagnosis- related groups (DRGs) without a global budget OP: capitation; IP: capitation & DRGs if relative weight 2+ within a global budget; some fee- schedule items Outpatient (OP): capitation; Inpatient (IP): DRGs within a global budget; some fee- schedule items Retrospective reimbursement 64 Insurance scheme Civil Servant Medical Benefit Scheme (CSMBS) Social Health Insurance Scheme (SHI) Universal Coverage Scheme (UCS) Private health insurance Copayment at the point of service Balanced billing is allowed for all items exceeding maximum reimbursement rate Extra/balanced billing is allowed for some items with cap, e.g. private wards, dental service 30 Baht per visit/admission No balanced billing Balanced billing is allowed for all items exceeding maximum reimbursement rate Access to service Free choice of public providers (including university hospitals) no registration required Registered public and private competing contractors Registered contractor provider, notably district health system Free choice of health-care providers, either public or private DRGs: diagnosis-related groups Sources: (1) Number of health insurance members in 2019 (National Health Security Office, 2022f) (2) Synthesis by the author Analysis of the 2021 nationally representative household survey on health and welfare conducted by the NSO shows that about one fourth of UCS members (17.4%) belonged to the poorest quintile and 17.6% belonged to the richest quintile. In contrast, CSMBS covered mostly the rich group; 59.7% belonged to the richest quintile. Among SHI members, 34.1% belonged to the richest quintiles (see Fig. 3.4). Fig. 3.4 Scheme beneficiaries by income quintile, 2021 17.4% 8.5% 2.4% 20.6% 15.2% 5.9% 22.7% 17.0% 7.0% 21.6% 25.1% 25.0% 17.6% 34.1% 59.7% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% UCS SHI CSMBS Q1 (the poorest) Q2 Q3 Q4 Q5 (the richest) Source: Analysis by author using the data from the Health and Welfare Survey, 2021 (National Statistical Office, 2021a) Table 3.4 Characteristics of public and private health insurance schemes (contd) 65 Despite making good progress on extending population coverage, there is a group of uninsured people with nationality problems or stateless persons. The majority of them are ethnic minorities and have no documentation such as birth certificates or identity documents (Suphanchaimat et al., 2019a). To deal with a risk of exclusion in health-care access, the MoPH has developed a unique health insurance programme for stateless persons called the “Health Insurance for People with Citizenship Problems” (HI-PCP). This special fund aims to subsidize medical costs for stateless patients without copayment, and the benefit package includes outpatient care, inpatient care, emergency treatment, and health promotion (Suphanchaimat et al., 2016). However, there are remaining challenges such as the low utilization due to migrants’ experience of inadequately responsive services and litigation issues, and underdevelopment of portability of insurance coverage for migrants (Tangcharoensathien et al., 2017). In order to tackle community health problems and for community health services to reach underprivileged groups, an initiative of the Local Health Security Fund (LHF) with matching funding from the NHSO and local governments was piloted in 2004 and expanded to cover nearly all local governments (7741 or 99.58%) in 2022 (National Health Security Office, 2022e). Contracting units for primary care (CUP), which are mostly district hospitals together with their networks, PHC units and health centres or subdistrict health-promoting hospitals, are the key providers of health promotion and prevention services to the targeted populations in their localities. Patient pathway As the UCS applies the capitation contract model, beneficiaries are required to register with a preferred provider. UCS beneficiaries are required to register with the district health-care provider networks according to their residence. Due to geographical monopoly in rural areas, UCS beneficiaries have limited choices. Normally, their provider network in their domicile districts is the MoPH district provider network (consisting of a district hospital and 10–15 health centres). For UCS members who reside in urban areas, there are various public and private networks from which they are free to choose a network near their home. UCS members can change their provider network four times a year (National Health Security Office, 2022e; National Health Security Office (NHSO), 2022b). This is to facilitate internal temporary migration. To achieve this, applicants need to prove that they reside in that area through one of the following proofs: (a) certification letter by house owner where they reside, (b) by the village head or other community leader, or (c) by electricity or piped-water bills (showing their residency). 66 Beneficiaries are entitled to free services only from their registered provider network plus referral. Self-referral by patients is liable for full OOP payment. If the registered hospital cannot provide appropriate treatment, patients are transferred to a higher-level health-care facility such as a provincial or regional hospital, and sometimes a university hospital without any cost sharing; the contracting providers are responsible for paying for services when transferring to higher levels of health-care providers outside their network. This design is called a fundholder primary care network. Similar to the UCS, SHI beneficiaries are required to register with either a public or private facility under contract with SHI. They are free to choose their preferred facility and have a right to change it once a year. In addition to statutory insurance coverage for the employee, SHI also offers insurance coverage to voluntary members according to article 39 (i.e. retirees or members who have lost their employment). These voluntary members are responsible for the entirety of their premium; neither employer nor the government provides a matching contribution. Population coverage of the voluntary component is low. To avoid duplication of coverage, these voluntary SHI members are not covered by UCS, as the national beneficiary dataset of the three public insurance schemes are shared daily across the three scheme managers. With the application of fee-for-service payment for outpatient care, CSMBS beneficiaries have the choice to go to any public health-care facility, including university hospitals, to receive health services where they have to pay the bill and are reimbursed later. In 2007, CSMBS encouraged its beneficiaries to register with a preferred public hospital to receive outpatient services without having to pay upfront and claim reimbursement later, as the Scheme directly reimburses these providers. There are 12 337 public and private health facilities registered with the NHSO, of which private facilities make up less than 5%. Almost all primary care units belong to the public sector, while around 20% of the main contracting units and referral units are private. However, in Bangkok, private facilities make up nearly 70% of all NHSO-registered service providers. The NHSO has introduced various mechanisms to regulate and ensure service quality and efficiency of payment systems. The Health Service Standard and Quality Control Board (HSQCB), one of the two governing bodies of the NHSO, sets and monitors the standards, adequacy and quality of health- care providers. The Quality Control Subcommittee of the HSQCB sets both national and regional standards to ensure and monitor the quality applicable to different regional contexts, including criteria for entry and contract renewal. Health service providers that do not meet the assessment criteria are unable to be contracted and facilities that fail annual inspections 67 may be subject to dismissal or unable to renew contracts. The NHSO also conducts “surprise visits” or unannounced visits to health facilities, usually for facilities suspected to be non-compliant with NHSO requirements based on document audits, complaints, and random checks with users. The audit system implemented by the Bureau of Claims and Medical Audits is designed to enhance quality, operational efficiency, and data accuracy. They conduct coding audits, billing audits, and quality audits to improve overall systems. The NHSO has the authority to recover payments from service providers who make excessive or false claims. This helps the NHSO gain insights into patterns of false claim behaviour, improve auditing criteria and techniques, and enforce standards when errors are identified (Sakamoto et al., 2023). For SHI, in 2020, there were 163 public and 79 private hospitals registered with the SSO as the main contractors to provide services for 12.7 million beneficiaries of SHI. The distribution of private hospitals is unevenly skewed, with a majority of them operating in Bangkok and other affluent provinces. Most provinces in the country have only between one and three hospitals, while some larger cities have between four and eight registered hospitals. A few provinces have more than 10 hospitals registered under the SHI. Out of the 79 private hospitals contracted by the SSO, 28 are in Bangkok, while the remaining 51 hospitals are spread across 19 provinces. This leaves 57 provinces without any private main contracting facilities registered with the SSO for SHI members. The SSO conducts regular quality and financial audits for both public and private health-care facilities. Private facilities are assessed annually through quality audits, while public providers undergo audits once every 2–3 years. These audits and evaluations are performed by a team of consultants from the SSO. Financial audits are conducted electronically for approximately 10% of all reimbursements, along with the other two public insurance schemes, UCS and CSMBS. In cases of fraudulent claims, future payments to contracted hospitals are adjusted downwards. The SSO has the authority to terminate contracts if intentional misconduct or failure to meet the agreed standards is identified. However, there have been no reported cases of severe non-compliance thus far (Sakamoto et al., 2023). Scope of benefit coverage All three public insurance schemes apply a negative-list concept, in which all services are included except those defined on the negative list. Included in the negative list are services without proven clinical effectiveness or considered non-essential such as cosmetic surgery. The CSMBS benefit package includes outpatient services and hospitalization, medical and surgical services, emergency services, operations, expensive health services and medicines. However, the benefit package excludes some services such as cosmetic surgery and preventive services, except for annual health check- 68 up. By concept, the services not on the negative lists are covered by the benefits package, which includes rehabilitative care, long-term care, patient transportation, and other necessary health services. However, the payment mechanisms for health-care providers are designed for only the services that meet the criteria and conditions. The 1990 Social Security Act article 62 stated that the SHI benefit package includes diagnostic and medical treatments; hospitalization including a room, nutrition and other treatments; pharmacy and medical supplies for which quality is not lower than those included in the National Drugs List (Valee- Ittikul, 2002). These benefits apply to all diseases except self-inflicted illness or injury. Health services must be provided until patients have completely recovered. Conditions that are not a medical necessity (e.g. for cosmetic purposes) and those that are considered too expensive are excluded from the benefit package. The Scheme applies some negative lists, i.e. non-medical necessities such as those for cosmetic purposes. The design of the benefit package for the UCS is very similar to the SHI. The UCS provides a comprehensive benefits package, including ambulatory care, hospitalization, laboratory investigation, dental care, rehabilitative care, long- term care, disease prevention, health promotion and many high-cost medical services such as radiotherapy and chemotherapy for cancer treatment, surgical operations, and renal replacement therapy (RRT) for patients with end-stage renal disease (ESRD). Prescription drugs are also free of charge. It should be noted that dental care coverage differs between the UCS and SHI. The UCS limits dental conditions covered (e.g. extraction, filling, scaling and acrylic partial and full dentures). SHI limits the maximum reimbursement amount per annum. The CSMBS does not cover prevention and health promotion. The NHSO provides prevention and health promotion not only for the UCS but also for the whole population. The budget for prevention and health promotion is set as a part of the total budget managed by the NHSO (Hfocus, 2023b). The benefits package for prevention and health promotion services provided at health-care facilities are approved by the NHSO board; the fees for services provided are paid to health-care providers by capitation. Another institution that has a big role in health promotion in Thailand is the Thai Health Promotion Foundation (ThaiHealth), an autonomous government agency under the Thai Health Promotion Foundation Act, 2001. It has been designed to empower individuals and organizations and support the health promotion movement. Referring to Chapter 2, ThaiHealth’s budget was earmarked at 2% of the sin tax (tobacco and alcohol excise tax). Financial support for disease 69 prevention and health promotion was project based and focused on capacity- building and multisectoral movement (Adulyanon, 2012). The benefit package of curative services of the three public health insurance schemes is similar. The extensive coverage of health services and comprehensive benefits package resulted in a low prevalence of unmet health need, which was lower than 3% between 2011 and 2019. The main reason for unmet health need was the long waiting times, while unaffordable cost of treatment was not a significant issue (Vongmongkol et al., 2021). However, the difference in provider payment methods (such as fee-for-service under the CSMBS and capitation under the SHI and UCS for outpatient services) can lead to differences in the services provided; for example, brand-name medicines outside the National List of Essential Medicines may be prescribed under the CSMBS, while locally manufactured medicines are normally used under the UCS and SHI. This also results in different health spending per capita of their members. New technologies such as pharmacogenomics, surgical procedures and diagnostic imaging are expensive and some of them are unaffordable. Experiences of the Organisation for Economic Co-operation and Development (OECD) have shown that technology advancement is an important cost driver (Oxley et al., 1994) for which appropriate mechanisms should be introduced to generate evidence of cost–effectiveness and other information to guide decisions on technology adoption. The UCS Board is facing high demand from stakeholders (e.g. health-care providers and patient groups) for coverage of technological advancements, such as new medicines, diagnostic procedures and interventions. Since 2009, a subcommittee on the benefit package has called for evidence-based policy decisions on specific interventions. The nomination and prioritization processes comprise (a) selection of topics or interventions by stakeholders; (b) economic appraisal through Health Technology Assessment (HTA), which is a tool for the selection process applied to select the interventions based on incremental cost–effectiveness ratio (ICER); (c) budget impact analysis; and (d) consideration of other essential information, such as supply-side capacity to provide services. The evidence has been regularly produced every year by a research team from HITAP and translated into a policy process for the final decision made by the UCS Board. Examples of new interventions that have been included in the benefits package in 2022 are oral cancer screening, HIV post-exposure prophylaxis (PEP), tandem mass spectrometry, BRCA1 and BRCA2 screening, and implants for teeth (National Health Security Office, 2021d). HTA is also used for selection of medicines for the National List of Essential Medicines (NLEM). Other criteria such as the number of 70 patients and budget impact were applied for the selection criteria. This process extends service coverage and supports the progress of UHC in Thailand (Tanvejsilp et al., 2019). In 2019, the NLEM in Thailand covered 857 medicines, which is close to the list of essential medicines proposed by WHO (Tangcharoensathien et al., 2020a). These processes of producing the evidence and evidence-informed policy decisions are transparent and based on scientific methodology. Importantly, a multi-stakeholder participatory process facilitates fine-tuning of the benefit package for the UCS (Jongudomsuk et al., 2012; Mohara et al., 2012).It is hoped that this transparent, inclusive and accountable process of evidence- based policy decisions for the benefit package will be applied to SHI and CSMBS sooner or later. 3.3.2 Financial risk protection The achievement of population-wide coverage and a comprehensive benefits package with low OOP payment resulted in a dramatic decrease in catastrophic health spending and impoverishment from medical bills. Catastrophic health spending, an indicator of SDG 3.8.2 (United Nations General Assembly, 2017), is defined as household health spending greater than 10% of household consumption, while impoverishment happens when households’ consumption is reduced to below the poverty line after paying OOP (Tangcharoensathien et al., 2020c). The incidence of catastrophic health spending decreased sharply from 6.0% in 1996 to 1.9% in 2020 after the implementation of UHC. A similar trend was found in the reduction of impoverishment from 2.2% in 1996 to 0.2% in 2020, see Fig. 3.5. 71 Fig. 3.5 Catastrophic health spending and impoverishment, 1996–2020 6.0% 4.1% 1.9% 2.2% 1.3% 0.2% 0.0% 0.5% 1.0% 1.5% 2.0% 2.5% 3.0% 0.0% 1.0% 2.0% 3.0% 4.0% 5.0% 6.0% 7.0% 19 96 19 98 20 00 20 02 20 04 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17 20 18 20 19 20 20 In ci de nc e of im po ve ris hm en t, % o f t ot al h ou se ho ld In ci de nc e of c at as tr op hi c he al th e xp en di tu re , % o f t ot al h ou se ho ld Catastrophic health spending Impoverishment Sources: (National Health Security Office, 2021c; Tangcharoensathien et al., 2020c) 3.3.3 Collection Government revenue Taxation is the main source of the Thai Government’s revenue, collected by three departments of the Ministry of Finance: the Revenue Department, the Excise Department for excise tax, and the Customs Department.Their collections accounted for 85–91% of total government revenue (see Table 3.5). The Revenue Department is responsible for collecting personal and corporate income tax and value-added tax, which contributes to more than half of the total tax collected. In the tax revenue structure, indirect tax with a high share of value-added tax was the largest portion, followed by direct tax (personal income, corporate income tax, petroleum income tax, and inheritance tax). This tax profile did not change between 1995 and 2019. Note that in 1998, the years after the 1997 Asian economic crisis, the share of general sales tax was larger than direct tax due to corporate shutdowns, unemployment and reduced disposable income. The main source of direct tax was personal income tax, for which progressive tax rates were applied depending on income, varying from 0% for those with an annual income under THB 150 000 to 35% for any annual income over THB 5 million (Thairath Money, 2023). 72 Revenue collection from the payroll tax tends to be proportionate but the ceiling of the contribution could lead to a regressive and increasing gap in contributory wages between the rich and the poor. The maximum salary for assessed contributions was fixed at THB 15 000 per month and has not increased since the launch of SHI in 1991. The minimum wage has been adjusted annually to catch up with inflation, while the maximum salary has not been adjusted. The payroll tax contribution is 5% of salary with a ceiling at THB 15 000. Hence, there is insignificant difference in contributions between minimum wage blue-collar workers and high-income white-collar workers whose salary may be up to THB 80 000–100 000. Workmen’s Compensation Fund The Workmen’s Compensation Fund (WCF) was formally established through government regulation on 16 March 1972 to cover medical expenditure related to work injuries and occupational diseases, death and disability. After more than two decades of implementation, the 1994 Workmen’s Compensation Act replaced the outdated 1972 regulation. It was managed by the Workmen Compensation Office, a part of the SSO. In 2021, the WCF surplus accumulating over the years was around THB 72.6 billion (Social Security Office, 2022). WCF is solely financed by employers on an annual basis. The contributions are calculated on the total wages of employees multiplied by the contribution rate according to the type of business, which varies from 0.2% to 1.0% of wages based on the risk rating of the type of establishment by industrial classification. The rate is used for the first four years of contribution. In the fifth year, this basic rate of contribution may increase or decrease depending upon the accident record (and hence the size of the compensation to employees) of each enterprise. This is termed the experience rating. Higher accident records and higher claims from the fund result in a higher experience rate and thus the basic rate in the fifth year is adjusted accordingly. Similar to SHI, the employer’s failure to comply with the contribution is subject to a fine and imprisonment. Traffic accident protection insurance The Traffic Victim Protection Act, promulgated in 1992, requires all vehicle owners to pay a premium to the scheme, which covers treatment for traffic injuries and funeral costs for victims. Though it is a mandatory public scheme, it is managed by private for-profit insurance companies – the loss ratio of this scheme was approximately 71% in 2021 (The Insurance Premium Rating Bureau, 2022), with significant administrative expenditure and profit. In light of achieving UHC in 2002, the provision of this Act duplicates that of the UHC; however, previous reform attempts have failed due to entrenched benefit across all stakeholders involved in these businesses: insurance 73 brokers, insurance companies, the Insurance Association of Thailand, and the Department of Insurance of the Ministry of Commerce. There have been public complaints of inadequate attention by insurance companies, and disputes with hospitals on who is responsible for the bills. Revenue collected by the private sector The majority of private health spending was driven by OOP payments and private voluntary health insurance. Household OOP payment was the lion’s share in 1995, at 44.9% of CHE, but this regressive direct payment at point- of-service provision dropped to 8.5% in 2019. Voluntary health insurance spending had increased from 2.5% of CHE in 1995 to 13.6% in 2019. Funding from external sources is negligible. Details of revenue collection are described in sections 3.2.2 and 3.2.3. 3.3.4 Pooling of funds There are four major pooling agencies, Comptroller-General Department for CSMBS, SSO for SHI, NHSO for UCS, and private insurance firms for voluntary health insurance schemes. These agencies play two roles – pooling funds and purchasing services on behalf of their respective members (Fig. 3.6). Fig. 3.6 Flows of funds to pooling or management agencies Pooling / purchasing agencies Collecting agencies Private insurance firms collect premium from their members SSO collects payroll contribution from employers and employees Revenue departments Bureau of Budget NHSO for UCS CGD for CSMBS SSO for SHI Private insurance firms Annual Budget Act SSO: Social Security Office, NHSO: National Health Security Office, CGD: Comptroller General’s Department, CSMBS: Civil Servant Medical Benefit Scheme, SHI: Social Health Insurance Scheme Source: Synthesis by the author 74 The funding from tax revenue is sent to the NHSO and CGD to manage health services for UCS and CSMBS, while the SSO receives funds from tripartite contributions. The funds for UCS and SHI are centrally pooled for risk- sharing due to the close-ended budget. However, pooling and risk-sharing is not necessary for the CSMBS because of the open-ended budget. The funds are disbursed by types of services and their payment methods. Although UCS members cover more than 70% of the Thai population and are combined into a big pool, there are separate payments for some health services such as HIV/AIDS and kidney disease. The budget for medicines for some specific diseases are also carved out from the total budget of the SSO contributions, while the CSMBS does not separate funding for any specific disease. The UCS global budget is allocated to the regional level based on the size of the population and health-care utilization in each area. The NHSO at the regional level has the authority to manage this fund; however, the payment methods for health services are set by the central level (National Health Security Office, 2021a). The size of the budget pooled at the NHSO for the UCS is negotiated annually between the NHSO and the Budget Bureau. The final budget decision is made by the National Health Security Board, chaired by the Minister of Health. The budget is proposed on the estimated total expenditure per UCS member for that budget year, based on the previous year’s utilization rate of outpatient and inpatient services, projections for that budget year, the cost of outpatient and inpatient services, plus other components such as prevention and health promotion services. In the past, the budget has increased significantly for service utilization and labour costs as a result of the annual 5–6% government salary adjustments and inflation of other medical products. The size of the CSMBS budget is proposed by the CGD based on the historical total expenditure trend and projection. However, as a result of fee-for- service for outpatient services, there were significant cost escalations for these services. Expenditure for inpatient care stabilized as a result of implementation of conventional DRG payment. The CGD has overspent the approved budget since 1994, but was cross-subsidized by the Central Fund earmarked for national contingencies such as flood and drought. Recently, cross-subsidy has not been permitted by the Constitution, and legal approval for overspending is required by Parliament. Recent interventions include tight control of outpatient expenditure through stringent approval of the use of non-essential medicines and including the individual prescriber’s name in the dataset for close monitoring among 34 priority hospitals having a major share of outpatient reimbursement (mostly teaching and 75 super-tertiary hospitals). The rate of increase in outpatient expenditure has thereby been curbed. The per capita expenditure for SHI is fixed by the SSO and adjusted every few years. Similar to the UCS, the SHI estimates per capita total expenditure for that budget year based on the service utilization rate and unit cost of services, including some other service components covered outside capitation. Other parallel government health systems, such as the MoPH for public health programmes, Ministry of Defence for the Armed Forces Medical Services and Ministry of Justice for prison medical services, are based on annual budget allocation, based on the historical budget with slight adjustments. Private insurance companies pool premiums from their members on an annual basis, as policies are renewed (or terminated) annually, and purchase services for their members, often from private providers. The characteristic of the market structure of collecting, pooling and purchasing is multiple non-competing insurers/purchasers. It is multiple in nature as there are four purchaser agencies; non-competing as each of the three public insurers covers a distinct population. The three public insurance schemes do not compete for members, as CSMBS and SHI are occupation linked, while UCS is an entitlement for anyone not covered by CSMBS or SHI. When SHI members become unemployed, they are automatically transferred to UCS. Child dependents of CSMBS, once they reach the age of 20 years, are also automatically transferred and covered by the UCS unless they are employed in the private sector, in which case they are covered by SHI. When UCS members are employed in the private sector, they are covered by SHI and removed from the UCS. Members of these three public insurance schemes are not allowed to opt out from the schemes; though they are free to enrol in voluntary private health insurance schemes. 3.4 Out-of-pocket payments OOP payment has steadily declined since 1995 (see Table 3.3). This is because Thailand has gradually expanded financial risk protection for health using several approaches. Examples include expanded social welfare programmes for the poor and vulnerable (including older people and children under 12 years of age) and subsidized voluntary public health insurance for the non-poor informal sector (Tangcharoensathien et al., 2018). When UHC was achieved in 2002, a comprehensive benefits package was provided, 76 resulting in a decline in OOP payments to 8.5% of CHE in 2019. Households are liable to pay OOP for services provided by public or private health-care facilities not covered by the benefits package of the three public health insurance schemes, e.g. self-prescribed medicines in private pharmacies, services provided by private clinics and hospitals or public provider networks without referral by their registered network (self-referrals), or for services on the negative lists announced by SHI and UCS. In 2019, almost half of OOP payment was spent on medical goods, particularly over-the-counter medicines followed by outpatient services (38.1% of OOP payments). A small amount was paid for preventive care; see Fig. 3.7. Fig. 3.7 The structure of OOP payments, 2019 1137.4 Million Baht, 2.0% 26 160.3 Million Baht, 47.1% 7033.6 Million Baht, 12.7% 21 173.4 Million Baht, 38.1% Inpatient care Outpatient care Medical goods Preventive care Source: (National Health Accounts Working Group, 2021) Services provided by contracted providers are free and without copayment for UCS members. There are no deductibles, no maximum ceiling of coverage and no extra billing allowed by health-care providers. For most services, SHI members do not have to pay OOP except for some services having a minimum reimbursement ceiling such as dental care, which has THB 900 reimbursable per year. Services beyond THB 900 during a year need to be paid by copayment. In 2021, SHI provided THB 1500 for antenatal care and a lump sum of THB 15 000 per pregnancy (Bangprapa, 2022) for delivery and postnatal care. Hence, copayment at 100% is required when the actual payment by members goes beyond the lump sum. Also, the SSO does not 77 actively control the private market prices. These are SHI services covered outside the mainstream capitation for outpatient and inpatient services. Unofficial or so-called under-the-table payment is almost nonexistent and is socially unacceptable. Services are literally free under all three schemes. There are still some practices of gratitude payment for special private attendance by an obstetrician during birth delivery practised particularly by CSMBS members and high-income groups (Hanvoravongchai et al., 2000; Riewpaiboon et al., 2005). User charges were adopted in 1945 and historically played a critical role in financing health services in Thailand. The Finance Ministry allowed public health-care facilities to keep any revenue generated and use it, following the rules and regulations of the MoPH or other concerned ministries, all subject to external audit by the auditor-general. After the UCS launch in 2002, members were liable to copay a flat fee of THB 30 (around US$ 1) per visit or admission; until in November 2008 the then- new government abolished this copayment not only for political reasons, but also because some poor UCS members who were supposed to be exempted from copayment still had to pay due to poor implementation of exemption mechanisms. In 2012, the government reintroduced the THB 30 copayment; however, there are 21 groups of people who are exempted from copayment, including people who do not want to pay THB 30 (Royal Thai Government Gazette, 2012a, 2012b). There have been some attempts to introduce copayment for medical care for UCS members choosing to stay in a private room, but the Council of State ruled that this practice was unlawful as it is against the National Health Security Act. Hospitals can charge the patient only for a private room and board, but not for medical care. Also, there is currently an attempt to introduce additional payment for medicines outside the national essential drugs list (which is the available drug package under the UCS, CSMBS and SHI) and brand-name pharmaceutical products, which are currently available only for CSMBS members. This was discouraged by the government for fear of undermining the national essential drugs policy and lower-cost generic products, and the fear that such a policy may result in two-tier systems, and loss of confidence by patients in non-copayment systems. Arguments in favour of cost-sharing to discourage moral hazards by beneficiaries have been counteracted by the fact that using close-ended payment methods to providers (e.g. capitation for outpatients and global budget plus DRG for admissions) sends a strong signal about cost 78 containment and protects against the effects of information asymmetry – it is very unlikely to be seen as a moral hazard by patients, particularly when they have to trade-off with a period of waiting time. 3.5 Voluntary health insurance In 1993, Thailand introduced a public voluntary health insurance scheme called the Health Card Project, which was partially subsidized by the government budget. When UCS was fully implemented in 2002, the Health Card Project was terminated and replaced by the UCS. Only private voluntary health insurance is now available. Private commercial insurance has been operating in the Thai market since 1929 mostly for the higher-income population. There are two major types of private health insurance policies: (1) health benefits as part of life insurance policies (which make up the majority of the market) and (2) health insurance products alone. Both types provide individual and group insurance policies (Pitayarangsarit et al., 2002; Surasiengsang, 2004). Private insurance companies are regulated by an independent commission established by the 2007 Insurance Business Regulation and Support Act, Office of Insurance Commission (Office of Insurance Commission, 2007). This is a major reform, as formerly regulation of the insurance business was supervised by the Department of Insurance of the Ministry of Commerce. Membership for private insurance is on a voluntary basis. Prior physical screening and exclusion of existing conditions are common practices. Older people beyond 60 years of age are usually not accepted. The health insurance policy is renewed or terminated annually when premiums are adjusted based on the previous year’s risk, actual use of services and reimbursement. Population coverage by voluntary private insurance is low as it includes only people who can afford the premiums. Personal income tax relief is applied for the premiums paid for voluntary health (including life) insurance. The premium is deducted as annual expenditure to provide incentives for purchasing coverage. There is no complementary private insurance to offer additional services with a reduced premium, as the three public insurance schemes’ benefit packages are comprehensive. There has never been any policy discussion on introducing such a complementary benefits package. With full premium, all private voluntary health insurance offers similar benefits to the three public health insurance schemes, but with more choices of private hospitals. Society appears to be accepting of the supplementary payment in addition to payment of taxes that finance public insurance. 79 3.6 Other financing 3.6.1 Parallel health systems Other parallel health systems are very small and mostly historical. For example, the State Railways runs a small hospital in Bangkok at its headquarters at Makasan, mainly providing services to State Railway employees; the Tobacco Monopoly of Thailand also runs a small hospital in Khlong Toey. CSMBS rules and regulations are also applicable to employees and dependents of State enterprises with slightly higher benefits. Note that Armed Forces and defence personnel are fully covered by CSMBS. 3.6.2 External sources of funds External funding makes up a very small portion of Thai health financing– approximately 0.1% of CHE between 1995 and 2019 (Table 3.3). Part of this funding was paid by the Global Fund to Fight AIDS, Tuberculosis and Malaria for combating the HIV/AIDS epidemic, but is still small-scale compared to government budget for antiretroviral therapy (Patcharanarumol et al., 2013). 3.6.3 Other sources of financing Voluntary charitable funds play an insignificant role in financing health care in Thailand. Most are small scale and have limited funding roles, such as helping low-income individuals pay for medical bills prior to 2002. The Chinese Foundation Poh Tek Tung funds charitable prehospital emergency services for traffic accidents. However, the emergency medical services system was formalized by the 2008 Emergency Medical Services Act. These prehospital emergency services and referrals are fully funded by the National Institute for Emergency Medicine free for the whole population. The Institute was established by the Emergency Medicine Act 2551 B.E. (2008) and is fully financed by annual budget allocation. 3.7 Payment mechanisms 3.7.1 Paying for health services In Thailand, the MoPH owns a lion’s share of the health-care facilities, a monopoly on health centres (outside Bangkok) and the largest share of public hospital beds (see details in Chapter 4). These public providers earn their revenue from the three public health insurance schemes, with additional revenue from OOP payments by patients who opt out of their entitlement. The dominant form of organizational relationship between purchasers and providers in Thailand is a contract model. Exceptions include certain government-parallel systems that apply an integrated model, such as the 80 State Railways, which sets its budget to purchase services from its own State Railway hospital in Makasan. The State Railway employs its own hospital staff and provides an annual budget to finance the operation. The Department of Correction prisoner medical service owns a number of hospitals, employs staff and funds them directly. However, these parallel systems play a very small role in health-care provision. In the contract model, public and private health-care providers are independent from and contracted by third-party payers – the CGD for CSMBS, SSO for SHI and NHSO for UCS. There is a separation between purchaser and provider functions in the contract model, commonly referred to as the purchaser–provider split. Table 3.6 shows that the approved budget per capita for UCS members slowly increased from US$ 29 in 2003 to US$ 115 in 2020, the annual growth rate reduced from 8.1% in 2005 to 4.9% in 2020. Table 3.6 Different components of the approved budget per UCS member, 2003–2020   2003 2005 2010 2015 2020 Outpatient services 47.7% 38.2% 31.4% 36.5% 34.8% Inpatient services 25.2% 31.2% 36.9% 35.5% 38.1% Additional services with specific conditions 0.0% 0.5% 3.0% 0.0% 0.0% Specialize care, high-cost services 2.7% 8.9% 8.6% 9.4% 10.0% Prevention – promotion 14.6% 15.0% 11.3% 13.3% 12.6% Rehabilitation medical services 0.3% 0.3% 0.3% 0.5% 0.5% Emergency services 0.5% 0.4%   0.0% 0.0% Thai traditional medicines 0.0% 0.0% 0.1% 0.3% 0.4% Others 9.0% 5.5% 8.4% 4.6% 3.7% Total 100.0% 100.0% 100.0% 100.0% 100.0% Capitation per UCS member (THB)a 1202.4 1396.3 2401.3 2895.1 3600.0 Capitation per UCS member (US$)a 29.0 34.7 75.8 84.5 115.0 Average annual growth (%)   8.1% 14.4% 4.1% 4.9% Note: a: includes all items for special payment such as dialysis, antiretroviral treatment and other additional payments. Baht per capita at nominal price. Sources: NHSO annual reports (2009, 2011a, 2015, 2021c) SHI allocates inclusive capitation for outpatient and inpatient services to contracted hospitals based on the number of members registered with that contractor. The SHI provides extra payments in addition to the outpatient capitation rate for members with higher risks, mainly based on specific 81 disease groups, while the NHSO applies age-adjusted capitation to provider networks. DRGs are also applied for diseases having a relative weight equal to or more than 2 (National Health Accounts Working Group, 2019), which reflect greater intensity of disease. Public and private hospitals are competing contractors for SHI members. Members have the choice to change their preferred provider registration once a year, or when they change their employer or domicile to facilitate better access to care. In return, contractors have to report the service output of both outpatients and inpatients (including DRG information) to the SSO on a monthly basis. The number of registered members is updated monthly. There are also payments to providers based on a fee schedule, such as dialysis and other high-cost treatments. These additional payments aim to mitigate the negative impact of capitation, which may lead to underprovision of services. The CSMBS has directly reimbursed health-care providers for outpatient bills on a monthly basis since 2007. Prior to 2007, fee-for-service reimbursement was used by CSMBS members, where members had to pay for services upfront and obtain reimbursement later. For admission services, the CGD has not set a global budget ceiling (unlike NHSO), but fully applies a conventional DRG, the reimbursement rate per relative weight varies by hospital. Individual hospitals have different compensation per DRG’s relative weight. As a result, expenditure on outpatient care has increased significantly while inpatient care expenditure has stabilized. There was a rapid escalation in CSMBS costs in 2008 after direct disbursement was fully applied (Fig. 3.8), although direct disbursement had been piloted in 2004 for some chronic diseases, and in 2006 for pensioners. Besides this, health spending per capita among the three public health insurance schemes differed significantly. Health spending per CSMBS member was six times higher than per UCS member (Fig. 3.9). This information reflects that the open-ended budget applied by the CSMBS could lead to an increase in health spending and extend the gap in health spending by the member of each health insurance scheme. The higher government health spending raises a concern of sustainability of health financing, while the different payment methods raise awareness on harmonization among the three health insurance schemes. 82 Fig. 3.8 CSMBS expenditure, 1995–2019, nominal price 0 10 000 20 000 30 000 40 000 50 000 60 000 70 000 80 000 90 000 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17 20 18 20 19 M ill io n Ba ht OP IP Total Note: Outpatient and inpatient spending, including rehabilitative care Source: (National Health Accounts Working Group, 2021) Fig. 3.9 Health spending per capita by the three public health insurance schemes, 2019, nominal price 17 288.82 4810.28 2757.04 0 2000 4000 6000 8000 10 000 12 000 14 000 16 000 18 000 20 000 CSMBS SHI UCS Ba ht Sources: (1) Health spending from the National Health Accounts Working Group (National Health Accounts Working Group, 2021), (2) Number of health insurance members in 2019 from the National Health Security Office (National Health Security Office, 2022f) 83 Voluntary health insurance purchases services mostly from private providers. However, it introduces implicit copayment as there are ceilings for all items of services (e.g. room and board, medical and surgical interventions). Table 3.7 summarizes how the different health services are paid for by the three public and voluntary health insurance schemes. There is harmonization of payment for health services by the NHSO and SSO as they apply close- ended provider payment, while the CGD applies fee-for-service, open- ended provider payment for outpatient services and conventional DRGs for inpatient services. 84 Ta bl e 3. 7 Pa yi ng fo r h ea lth s er vi ce s   UC S SH I CS M BS a VH I Ou tp at ie nt ca re C ap ita tio n to c on tr ac to r pr ov id er ne tw or k (m os tly d is tr ic t h ea lt h- ca re pr ov id er s, in cl ud in g th e di st ri ct h os pi ta l + al l h ea lt h ce nt re s or P H C u ni ts in th e di st ri ct ) b as ed o n th e nu m be r of re gi st er ed b en ef ic ia ri es C ap ita tio n ra te is b as ed o n ut ili za tio n ra te a nd u ni t c os t o f s er vi ce s in th e pr ev io us y ea r, an nu al ly n eg ot ia te d be tw ee n th e N H SO a nd th e B ud ge t B ur ea u. D ow ns tr ea m a llo ca tio n to th e co nt ra ct ed p ro vi de r ne tw or k is b as ed o n ag e- ad ju st ed c ap ita tio n fo r ou tp at ie nt se rv ic es A dd iti on al fe e- fo r- se rv ic e pa ym en ts in ca se o f s pe ci fic s er vi ce s an d m ed ic al eq ui pm en t In cl us iv e ca pi ta tio n fo r am bu la to ry c ar e an d ad m is si on s ba se d on th e nu m be r of re gi st er ed b en ef ic ia ri es fo r co m pe tin g pu bl ic a nd p ri va te h os pi ta ls (h av in g m or e th an 1 00 b ed s an d ot he r fa ci lit y an d pr of es si on al r eq ui re m en ts ) A dd iti on al r is k- ad ju st ed fi xe d pa ym en t p er b en ef ic ia ry fo r ef fe ct iv e m an ag em en t o f c hr on ic a nd h ig h- co st d is ea se s, a dd iti on al p ay m en t p er be ne fic ia ry fo r ut ili za tio n in th e pa st ye ar A dd iti on al fe e- fo r- se rv ic e pa ym en ts in ca se o f s pe ci fic s er vi ce s an d m ed ic al eq ui pm en t Fe e- fo r- se rv ic e, d ir ec tly re im bu rs ed to p ro vi de rs , no t b en ef ic ia ri es N ot e: o nl y pu bl ic pr ov id er s ar e el ig ib le Fe e- fo r- se rv ic e w ith v ar io us co nd iti on s, m or e fa vo ur ab le b en ef it fo r hi gh er p re m iu m In pa tie nt ca re A nn ua l g lo ba l b ud ge t b as ed o n ut ili za tio n an d un it co st . W ith in th is bu dg et , c as e- ba se d pa ym en t u si ng ac tu al r el at iv e w ei gh t p oi nt s ea rn ed b y pr ov id er s (m os tly p ub lic ) A dd iti on al fe e- fo r- se rv ic e pa ym en ts in ca se o f s pe ci fic s er vi ce s an d m ed ic al eq ui pm en t In cl us iv e ca pi ta tio n fo r am bu la to ry c ar e an d ad m is si on A dd iti on al fe e- fo r- se rv ic e pa ym en ts in ca se o f s pe ci fic s er vi ce s an d m ed ic al eq ui pm en t P ri or to 2 00 8, co nv en tio na l f ee - fo r- se rv ic e, w ith co m bi na tio n of fe e sc he du le fo r ro om an d bo ar d, m ed ic al ap pl ia nc es , a nd o th er sp ec ia liz ed s er vi ce s C on ve nt io na l D R G w as ap pl ie d in 2 00 8, B ah t pe r re la tiv e w ei gh t an no un ce d up fr on t Fe e- fo r- se rv ic e w ith c ei lin g of to ta l re im bu rs em en t p er ad m is si on 85   UC S SH I CS M BS a VH I Ce nt ra lly re im bu rs ed fo r s pe ci fic s er vi ce s su ch a s di ab et es , s tr ok e fa st -t ra ck , r et in op at hy , he ar t s ur ge ry , a nd h ea rt tr an sp la nt P oi nt s ys te m w ith G lo ba l B ud ge t N ot s ep ar at e pa ym en t m et ho ds fr om ou tp at ie nt a nd in pa tie nt s er vi ce s N ot s ep ar at e pa ym en t m et ho ds fr om o ut pa tie nt an d in pa tie nt s er vi ce s N ot s ep ar at e pa ym en t m et ho ds fr om o ut pa tie nt a nd in pa tie nt s er vi ce s Pr ev en tio n an d he al th pr om ot io n (p er so na l pr ev en tiv e an d he al th pr om ot io n se rv ic es ) C ap ita tio n fo r pr ov id er s (m os tly p ub lic ) co ve rs th e w ho le T ha i p op ul at io n (n ot on ly U C S m em be rs ) a s a na tio na l sc he m e. B le nd ed p ay m en t m et ho ds , in cl ud in g pr oj ec t- ba se d, a re a- ba se d qu al ity a nd o ut co m e fr am ew or k (Q O F) ar e ap pl ie d fo r pr ev en tio n an d he al th pr om ot io n se rv ic es C ov er ed b y N H SO C ov er ed b y N H SO N ot c ov er ed M at er ni ty a nd p re gn an cy , in cl ud in g an te na ta l a nd po st na ta l c ar e C ov er ed u nd er in pa tie nt c ar e A dd iti on al fi xe d pa ym en t f or a nt en at al se rv ic es , d el iv er y an d po st na ta l c ar e pe r co nf in em en t t o be ne fic ia ry , n ot m or e th an tw o co nf in em en ts C ov er ed u nd er in pa tie nt ca re M os tly c ov er ed un de r in pa tie nt ca re Re ha bi lit at io n se rv ic es P oi nt s ys te m w ith G lo ba l B ud ge t Fe e- fo r- se rv ic e w ith c ei lin g (T H B 2 00 0/ m on th fo r ou tp at ie nt s an d TH B 4 00 0/ m on th fo r in pa tie nt s) Fe e- fo r- se rv ic e N ot c ov er ed Pa lli at iv e ca re C ov er ed u nd er in pa tie nt c ar e an d su pp ly of m or ph in e fo r co m m un ity p al lia tiv e ca re C ov er ed u nd er in pa tie nt c ar e C ov er ed u nd er in pa tie nt ca re N ot c ov er ed Ta bl e 3. 7 Pa yi ng fo r h ea lth s er vi ce s (c on td ) 86   UC S SH I CS M BS a VH I Re na l r ep la ce m en t th er ap y N H SO n eg ot ia te s pu rc ha se o f p er ito ne al di al ys is s ol ut io n th ro ug h go ve rn m en t ph ar m ac eu tic al o rg an iz at io n de liv er ed to d is tr ic t h os pi ta ls . N H SO p ur ch as es ha em od ia ly si s fr om p ub lic a nd p ri va te ce nt re s ba se d on fi xe d fe e, c op ay m en t is fi xe d pe r ha em od ia ly si s se ss io n by N H SO A dd iti on al p ay m en t, fix ed fe e pe r se ss io n of d ia ly si s, fr ee c ho ic e by be ne fic ia ri es , n o co nt ro l o f p ro vi de r fe e, im pl ic it co pa ym en t w he n ac tu al fe e be yo nd th e ra te g iv en b y SS O Si m ila r ar ra ng em en t a s SH I, se pa ra te a dd iti on al pa ym en t, fix ed fe e pe r se ss io n of d ia ly si s (b ut hi gh er th an S H I), fr ee ch oi ce b y be ne fic ia ri es , no c on tr ol o f p ro vi de r fe e sc he du le , i m pl ic it co pa ym en t w he n ac tu al fe e be yo nd th e ra te gi ve n by C G D N ot c ov er ed An tir et ro vi ra l s er vi ce s N H SO p ur ch as es a nt ir et ro vi ra l m ed ic in es th ro ug h ve nd or -m an ag ed in ve nt or y, a dd iti on al p ay m en t t o pr ov id er s fo r vo lu nt ar y co un se lli ng an d te st in g (V C T) , v ir al lo ad te st s, re gi st ra tio n of p at ie nt s re qu ir ed SS O p ur ch as es a nd d is tr ib ut es an tir et ro vi ra l m ed ic in es to p ro vi de rs , ad di tio na l p ay m en t t o pr ov id er s fo r VC T, vi ra l l oa d te st s, r eg is tr at io n re qu ir ed Fe e- fo r- se rv ic e m et ho ds , c ov er ed in am bu la to ry c ar e N ot c ov er ed Ch ro ni c k id ne y di se as es P er ito ne al d ia ly si s so lu tio n, fe e sc he du le , p ro je ct b as ed C ov er ed b y th e ca pi ta tio n bu dg et C ov er ed u nd er fa ci lit ie s   Pu bl ic h ea lth s er vi ce s N at io na l p ro gr am m e un de r re sp on si bi lit y of th e M oP H , e .g . di se as e su rv ei lla nc e, c ov er s th e w ho le po pu la tio n B y la w , s er vi ce s no t c ov er ed , i t i s co ve re d by th e na tio na l p ro gr am m e B y la w , s er vi ce s no t co ve re d, it is c ov er ed b y th e na tio na l p ro gr am m e N ot c ov er ed Ph ar m ac eu tic al ca re P ha rm ac eu tic al b en ef it re fe rs to m ed ic in es o n th e na tio na l E ss en tia l D ru gs (E D ) L is t, w hi ch is fu lly c ov er ed b y ca pi ta tio n fe e fo r am bu la to ry c ar e an d gl ob al b ud ge t + c as e- ba se d pa ym en t f or in pa tie nt s er vi ce s D ru g be ne fit r ef er s to n at io na l E D lis ts . D ru g pa ym en t i s in cl ud ed in th e in cl us iv e ca pi ta tio n fo r am bu la to ry a nd in pa tie nt s er vi ce s D ru g be ne fit r ef er re d to na tio na l E D li st s. F ee - fo r- se rv ic e fo r dr ug s in am bu la to ry c ar e, a nd D R G fo r ad m is si on s C ov er ed u nd er am bu la to ry a nd ad m is si on c ar e Re ha bi lit at io n C ov er ed b y in - an d ou tp at ie nt bu dg et s, fe e sc he du le fo r co m m un ity re ha bi lit at io n fr om a s ep ar at e re ha bi lit at io n an d di sa bl ed b ud ge t C ov er ed u nd er fa ci lit ie s Fu lly c ov er ed u nd er fa ci lit ie s   Ta bl e 3. 7 Pa yi ng fo r h ea lth s er vi ce s (c on td ) 87   UC S SH I CS M BS a VH I Th ai tr ad iti on al m ed ic in e P oi nt s ys te m w ith G lo ba l B ud ge t C ov er ed u nd er th e ca pi ta tio n bu dg et C ov er ed fo r tr ea tm en t an d re ha bi lit at iv e pu rp os es Lo ng -t er m ca re Fi xe d fe e pe r pa tie nt C ov er ed u nd er fa ci lit ie s C ov er ed u nd er fa ci lit ie s N ot c ov er ed Em er ge nc y m ed ic al se rv ic es (p re ho sp ita l ca re ) N H SO p ro po se s a bu dg et fo r pr eh os pi ta l ca re a nd r ef er ra l t o its b en ef ic ia ri es , f ee pe r th re e di ff er en t t yp es o f s er vi ce s N ot c ov er ed N ot c ov er ed   De nt al ca re C ov er ed e xc ep t c os m et ic p ro ce du re s an d in te gr at ed in th e am bu la to ry c ar e pa ym en t Fe e- fo r- se rv ic e w ith c ei lin g N ot c ov er ed e xc ep t a fe w ba si c de nt al s er vi ce s M os tly n ot c ov er ed M en ta l h ea lth ca re Fu lly c ov er ed u nd er a m bu la to ry c ar e. Fo r ad m is si on , a ny p sy ch ot ic e pi so de is fu lly c ov er ed e ith er a s ou tp at ie nt o r in pa tie nt A cu te p sy ch ot ic e pi so de is c ov er ed fo r no m or e th an 1 5 da ys o f a dm is si on N o lim ita tio n, fu lly co ve re d by a m bu la to ry ca re a nd a dm is si on N ot c ov er ed He al th ca re fo r s pe ci al po pu la tio ns , e .g . pr is on er s, m ili ta ry pe rs on ne l N ot c ov er ed ; m ed ic al s er vi ce s fo r pr is on er s ar e co ve re d by th e D ep ar tm en t o f C or re ct io n, r ou tin e bu dg et a llo ca tio n. T he D ep ar tm en t a ls o m an ag es s om e ho sp ita ls , o r re fe rs to M oP H h os pi ta ls fo r w hi ch p ay m en t i s m os tly fe e- fo r- se rv ic e   C iv il se rv an ts , m ili ta ry pe rs on ne l a nd th ei r de pe nd an ts a re fu lly co ve re d by C SM B S   No fa ul t c om pe ns at io n to pa tie nt s Fe e sc he du le Fe e sc he du le N ot c ov er ed D ep en di ng o n co nd iti on s N ot e: a T he re a re in cr ea si ng n um be rs o f l oc al g ov er nm en t o ff ic ia ls a nd e m pl oy ee s of in de pe nd en t p ub lic o rg an iz at io ns . T he p ro vi de r pa ym en t m ec ha ni sm o ft en ap pl ie s th e C SM B S re im bu rs em en t m od el . A ny r ef or m in th e C SM B S m ay h av e ef fe ct s on th es e gr ou ps . So ur ce : S yn th es is b y th e au th or Ta bl e 3. 7 Pa yi ng fo r h ea lth s er vi ce s (c on td ) 88 3.7.2 Payment for health workers Table 3.8 shows how different health personnel working in public and private health-care services are paid, regardless of the source of finances. There are large discrepancies in salary payment across the different public sectors and between public and private providers. This indicates a need for further harmonization of payments within the public sectors as discrepancies can have an impact on morale and outmigration of health-care workers. Note that dual practice among public practitioners exists and no permission is required. However, observations suggest that there are no negative consequences to dual practice as quality is maintained via peer and social pressure as well as disciplinary mechanisms. The sources of funding for health personnel come from the government budget and the revenue collected by health-care facilities. The budget from the government mostly pays for the salaries of civil servants. Health-care providers pay the salaries for non-civil servants through their own revenue from public and private health insurance that purchases health services for their members, through OOP payments, donations, and others. Additional payments such as overtime allowance and other allowances are also paid through the hospital or health-care facility budget, see Table 3.9. 89 Ta bl e 3. 8 P ay m en t o f h ea lth p er so nn el Ca te go ry o f pr of es si on al PH C ce nt re M oP H di st ri ct ho sp ita l M oP H pr ov in ci al / re gi on al h os pi ta l Un iv er si ty h os pi ta l Pr iv at e cl in ic Pr iv at e ho sp ita l M ed ic al d oc to r i n cl in ic al s er vi ce s N o m ed ic al d oc to r at th is le ve l of c ar e M os tly n on - sp ec ia lis ts , t he y ar e pa id a s al ar y (s al ar y sc al e is s ta nd ar d fo r al l c iv il se rv an ts ac ro ss s ec to rs , ba se d on g ra de o n en tr y in to s er vi ce ), ad di tio na l p ay in cl ud es n on -p ri va te pr ac tic e al lo w an ce , ov er tim e al lo w an ce , ha rd sh ip a llo w an ce , lu m p su m al lo w an ce , s pe ci al ty al lo w an ce M os tly s pe ci al is ts , pa id a s al ar y, s im ila r sa la ry s ca le to a c iv il se rv an t, gr ad es a re hi gh er th an d is tr ic t ho sp ita l d oc to rs du e to s en io ri ty a nd sp ec ia lis t t ra in in g. O th er a llo w an ce s si m ila r to th os e of d is tr ic t h os pi ta l do ct or s th ou gh ne ith er h ar ds hi p no r lu m p su m a llo w an ce is p ay ab le M os tly s pe ci al is ts , re ce nt r ef or m s w he n m os t u ni ve rs ity ho sp ita ls b ec om e au to no m ou s bo di es , hi gh er s al ar y sc al e th an c iv il se rv an ts , ot he r al lo w an ce s P ri va te c lin ic s pr ov id e di ag no si s an d di sp en se m ed ic in es . M os tly sp ec ia lis ts a re p ai d a sa la ry p lu s do ct or ’s fe e D iff er en t m od es , m os t c om m on is fe e- fo r- se rv ic e w ith m in im um m on th ly gu ar an te e. R at e of p ay v ar ie s by s en io ri ty a nd sp ec ia lt y, e .g . f ee pe r co ns ul ta tio n, su rg ic al fe es o r an ae st he si ol og is t fe es . O th er m od es ar e pa ym en t pe r se ss io n of se rv ic e, e .g . 4 ho ur s of o ut pa tie nt co ns ul ta tio n Pr of es si on al n ur se Th ey c an b e ei th er ci vi l s er va nt s or no n- ci vi l s er va nt s de pe nd in g on th e av ai la bi lit y of c iv il se rv ic e po st s. T hi s m ea ns th at th ey w ill be in tr od uc ed to th e sa m e pa ym en t m ec ha ni sm a s pr of es si on al n ur se s in d is tr ic t h os pi ta ls C iv il se rv an ts a re pa id a s al ar y pl us ot he r al lo w an ce s, su ch a s nu rs in g lic en se , h ar ds hi p al lo w an ce , o ve rt im e pa ym en ts C iv il se rv an ts a re pa id s im ila r to th os e w or ki ng in d is tr ic t ho sp ita ls p lu s in ce nt iv es s uc h as sp ec ia liz at io n P ai d a sa la ry , p lu s ot he r in ce nt iv es su ch a s nu rs in g lic en se , o r sp ec ia liz at io n su ch as n ur se s in th e in te ns iv e ca re u ni t, ca rd ia c ca re u ni t, di al ys is u ni t; p lu s ot he r al lo w an ce s, an nu al b on us N ot a pp lic ab le N ot a pp lic ab le 90 Ca te go ry o f pr of es si on al PH C ce nt re M oP H di st ri ct ho sp ita l M oP H pr ov in ci al / re gi on al h os pi ta l Un iv er si ty h os pi ta l Pr iv at e cl in ic Pr iv at e ho sp ita l No n- ci vi l s er va nt s, e. g. co nt ra ct s ta ff, ar e pa id a s al ar y bu t a h ig he r r at e th an ci vi l s er va nt s as th ey a re n ot en tit le d to m ed ic al an d pe ns io n be ne fit s. O th er w is e, th ey g et th e sa m e al lo w an ce s an d pa y as th os e go ve rn m en t o ffi ce rs Si m ila r to th at of M oP H d is tr ic t ho sp ita ls . U su al ly hi gh er in co m e fr om ov er tim e sh ift s (a nd pr iv at e pr ac tic e) W he n un iv er si ty ho sp ita ls b ec om e au to no m ou s, nu rs in g st af f a re co nt ra ct s ta ff (n on -c iv il se rv an t st at us ), an d ar e pa id a s al ar y (w ith hi gh er s ca le th an ci vi l s er va nt s) , p lu s ot he r al lo w an ce s an d in ce nt iv es N ot c om m on P ai d a sa la ry , p lu s ot he r in ce nt iv es su ch a s nu rs in g lic en se , o r sp ec ia liz at io n su ch as n ur se s in th e in te ns iv e ca re u ni t, ca rd ia c ca re u ni t, di al ys is u ni t; p lu s ot he r al lo w an ce s, an nu al b on us N ot a pp lic ab le N ot a pp lic ab le De nt is t D en ta l n ur se s an d de nt al a ss is ta nt s ar e us ua lly c iv il se rv an ts , t he y ar e pa id a s al ar y Si m ila r to d oc to rs in d is tr ic t h os pi ta ls , al m os t a ll ar e ci vi l se rv an ts a nd a re pa id a s al ar y, p lu s ot he r in ce nt iv es , e .g . ov er tim e pa ym en t, ha rd sh ip a llo w an ce , no n- pr iv at e pr ac tic e in ce nt iv es , a nd lu m p su m a llo w an ce Si m ila r to th os e w or ki ng in d is tr ic t ho sp ita ls St at us a nd p ay m en t ar e si m ila r to th os e of d oc to rs in un iv er si ty h os pi ta ls P ri va te d en ta l c lin ic s ea rn a li vi ng fr om de nt al s er vi ce s, ba se d on fe e- fo r- se rv ic e fo r di ff er en t se rv ic es r en de re d. Th e fe es c ov er m ed ic al s up pl ie s, m at er ia ls a nd th ei r w ag es A lm os t a ll pa id ba se d on d en tis t fe es fo r di ff er en t se rv ic es p ro vi de d, an nu al b on us Ta bl e 3. 8 P ay m en t o f h ea lth p er so nn el (c on td ) 91 Ca te go ry o f pr of es si on al PH C ce nt re M oP H di st ri ct ho sp ita l M oP H pr ov in ci al / re gi on al h os pi ta l Un iv er si ty h os pi ta l Pr iv at e cl in ic Pr iv at e ho sp ita l Ph ar m ac is t N ot a pp lic ab le a t th is le ve l M os tly th ey a re ci vi l s er va nt s, bu t a n in cr ea si ng nu m be r is c on tr ac t st af f; al l a re p ai d a sa la ry , w ith a lo w er le ve l o f i nc en tiv es an d al lo w an ce s co m pa re d to d oc to rs an d de nt is ts Si m ila r to th os e w or ki ng in d is tr ic t ho sp ita ls Si m ila r to th os e w or ki ng in p ro vi nc ia l ho sp ita ls P ha rm ac is ts in pr iv at e ph ar m ac ie s ea rn a li vi ng fr om se lli ng p re sc ri be d m ed ic in es a nd O TC m ed ic in es b as ed on fe e- fo r- se rv ic e fo r ea ch it em o f m ed ic in e, fo r w hi ch th e m ar k- up c ov er s th ei r w ag e. T he m ar k- up v ar ie s gr ea tly P ai d sa la ri es p lu s ot he r in ce nt iv es su ch a s ov er tim e pa ym en t, an d an nu al bo nu s Pu bl ic h ea lth w or ke r P ai d a sa la ry as m os t a re go ve rn m en t o ff ic ia ls P ai d a sa la ry as m os t a re go ve rn m en t o ff ic ia ls P ai d a sa la ry as m os t a re go ve rn m en t o ff ic ia ls N ot a pp lic ab le N ot a pp lic ab le N ot a pp lic ab le Al lie d pr of es si on al s: ph ys io th er ap is t, th er ap is t, m ed ic al te ch no lo gi st N ot a pp lic ab le a t th is le ve l o f c ar e P ai d a sa la ry as m os t a re go ve rn m en t o ff ic ia ls P ai d a sa la ry as m os t a re go ve rn m en t o ff ic ia ls P ai d a sa la ry , co nt ra ct s ta ff in a ut on om ou s un iv er si tie s ha s a hi gh er s al ar y sc al e th an c iv il se rv an ts N ot a pp lic ab le P ai d a sa la ry w ith ov er tim e pa ym en t O TC : o ve r th e co un te r So ur ce : S yn th es is b y th e au th or Ta bl e 3. 8 P ay m en t o f h ea lth p er so nn el (c on td ) 92 Table 3.9 Source of payment for health personnel Payment category Type of employees PHC centre MOPH district hospital MOPH provincial/ regional hospital University hospital Private clinic Private hospital Salary Civil servants Government budget Not applicable Not applicable Non-civil servants Health-care facility budget Other allowances Civil servants Health-care facility budget Non-civil servants Health-care facility budget Note: Hospital/health-care facility budget is the revenue paid by the health insurances (UCS, SHI, CSMBS, and private insurance), OOP, donation, and others. Source: Synthesis by the author 3.8 Summary The achievement of population coverage through the three health insurance schemes in Thailand was enhanced by the health financing system. After the introduction of UHC in 2002, government spending has become the dominant factor of the health financing profile, which resulted in a significant reduction in OOP payments, low catastrophic health spending and impoverishment from medical bills. The three public health insurance schemes were designed at different times of historical evolution. Hence, the fragmented systems, particularly the payment methods, could lead to differences in service provision. Despite the good progress on UHC implementation, some challenges remain. Tax is the main source of health spending for the CSMBS and UCS, while the tripartite contributions by government, employer and employee is applied by the SHI. The narrow tax-based and fixed contributions of the SHI could generate inequity issues. Increasing government health spending and the cost escalation payment method and open-ended budget applied by the CSMBS could bring about a concern of sustainability. This payment mechanism also increases health spending per capita of the CSMBS compared to the other health insurance schemes. In addition, there is a gap in extending coverage to non-Thai vulnerable groups such as the stateless population and migrant workers. Although a health insurance scheme for migrants has been opened by the MoPH, continued policy support is needed for better health care for migrants.  93 4 Physical and human resources Chapter summary As a result of strong political commitment to the health of the population, during the 1980s, there was a heavy investment in government health-care delivery systems: health centres covered all subdistricts; a district hospital in every district; a provincial hospital in each of the 77 provinces; and regional hospitals as referral centres at regional level. Health delivery systems are dominated by the public sector, for which the Ministry of Public Health (MoPH) has the majority share, accounted for 67.2% of the total hospital beds in 2021. The local government organizations play an increasingly important role in health service provision. Decentralization efforts have led to a growing number of health centres and sub-district health promotion hospitals being transferred from the MOPH to the Tambon Administrative Organizations (TAOs) in 2007 and to the Provincial Administrative Organizations (PAOs) in 2022. Private non-profit-making charity-run hospitals account for a negligible share of hospital beds. The extensive geographical coverage of primary health care (PHC) and hospital services down to subdistrict and district levels is the foundation for successful implementation of universal health coverage (UHC), especially pro-poor health service utilization and public subsidies. Hospital information technology has significantly improved, supporting Universal Coverage Scheme (UCS) implementation. Public hospitals have embraced information technology, incorporating paperless systems and successfully implementing e-health since 2009. Efforts for harmonization and interoperability are underway to address software diversity resulting from a lack of centralized technical leadership from the MOPH. In 2021, National Telecom (NT) and the Government Big Data Institute (GBDi) launched the “Health Link” platform, with around 1 100 public hospitals joining by 2023. Additionally, telemedicine, including telepharmacy, gained prominence during the COVID-19 pandemic, accelerating its adoption across Thailand. Improvements in inpatient discharge summaries’ quality and accuracy, crucial for UCS e-claiming, have been achieved through stringent NHSO audits, curbing upcoding in DRG systems. 94 The health-care workforce density per 1000 population was 4.10 in 2020, which is above the 2.28 per 1000 population, the indicative threshold of doctors, nurses, and midwives as proposed by WHO in 2006, but still below the 4.45 per 1000 population, the newer indicative threshold in 2016 (World Health Organization, 2006, 2016a, 2022d). To ensure adequate healthcare workforce serving the rural health services, continued efforts of multiple interventions were applied, such as an education strategy with recruitment of students from rural backgrounds, curriculum reflecting rural health problems, mandatory rural service by all graduates, doctors, nurses, pharmacists and dentists since 1972, financial and non-financial incentives such as social recognition; also task-shifting has been applied throughout, such as nurse practitioners and other specialized nurses, dental nurses and pharmacist assistants. Thailand is self-reliant in producing health-care workforce of a high quality and standard. Quality is ensured through national license examination for all cadres of the healthcare workforce by professional councils. Additionally, professional nurses are relicensed every five years. The mobility of health workers in Thailand is influenced by factors such as economic trends, and government policies; while international migration of health personnel is considered minor, internal migration from rural to urban areas and between public and private sectors has been observed. The government’s push to position Thailand as a medical hub has led to an increase in internal brain drain. During the COVID-19 outbreak, the health- care workforce faced increased demand, prompting government measures to enhance capacity and retain healthcare workers. However, the health-care workforce is currently grappling with high resignation rates, particularly among nurses and newly graduated doctors, due to heavy workloads and insufficient compensation. 4.1 Physical resources 4.1.1 Capital stock and investment Current capital stock in 2021 It took three decades from the 1970s to the 2000s of gradual investment in health-service delivery infrastructure in urban and rural areas for Thailand to achieve the planned 100% geographical coverage of health-care services. In 2021, 775 community (or district) hospitals were the main health-care facilities at district level, covering all districts; and 126 regional/general hospitals (excluding Bangkok Metropolitan) served as tertiary referral hospitals located in large provincial cities in 76 provinces throughout the country (Strategy and Planning Division, 2021c). The size of community hospitals varies from 10 to 120 beds, while general/regional hospitals have larger capacities, at least 150 beds. The largest regional hospitals 95 have more than 1000 beds. Other government hospitals include 59 military hospitals, 21 university hospitals, 62 specialized hospitals, 9 hospitals under other ministries, 16 hospitals under local government (municipalities and Bangkok Metropolitan Authority) and a few State enterprises. There are 326 private hospitals, 29% of which are located in Bangkok (Strategy and Planning Division, 2021c). At PHC level, there are 9759 health centres offering PHC services at tambon (subdistrict) level, as well as 352 municipal health centres in urban areas. The availability and functioning of health- care facilities and the health-care workforce in the public and private sectors have been routinely assessed through an annual report on public health resources conducted by Strategy and Planning Division, Permanent Secretary Offices of the MoPH. Thailand health profiles (Prakongsai et al., 2016; Rojanapithayakorn et al., 2019; Wibulpolprasert et al., 2011b) are published on a regular basis to provide a compendium of the availability and use of health resources and other key health statistics. The numbers of beds, intensive care unit (ICU) beds and selected medical equipment are included in the annual Health Resources Survey. Recently, the MoPH has been conducting a new survey to assess the assets of all general/regional and community hospitals. This information is fed into decision-making on capital investment. Investment funding Two investment funding sources for public health-care facilities emerged after the advent of the Universal Coverage Scheme (UCS) in 2002: capital replacement budget included in the UCS budget is managed by the NHSO, and the MoPH budget for major new constructions and medical equipment. The capital replacement budget increased from about THB 3 billion (US$ 120.3 million) in 2002 to about THB 7 billion (US$ 217 million) in 2019 (exchange rate (THB to US$) 40.1 in 2002 and 31 in 2019) (Fig. 4.1). Prior to 2010, the capital fund for new investment from the MoPH was small compared with capital replacement held by the NHSO. This MoPH annual investment fund ranged from THB 1.4 to 3.6 billion during 2002–2010 but increased to about THB 11.9–15.3 billion during 2011–2019. The capital replacement fund from the NHSO is allocated to public and private health-care facilities according to the size of the population registered with them. The NHSO allocates to the MoPH for further allocation to different levels of health-care facilities. As the private provider network has limited UCS member registration, they have a lower share, e.g. THB 335 million out of the total of THB 6500 million (5.2%) in 2012. The MoPH is a legal entity, while public health-care facilities are not legal entities; consequently, they cannot enter into legal contract and are not allowed to borrow money for capital investment. 96 Fig. 4.1 Capital investment budget, 2002–2019 0 5 000 10 000 15 000 20 000 25 000 30 000 35 000 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17 20 18 20 19 Ca pi ta l i nv es tm en t b ud ge t (m ill io n Ba ht ) MOPH+NHSO NHSO MoPH: Ministry of Public Health, NHSO: National Health Security Office Source: (National Health Accounts Working Group, 2021) 4.1.2 Infrastructure Out of all the infrastructure under the MoPH, most are district public health offices (47%) or community hospitals (42%). Other than that, there are some general hospitals (5%), provincial public health offices (4%) and regional hospitals (2%) (Fig. 4.2). Fig. 4.2 Infrastructure under the MoPH (2023) 4% 47% 2%5% 42% Provincial Public Health Office District Public Health Office Regional Hospitals General Hospitals Community Hospital Source: (Health Administration Division, 2023) 97 Almost all hospitals are designed for acute care. There are 62 specialized hospitals, including 13 psychiatric hospitals under the MoPH, while there are no long-term care institutions. In 2021, there were a total of about 167 563 beds throughout the country, of which the MoPH had the largest share (67.2% of total beds), followed by private hospitals (19.5% in 2021) (Fig. 4.3). A rapid increase in the proportion of private-sector beds was noted between 1989 and 1997 due to an increase in private hospital demand before a big slump after the 1997 economic crisis. Fig. 4.3 Proportion of hospital beds by agency, 2003–2021 0 10 20 30 40 50 60 70 80 90 100 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17 20 18 20 19 20 20 20 21 Po rp ot io ns (% ) MoPH Other Ministry State enterprise Independent organization Local government Private Sources: Public health statistics (2003–2010) (Strategy and Planning Division, 2022b); Report of public health resources (2011–2021) (Strategy and Planning Division, 2022c) Bangkok has consistently had the largest number of hospital beds per 10 000 population out of all the regions, whereas the North-eastern region has the lowest number of beds, followed by the Southern region. Overall, the number of beds decreased or only slightly increased from 2014 to 2018, and then increased for all health regions from 2018 to 2022 (Fig. 4.4). 98 Fig. 4.4 Hospital beds per 10 000 population across regions, 2014–2022 North (Health Region 1,2) Central (Health Region 3,4) West (Health Region 5) East (Health Region 6) Northeast (Health Region 7- 10) South (Health Region 11,12) Bangkok (Health Region 13) 2014 23.6 23.6 24.6 24.4 16.4 20.6 49.3 2018 23.5 22.1 22.6 22.2 17.2 20.3 50.7 2022 25.6 25.0 26.5 27.5 20.6 23.6 55.4 0.0 10.0 20.0 30.0 40.0 50.0 60.0 Be ds / 10 0 00 p op ul at io n 2014 2018 2022 Source: (Strategy and Planning Division, 2014, 2018a, 2022d) Note that local government organizations play an increasingly important role in health service provision. Decentralization efforts have led to a growing number of health centres and subdistrict health-promoting hospitals being transferred from the MoPH to tambon administrative organizations (TAOs) in 2007 and to provincial administrative organizations (PAOs) in 2022. The transfer process has gained momentum, especially following the implementation of guidelines for transferring subdistrict health-promoting hospitals to PAOs established in 2021 (Decentralization to the Local Government Organization Committees, 2021). 99 Fig. 4.5 Bed occupancy rate by agency, 2011–2021 0 10 20 30 40 50 60 70 80 90 100 2011 2013 2015 2017 2019 2020 2021 Be d oc cu pa nc y ra te (% ) MoPH Ministry of Education Ministry of Defence Municipality Private sector Independent organization Source: (Strategy and Planning Division, 2022c) There has been an increase in bed occupancy rate across all agencies from 2011 to 2021, with the exception of the Ministry of Education. MoPH-affiliated hospitals have consistently had the highest bed occupancy rate (87% in 2021) of all agencies, while private hospitals had a lower rate (61% in 2021) (Fig. 4.5). The average length of hospital stay remained steady at around 4 days throughout 2011–2020 but increased to 4.9 days in 2021 (Fig. 4.6). This is shorter than the average length of hospital stay in countries in the Organization for Economic Co-operation and Development (OECD) (6.8 days in 2020) and much shorter than in Japan (16.4 days in 2020), which is the highest among OECD countries; (OECD, 2021). However, the proportion of older people (>65 years old) in OECD countries is higher, with an average of 17.6% in 2021, while Thailand’s is 15.0%. 100 Fig. 4.6 National average length of stay, all hospitals, 2011–2021 0 1 2 3 4 5 6 7 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Le ng th 0 f s ta y (d ay ) Source: Report of public health resources (2011–2021) (Strategy and Planning Division, 2022c) In 2020–2021, during the COVID-19 pandemic period, the bed occupancy rate of MoPH hospitals dropped to 74% in 2020 and went back up to 87% in 2021, while the average length of stay increased from four to five days. During the first wave of the pandemic, all patients with COVID-19 had to be hospitalized for infection control, and a negative polymerase chain reaction (PCR) test was required for discharge, increasing the length of hospital stay and decreasing hospital bed availability. Later in the pandemic, home isolation and care were implemented for patients with mild symptoms (green group). Thus, beds were made available for patients with more severe symptoms (Leeyaphan et al., 2021; National Health Security Office, 2022d). Hospitals also used surge capacity to combat the pandemic such as modifying existing spaces for COVID-19 patients, preparing cohort wards, preparing for quarantine of personnel, etc. In 2017, there were 21 hospital beds per 10 000 population. This was below the regional average for East Asia and Pacific of 45 beds per 10 000 population and global average of 29 beds per 10 000 population (Fig. 4.7). Within South-East Asia, Thailand had fewer hospital beds per 10 000 population compared to the Democratic People’s Republic of Korea (132), Timor-Leste (59), Maldives (43), and Sri Lanka (42) (Fig. 4.8). 101 Fig. 4.7 Hospital beds per 10 000 population, Thailand and countries in various regions and global average, 2017 21 15 28 19 47 45 6 29 0 10 20 30 40 50 Thailand Middle East &North Africa North America Latin America & Caribbean Europe & Central Asia East Asia & Pacific South Asia World H os pi ta l b ed s (p er 1 0 00 0 pe op le ) Source: (World Bank, 2023a) Fig. 4.8 Hospital beds per 10 000 population, countries in the WHO South-East Asia Region, 2017 132 59 43 42 21 17 10 10 8 5 3 0 20 40 60 80 100 120 140 DP R Ko re a Ti m or -L es te M al di ve s Sr i L an ka Th ai la nd Bh ut an M ya nm ar In do ne si a Ba ng la de sh In di a N ep al H os pi ta l b ed s (p er 1 0 00 0 pe op le ) Global average 29 Source: (World Bank, 2023a) 4.1.3 Medical equipment Investment in high-cost medical equipment is concentrated in larger specialized or tertiary care regional hospitals using the MoPH’s new capital investment budget, while private hospital investment in high-cost medical equipment is decided by the hospital’s executive team in response to increased demand and positive return on investment. There are regional discrepancies in the availability of major medical devices. There were 102 9.9 computed tomography (CT) scanners and 3.4 magnetic resonance imaging (MRI) units per million population in 2021. Bangkok had a higher concentration of major medical equipment compared to the national average and other regions, as Bangkok hosts a majority of super-tertiary care hospitals, including most of the medical schools (Table 4.1). Table 4.1 Ratio of high-cost medical devices per 1 million population by region, 2021 Region Ratio of medical devices per 1 million population CT s ca nn er M RI ES W L Ga m m a kn ife Ul tr as ou nd Co nv en tio na l ha em od ia ly si s Am bu la nc e North (Health region 1,2) 9.4 2.8 4.0 0.1 90.1 143.5 100.6 Central (Health region 3,4) 8.8 2.3 3.6 0.1 84.4 118.6 87.9 West (Health region 5) 10.8 1.9 4.5 0.4 81.2 143.9 85.6 East (Health region 6) 12.5 3.6 5.2 0.5 111.7 120.2 88.5 North-east (Health region 7–10) 5.6 1.7 2.2 0.3 84.9 76.6 76.6 South (Health region 11,12) 9.8 3.1 3.1 0.1 74.0 89.3 87.5 Bangkok Metropolis (Health region 13) 26.4 14.3 14.1 1.5 251.4 299.0 110.7 Nationwide 9.9 3.4 4.2 0.4 100.1 129.9 87.3 CT: computerized tomography; MRI: magnetic resonance imaging; ESWL: extracorporeal shock wave lithotripsy Source: Report of public health resources (2021) (Strategy and Planning Division, 2021c) 4.1.4 Information technology Hospital information technology has significantly improved since the 1990s and contributed to effective implementation of UCS, which requires hospital inpatient details for reimbursement under DRGs within a global budget. With the growth of the Internet, 85% of the population were Internet users in 2021 (World Bank, 2023b). Though civil registration of all births and deaths was mandatory by law from 1909, rapid progress was observed only in 1982 when a unique citizen identification number, assigned to all 103 citizens at birth, was initiated and gradually transformed to computerized systems. All births and deaths must be reported by law and registered with the local civil registration office within 15 days and 24 hours, respectively. Computerized civil registration covering almost all births (98.4% of total births had been properly registered and 96.7% received birth certificates) and deaths (98.4% had registered the death and 95.2% received death certificate) (National Statistical Office, 2007) supports the development of a membership database by the three insurance schemes. The sharing and interoperability of this database ensures citizen entitlement to health care. For example, all births are daily registered to the UCS or as child dependant with the CSMBS (SHI does not cover dependants), unemployed SHI members are automatically transferred to the UCS, and a UCS member, once employed, will be transferred to SHI. Once a CSMBS child dependant exceeds the legal age of 20 years, they are transferred to the UCS, or SHI if employed. The daily sharing of births and deaths and updating membership across schemes results in real-time accuracy ensuring entitlement to health benefits by members, as all health-care providers can access the membership database via the Internet. Most public hospitals have advanced information technology development to facilitate service provision and reimbursement of inpatient costs based on DRG systems; some hospitals have developed paperless systems covering all medical records, ancillary service requests, reports, and discharge summaries. Hospitals have successfully implemented e-health systems since 2009. Invoice payment, human resources, record-keeping and inventory can all be done electronically. However, a lack of technical leadership in the MoPH has resulted in different software being developed in various hospitals by different vendors; efforts are under way to achieve harmonization and ensure interoperability. In 2021, National Telecom (NT) joined forces with the Government Big Data Institute (GBDi) to launch a “Health Link” centralized platform to gather patients’ records. The platform, which leverages NT’s cloud system, is expected to follow international standards for data storage and exchange. The move should make it easier for patients who transfer hospitals to share their medical records. People aged over 18 years can apply for the system through the Pao Tang app. The Health Link was developed under the international security standard ISO 27001 and Cloud Security Alliance – Security, Trust & Assurance Registry (CSA STAR) to ensure safe personal data storage with the international standard of Fast Healthcare Interoperability Resources (FHIR), which is the standard used globally for the exchange of health information. Data are encrypted in storage to prevent data leaks, and only doctors who work in participating hospitals with licenses from 104 the Medical Council can access the information (Tortermvasana, 2021). As of 2023, around 1100 public hospitals have joined the Health Link platform. Health Link has nearly finished connecting all the data from almost all hospitals nationwide. However, the data cannot be shared until patients give consent via the platform (Ajanapanya, 2023). Telemedicine is a health-care service that utilizes technology and video conferencing to connect patients with health-care providers, enabling remote communication and diagnosis, regardless of time and location. For treatment, there is telepharmacy and medicine delivery (Health Administration Division, 2020). While there have been efforts to implement telemedicine, telehealth, and telepharmacy in routine practice, the COVID-19 pandemic has significantly accelerated the adoption of telemedicine services in many hospitals across Thailand (National Health Security Office, 2020d). During the COVID-19 outbreak, telemedicine gained significant importance by providing convenient health-care services that reduce the need for travel, save time in queues, and minimize the risk of COVID-19 transmission. There are 72 health-care facilities providing telemedicine services and serving a total of 71 732 patients with 184 016 visits. The postal delivery of medicines and medical supplies was initiated in collaboration with the NHSO, Thailand Post Company Limited, MoPH and medical schools. Two hundred twenty-five health-care facilities provided postal delivery and served 315 711 patients with 1 501 586 visits (National Health Security Office, 2022e). In 2020, the NHSO paid THB 50 per medicine parcel handled. However, as more hospitals join the programme, they hope to bring the costs down to THB 30 per parcel (National Health Security Office, 2020c). Quality and accuracy of inpatient discharge summary has significantly improved, in particular, diagnosis, comorbidity and complications using the International Classification of Diseases, version 10 (ICD-10). This information is vital for e-claiming inpatient services by UCS patients to the NHSO and by CSMBS patients to the Comptroller-General Department (CGD). Upcoding in DRG systems (so-called DRG creep) was curbed by stringent NHSO audits, so the amount overclaimed is returned to the NHSO, which makes additional payment for amounts underclaimed. The accuracy of the discharge summary is facilitated by a Bachelor degree programme and Diploma training of medical coders responsible for medical records in hospitals (Kanchanabhishek Institue of Medical and Public Health, 2023). Inpatient claims under the DRG system facilitate a complete and accurate national inpatient dataset, in full electronic form. When the inpatient dataset is linked with civil registration (anonymously using data encryption), the mortality outcome of selected conditions can be compared across the three insurance schemes. 105 In addition to hospital inpatient claims, the standard dataset for PHC was developed to capture minimum databases on individual outpatients and services offered by health centres and PHC units to provinces and the MoPH. 4.2 Human resources 4.2.1 Health workforce trends The number of staff and population density in the four cadres of health-care professionals (doctors, dentists, pharmacists, and professional nurses) has increased over the years (Tables 4.2 and 4.3). By 2019, there were 63 974 doctors (8.97 per 10 000 population), 16 102 dentists (2.56 per 10 000), 43 936 pharmacists (6.16 per 10 000) and 219 437 professional nurses (30.78 per 10 000). The jump in the number of doctors in 2017 can be explained by the data source. From 2001 to 2016, the data to identify the number of doctors were obtained from the MoPH, which was known to be underreported. From 2017 onwards, data were obtained on the number of licensed doctors from the Medical Council of Thailand, which may be overreported because some doctors have medical licenses but do not practice. In 2021, population density varied among the four cadres in each health region. Bangkok had the highest density of the four cadres. The lowest density of doctors and dentists was observed in the North-eastern regions, the lowest density of pharmacists was in the Central region, and the lowest density of nurses was in the North region. Table 4.2 Numbers of the four cadres of health-care professionals and their density per 10 000 population Year Number Health workforce density, per 10 000 population Do ct or * De nt is t Ph ar m ac is t Pr of es si on al nu rs e Do ct or De nt is t Ph ar m ac is t Pr of es si on al nu rs e 2001 18 947 4 317 6 858 78 042 2.98 0.68 1.08 12.26 2002 18 987 4 471 7 350 84 683 2.96 0.70 1.14 13.19 2004 18 918 4 129 7 413 96 704 2.90 0.63 1.14 14.81 2006 18 918 8 809 7 937 10 1664 2.85 1.33 1.20 15.33 2007 19 584 9 337 7 940 10 1143 2.93 1.40 1.19 15.14 2008 21 051 9 646 8 565 10 5398 3.13 1.43 1.27 15.65 2009 22 651 9 926 8 390 10 9797 3.34 1.46 1.24 16.19 106 Year Number Health workforce density, per 10 000 population Do ct or * De nt is t Ph ar m ac is t Pr of es si on al nu rs e Do ct or De nt is t Ph ar m ac is t Pr of es si on al nu rs e 2010 26 244 11 847 8 700 138 710 3.84 1.74 1.27 20.32 2015 31 959 - 12 231 162 734 4.55 - 1.74 23.15 2016 30 691 11 158 35 767 191 218 4.35 1.58 5.07 27.08 2017 55 890 11 575 28 896 204 675 7.88 1.63 4.08 28.87 2018 55 890 16 102 38 398 191 575 7.86 2.26 5.40 26.93 2019 63 974 18 202 43 936 219 473 8.97 2.55 6.16 30.78 2020 66 301 - - - 9.28 - - - Note: *data of doctor, during 2001–2016, was sourced from reports on public health resources produced by the Strategy and Planning Division, Office of Permanent Secretary, MoPH. From 2017 onward, the HRH focal point to WHO decided to use the data of licensed doctors from the Medical Council of Thailand (https://www.tmc.or.th/pdf/tmc-stat-04-04-23-00.pdf). Source: Global Health Workforce statistics database (World Health Organization, 2023) Table 4.3 Density of the four cadres of health-care professionals (number of professionals per population) by region, in 2001 and 2021 Region Health workforce density, per 10 000 population Doctors Dentists Pharmacists Nurses 2001 2021 2001 2021 2001 2021 2001 2021 North (Health region 1,2) 2.2 4.1 0.5 1.2 0.9 1.8 11.7 20.8 Central (Health region 3,4) 0.5 5.7 0.5 1.4 0.5 1.0 6.5 21.1 West (Health region 5) 3.2 5.7 0.6 1.3 1.0 2.3 14.7 27.0 East (Health region 6) 0.9 8.0 0.1 1.4 1.1 3.4 14.8 39.2 North-east (Health region 7–10) 1.3 3.6 0.3 1.0 0.6 1.7 6.7 21.2 South (Health region 11,12) 3.9 4.8 1.0 1.2 2.0 2.1 24.7 26.7 Bangkok (Health region 13) 13.1 19.2 3.1 1.8 4.0 5.7 35.0 68.2 Nationwide 3.0 5.9 0.7 1.2 1.1 2.4 12.5 27.9 Note: In 2021, the source of data was the report of public health resources, which gave the number of professionals who responded to the survey. Therefore, the density of the doctors in 2021 in Table 4.3 was less than the density of the doctors in Table 4.2 in 2020, which is the latest year data were available from WHO. Source: Report of public health resources (2001, 2021) (Strategy and Planning Division, 2021c) The health workforce at PHC level is critical for contributing to basic health services and health outcomes. Most health centres are managed by four-year Table 4.2 Numbers of the four cadres of health-care professionals and their density per 10 000 population (contd) 107 trained public health officers. In a small proportion, professional nurses or nurse practitioners support clinical service provision. Adequate competence and skill mix have yet to develop in managing chronic noncommunicable diseases (NCDs) and catering for changing health needs due to ageing and disability such as home health-care services and primary prevention, screening and management. Doctors According to Table 4.2 data from WHO, Thailand had 66 301 doctors in 2020 (World Health Organization, 2023). However, the data show the number of licensed doctors only and do not indicate whether they are actively practising. In 2021, the Strategy and Planning Division, MoPH, conducted a survey in public and private hospitals. The survey gathered responses from 38 820 doctors, which may cover only a portion of the private sector (Strategy and Planning Division, 2021c). Nonetheless, this finding provides insights into the distribution of doctors across different administrative types. The survey revealed that about half of the doctors (54.3% of the total respondents) worked for the MoPH, 21.3% worked on a full-time basis in the private sector, 19.4% worked in other ministries, 3.1% worked in hospitals owned by local governments and 1.9% worked in independent organizations and State enterprises (Strategy and Planning Division, 2021c). Off-hours private practice among public-sector doctors is legally permitted. Among all part-time health-care providers, between 50% and 60% are doctors. As a result of improved doctor density, regional disparities declined significantly between 1979 and 1989. However, regional disparity widened again between 1989 and 1997, as a result of increased demand for private hospital services due to favourable economic growth. After the 1997 economic crisis, a positive trend in doctor distribution across regions was regained, reverse migration from private to public MoPH hospitals was noted, consistent with the closure of a number of private hospitals due to a slump in household demand for private hospital care. In 2011, the health resources surveys showed that doctors at district hospitals had the highest workload (9 beds per doctor), followed by those working in general hospitals (8 beds per doctor), and in regional hospitals (5 beds per doctor) while those at university hospitals had the lowest; doctors at private hospitals had workloads close to those of doctors at regional hospitals. For the eight-year period 2013–2021, the workload of doctors in district hospitals reduced to 5 beds per doctor, but those in other agencies remained stable, with 7–8 beds per doctor in general hospitals and 4–5 108 beds per doctor in regional hospitals (Strategy and Planning Division, 2011b, 2013, 2021c). Based on the survey in 2021, the average doctor density doubled from 2001 to 2021. The North-east region was the worst off, followed by the North and the South regions, respectively. Bangkok had the highest doctor density both in 2001 and 2021, with the highest density of private doctors and the lowest density of public doctors (Table 4.3) (Strategy and Planning Division, 2021c). Though most are general doctors, the proportion of specialists has increased due to the social prestige and financial benefits. In some years, postgraduate training of specialists surpasses family medicine. General doctors and some specialists provide services in district hospitals, while specialists mainly work in general or regional hospitals. The proportion of specialists increased from 3% in 1971 to 85% in 2009 but dropped to 76–82% in 2019–2021 (Fig. 4.9). Fig. 4.9 Proportions of generalist and specialist doctors, 2011–2021 0 20 40 60 80 100 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Pr op or tio n (% ) Generalist (%) Specialist (%) Sources: Report of public health resources (2011–2021) (Strategy and Planning Division, 2011b, 2012b, 2014, 2015, 2016, 2018a, 2020, 2021c) The survey in 2011 (Pagaiya ert al, 2012) showed that 13–18% of new medical graduates intended to apply for specialist training after one year (out of the three years) of mandatory rural service, 61–73% would do so after their three-year compulsory rural service. Fig. 4.10 compares the production trend of generalists and specialists between 2000 and 2022. Generalists are those who have completed six years of higher education in medicine. Meanwhile, medical specialists are those who have had further training for a period of two to six years in a special field, which includes family medicine. 109 Fig. 4.10 Trends in the production of generalist and specialist doctors, 2000–2022 0 500 1000 1500 2000 2500 3000 3500 4000 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17 20 18 20 19 20 20 20 21 20 22 N um be r Generalist Specialist Source: (Medical Council of Thailand, 2023b) Dentists In 2019, there were a total of 18 202 dentists in Thailand. The survey of the Strategy and Planning Division, MoPH in 2021 found that the majority of dentists (74.28 % of the total) worked in MoPH hospitals while the rest worked in others, e.g. 14.28% in health-care facilities owned by other ministries, 5.4% in the private sector, 3.4% in local government agencies, 2.42% in independent organizations and 0.06% in State enterprises (Strategy and Planning Division, 2021c). Between 1971 and 1995, the proportion of dentists in the public sector declined, while an increase was observed in the private sector. The dentist density improved significantly in the Eastern region. The distribution of dentists outside Bangkok has improved consistently as a result of the three-year mandatory rural service by all health-care professional graduates, including dental doctors; despite this improvement, however, density in the North-eastern region in 2021 was the lowest across regions (Table 4.3) (Strategy and Planning Division, 2021c). Dental nurses (two-year diploma trained) are key to providing dental health promotion and prevention to the population, especially schoolchildren in remote areas. Recognizing the importance of dental auxiliaries who can provide a wide range of basic public dental health services, the MoPH has scaled up the education programme. This has resulted in an increase in the number of dental nurses working in health centres from around 3307 in 2004 to more than 6800 in 2015 (Fig. 4.11). 110 Fig. 4.11 Number of dental nurses in health centres or subdistrict health-promoting hospitals 3307 3456 3697 3996 4164 4313 4664 4670 4992 5360 6613 6819 0 1000 2000 3000 4000 5000 6000 7000 8000 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 N um be r Source: (Department of Health, 2016a) Pharmacists There were 43 936 pharmacists in 2019. Between 1971 and 1985, about half of the pharmacists worked in the private sector (drug manufacturing, import companies and pharmacies), while the other half worked in the public sector. However, after the MoPH launched mandatory rural service for all pharmacy graduates, the proportion of pharmacists working in the public sector increased significantly between 1984 and 2021. Data from the survey in 2021 show that most of them worked in the public sector (67.34% of the total pharmacists worked in MoPH-affiliated hospitals, 10.21% in other ministries, 2.5% in local government agencies, 18.15% in the private sector, 1.75% in independent organizations and 0.03% in State enterprises (Strategy and Planning Division, 2021c). However, these data may be distorted as they do not include pharmacists working outside service settings, which constitute a large number of graduates. According to a study conducted in 2016, 25.5% of active pharmacists worked in non-service settings, including the pharmaceutical industry, regulation and consumer protection, and academia (Suwannaprom et al., 2020). The gaps in pharmacist density across regions has improved consistently. In 2021, the pharmacist density in the Central region followed by the North-east region has improved but these two regions still have the lowest density compared to the other regions (Table 4.3) (Strategy and Planning Division, 2021c). 111 Professional nurses In 2021, the majority of professional nurses (68.13% of the total professional nurses) worked in the MoPH, 12.38% in other ministries, 3.28% in local government agencies, 14.08% in the private sector, 3.08% in independent organizations and 0.01% in State enterprises (Strategy and Planning Division, 2021c). Off-hours part-time work in the private sector is allowed. Among all part- time health-care providers, professional nurses had the second-highest proportion (after doctors). The regional gaps in nurse density have been improving consistently. Density in the poorest Central and North-east regions has significantly improved. In 2021, the lowest density of professional nurses was in the North region followed by the Central and the North-east regions. The highest density was in Bangkok, in both 2001 and 2021 (Table 4.3) (Strategy and Planning Division, 2021c). Other health-care professionals There are many categories of health-related personnel, e.g. community public health officers, physiotherapists, Thai traditional medicine providers, etc. The numbers and distribution of these are difficult to retrieve by year and by health-care facility. Public health personnel work mainly in health centres. They primarily offer health promotion and prevention services and other public health actions, though basic health services are offered such as continued medication for patients with well-controlled hypertension and diabetes. In addition to professional nurses, task-shifting is commonly applied to this group, such as screening for NCDs and simple clinical management. It is estimated that around 21 000–25 000 health workers belong to this category, working in health centres in the 2000s. Apart from health-care professionals, there are more than 1 million village health volunteers (VHVs) supporting health activities in communities throughout the country. VHVs are individuals who volunteer to be change agents of health behaviour in the local community; they provide basic health-care services and health education. VHVs are recruited by village leaders and existing volunteers and are trained on health education, health promotion, disease prevention and basic medical treatment at health centres or subdistrict health-promoting hospitals. The VHV programme was established in the 1970s (Pongpirul, 2020). The time volunteered by VHVs varies, ranging from a few hours per week to extended shifts over several days, depending on the health situation and the province. Through their work, VHVs gain an understanding of the health-care needs of their 112 community and develop close relationships with the individuals they assist. In 2019, the MoPH initiated a policy to upgrade VHVs to the role of village doctors (Department of Helath Service Support, 2019). In 2020, VHVs were a part of the policy implementation of “Every Thai Family has Three Doctors” to develop seamless care models for people in the local community. VHVs received a monthly stipend of THB 600 in 2009, which was increased to THB 1000 in 2019. They also obtain benefits such as discounted hospital costs for themselves and their families. Additionally, there are incentives such as the opportunity for their children to pursue health-care education, the potential honour of receiving a Royal Decoration, and the satisfaction of serving their communities (Kaweenuttayanon et al., 2021; Primary Health Care Division, 2021). Their contribution is significant, in particular, in the chronic NCD era and in the COVID-19 pandemic (Eng et al., 2020; Treerutkuarkul, 2008). Fig. 4.12 Doctors, dentists, pharmacists, and professional nurses, 2001–2020 0 50 000 100 000 150 000 200 000 250 000 2001 2002 2004 2006 2007 2008 2009 2010 2015 2016 2017 2018 2019 2020 N um be r Doctors Dentists Phamacists Professional nurses Source: plotted based on data in Table 4.2 4.2.2 Mobility of health workers Expert opinion suggests that international migration of health personnel is not a major problem, though there are no data on outmigration of health- care workers from Thailand. The Thailand Nursing and Midwifery Council has reported, since 2002, that there are annually 300–400 registered nurses requesting endorsement of their licenses for the purpose of working abroad. 113 During the Viet Nam war in the 1960s and 1970s, there was a large demand for doctors in the United States of America, which resulted in a large outmigration of 1500 doctors (Wibulpolprasert et al., 2003). A rapid exodus of Thai medical graduates in the 1970s prompted the government to initiate three years of compulsory rural service upon graduation (Balabanova et al., 2013; Patcharanarumol et al., 2011). This resulted in a significant increase in the number of rural doctors (Wibulpolprasert et al., 2003). Internal migration of well-trained health-care professionals has been observed from rural to urban areas, from the public to the private sector, and from public-to-public institutions. In the 1990–1997 economic boom period, there was a large and increased demand for private hospital care, which resulted in massive resignation of public-sector doctors to join private services (Nittayaramphong et al., 1994). Reverse migration from private to public MoPH hospitals was observed after the 1997 economic crisis, in line with the massive shut down of private hospitals (Tangcharoensathien et al., 2000); migration and private hospitals are sensitive to economic boom and bust. In the 2010s, the government’s active policy to promote Thailand as a medical hub of Asia to attract international patients has had positive impact, contributing 0.4% of GDP. At the same time, catering for 400 000–500 000 international patients a year has had a negative impact on the internal mobility of the health-care workforce (NaRanong et al., 2011). The country neither adopts a policy for foreign health-care professionals to practise in Thailand nor encourages Thai health-care professionals to practise abroad. The medical hub policy has created a new market for Thai health-care professionals: they can find better employment in international hospitals, both private and public medical centres. This leads to an increase in internal brain drain. The trend in the proportion of private doctors increased from 6.7% in 1971 to 20% during 1994–2021 and private nurses from 6.8% to 14% in the same period (Rojanapithayakorn et al., 2019; Strategy and Planning Division, 2021c). Push and pull forces for professional nurses have become evident. Private hospitals offer higher salary packages, better welfare, overseas training and better work conditions to attract new nurses and retain existing ones. While the MoPH is constrained by the public-sector downsizing policy since 2006, whereby posts are terminated after retirement, young nurses become annual contract workers, and their health benefit is covered by SHI. Hard work and lower pay are strong pushing forces from the public sector. The result is a 114 high turnover rate: 48% of them leave for private hospitals during the first year of MoPH employment, as there are limited opportunities to move from contract worker status to become a civil servant. During the COVID-19 outbreak in 2020–2021, the demand for health-care services, such as contact tracing, testing for the virus, treating infected patients, administering vaccines, and maintaining essential services, experienced a rapid and significant increase. These capacity surges placed a heavy burden on the health-care workforce. To enhance their capacity to respond to the pandemic and promote retention, the government implemented various measures. These measures included mobilizing additional staff, reducing routine workloads, implementing occupational safety policies, and introducing support packages to boost morale and well-being. Notably, the government approved 40 000 civil servant positions, specifically upgrading contract employees, including nurses, to civil servant status. Additionally, health-care workers received national social recognition for their unwavering dedication to the pandemic response (Nittayasoot et al., 2021). In Thailand’s health workforce, a significant issue currently revolves around the high resignation rates among nurses and newly graduated doctors. Newly graduated dentists have also expressed concerns, citing problems such as limited time for patient care and intern supervision. Approximately 10 000 new nurses graduate annually, but as many as 7000 of them leave State-run hospitals each year due to heavy workloads and insufficient compensation for overtime. Alarmingly, up to 48.9% of new nurses resign within their first year of employment. These nurses often work an average of 80 hours per week, well above the stipulated 60-hour maximum set by the Thailand Nursing and Midwifery Council. This increase in workload is a consequence of the growing number of nurse resignations, as the health-care system struggles to cope with the demand (Post Reporters, 2023; The Nation, 2023). 4.2.3 Training of health workers Undergraduate education takes six years for doctors, dentists and pharmacists and four years for nurses. All four categories are trained in accredited public and private universities for a Bachelor’s degree. Postgraduate training is available in most universities. The Office of Higher Education Commission, Ministry of Education was the statutory body responsible for all higher education (undergraduate and postgraduate) training for any course or discipline. In 2019, this Commission was integrated into the new Ministry of Higher Education Science, Research 115 and Innovation (MHESI) (Royal Thai Government Gazette, 2019a). However, health-care professional training, both the curriculum and the institutes, are subject to additional accreditation and certification by related professional regulatory bodies, which are the concern of professional councils, before the training institute can be operational. The executive board of each school has to undertake quality assurance and conduct continuous quality improvement programmes in their schools to maintain certification by the professional council. With regard to related health professional acts, all graduates have to pass a national licensing examination and register with their professional council before clinical practice. Table 4.4 summarizes each health-care professional’s study period, its regulatory authority and the degree which the graduates receive. Table 4.4 Study years, regulatory bodies and degrees Health professional Study duration (year) Regulatory body Degree Doctor 6 Thai Medical Council Bachelor: Doctor of Medicine (MD) Nurse 4 Thailand Nursing and Midwifery Council Bachelor: Registered Nurse (RN) Dentist 6 Thai Dental Council Bachelor: Doctor of Dental Surgery (DDS) Pharmacist 6 The Pharmacy Council Bachelor: Doctor of Pharmacy (PharmD) Source: Synthesis by the author Doctors In 2021, there were 25 medical schools in Thailand; 21 of these are affiliated to public universities and four medical schools are affiliated to private universities (Medical Council of Thailand, 2021). Fig. 4.13 shows the dominant contributions of public medical schools to training medical graduates. In 2022, there were approximately 2900 graduates who obtained licenses – almost double the number in 2004. The annual number of licensed doctors was higher than the projection – 2661 per annum by 2030 (Suphanchaimat et al., 2013). This situation was a result of rapid expansion in the number of new training capacities of the existing public medical schools, from 13 to 21 over the past 25 years. The four private medical schools had also expanded their production capacity by threefold, from 58 in 2000 to 151 graduates in 2022. Licensed physicians from foreign countries were increasing as well, from 15 in 2000 to 196 per annum in 2022. 116 Fig. 4.13 Medical graduates gaining licenses from public and private domestic and foreign medical schools, 2000 and 2022, Thailand 0 500 1000 1500 2000 2500 3000 3500 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17 20 18 20 19 20 20 20 21 20 22 N um be r o f m ed ic al g ra du at es Domestic public medical school Domestic private medical school Foreign medical school Source: (Medical Council of Thailand, 2023b) After completing the six-year course, all domestic medical graduates have to pass the examination held by the respective schools for a diploma; and have to sit and pass the National Licensing Examination held by the Thai Medical Council to gain a licence to practise in Thailand. The national license examination for physicians is divided into three parts – the basic sciences, preclinical and clinical examinations – students must pass all three parts. Likewise, all foreign medical graduates are required to hold a diploma from a medical school recognized by the Thai Medical Council and hold a license to practise in that country (Medical Council of Thailand, 2023a) prior to applying to sit in the National Licensing Examination held by the Council before gaining a license to practise in Thai territory. A doctor’s license for practice is lifelong, no renewal is required. There was an attempt led by the Thai Medical Council to enforce mandatory continuous professional development (CPD) as a requirement for medical relicensing to ensure medical competency. However, resistance was exerted by the medical communities where there is no consensus on mandatory license renewal. Graduates who wish to continue with specialist training have to comply with the Thai Medical Council’s regulation: a minimum of three years’ experience in rural practice is required by most residency training programmes (e.g. general surgery, internal medicine, paediatrics), with some exceptions (e.g. 117 psychiatry, forensic medicine, pathology), which the MoPH aims to rapidly scale up due to scarcity of human resources in these disciplines. The study period of the residency training programmes ranges from three years in some specialities (internal medicine, obstetrics and gynaecology, psychiatry, paediatrics, etc.) to five years in others (e.g. neurosurgery, thoracic surgery, urology). Unlike undergraduate medical training, for which medical schools are responsible, any public or private tertiary hospital can offer residency training programmes but require accreditation and certification by the Thai Medical Council and the relevant Royal College of specialty. The involvement of a number of health-care facilities in residency training has led to a substantial increase in specialist training from around 500 to 1500 and to over 3000 per annum in 1990, 2010, and 2020 (Medical Council of Thailand, 2023b). Postgraduate specialist training is heavily subsidized, although training institutes benefit from these residents supporting clinical coaching and tutoring of medical students. Nurses Historically, nursing faculties in universities under the Ministry of Education had limited capacity to produce the numbers of nurses and midwives needed to meet the demand for scaling up MoPH rural health services. In response to this challenge, in 1961, the MoPH established its own nursing and midwifery colleges, which were licensed and certified by the Thai Nursing and Midwifery Council. In 2021, there were 97 nursing schools of which 71 were publicly run and 26 were privately run (Thailand Nursing and Midwifery Council, 2022a, 2022b), with an annual production capacity of 9000–10 000 nurses. This responded to the national target of one nurse per 400 population and the country reached the target by 2018 (one nurse to 395 population) and 2021 (one nurse per 353 population) (Strategy and Planning Division, 2018a, 2021c). The four-year professional nurse’s Bachelor curriculum combines nursing and midwifery. The Thailand Nursing and Midwifery Council decided in 1982 to combine both nursing and midwifery into one curriculum, as a standalone midwifery course is not appropriate for the Thai health system. Thai health systems require that a nurse provide midwifery services for the catchment population. Professional nurses are more highly qualified than those from most Association of Southeast Asian Nations (ASEAN) countries, where the majority of nurses are trained for less than four years at diploma level. 118 Professional nurses are trained for four years and receive a Bachelor’s degree. In response to the rapid increase in the number of district hospitals in the 1980s, scaling up the production of nurse personnel became a key policy goal. To do this, instead of nurses having four years of training, in 1982 a policy was introduced to produce a two-year trained diploma course for technical nurses. After a few years of mandatory rural service, these technical nurses have the opportunity to undergo an additional two-year training programme to obtain a Bachelor’s degree. Once they pass the national licensing examination, they become “registered nurses”, also known as professional nurses, with a Bachelor’s degree (Thailand Nursing and Midwifery Council, 2021). To implement this policy, the MoPH benefited from its existing nursing colleges. The Thai Nursing and Midwifery Council approved the technical nurse curriculum for a limited period until 1996, ensuring that all nurses ended up becoming professionally qualified. During its implementation, this policy led to a rapid increase in the number of technical nurses. After that, the Thai Nursing and Midwifery Council approved only the 4-year Bachelor’s degree programme, following which one can take the national licensing examination (Thailand Nursing and Midwifery Council, 2022a, 2022b). The number of technical nurses decreased from 29 465 in 2000 to 4093 in 2021, while the number of professional nurses increased from 70 978 in 2000 to 184 840 in 2021 (Strategy and Planning Division, 2000, 2021c). There are various clinical specializations, such as emergency care, orthopaedic nursing, medical or surgical nursing and oncology nursing, for in-service capacity-building as required by tertiary care hospitals. For postgraduate education, there are 15 and 7 nursing schools offering annual training of 1000 Master’s and 70 doctoral students, respectively. Nurses who have completed two years of experience in a nursing career and wish to become clinical nurse specialists (CNS) are eligible to apply for one- year training, such as nurse anaesthetist or apply for a two-year Master’s in Nursing programme. After completing the Master’s course, if they wish to become advanced practice nurses (APN), they can apply for a two-year training programme known as the APN Residency Training programme (Tarn et al., 2008). In addition, all nurses wishing to continue nursing practice are subject to renewal of their professional licences every five years. This is in line with the regulation endorsed in 2002 by the Thai Nursing and Midwifery Council. All professional nurses are required to gain 50 credits of the Continuing Nursing Education Unit (CNEU) to maintain nursing knowledge, skills and 119 competencies for license renewal. Failure to do so results in termination of the license. 4.2.4 Doctors’ career path Doctors in the public sector have a similar career path as other professions in the public services. Most clinical practising doctors in public hospitals are civil servants and usually start their career path at level 4 (of a total 11 levels) of the position classification (PC) system (Wibulpolprasert, 1999). To lift themselves up to a higher PC level, they have to be approved and evaluated by their hospital directors for either their academic or administrative performance. The framework of evaluation is a merit-based approach imposed by the Office of Public Sector Development Commission (OPDC) (Office of Permanent secretary, 2010). In Thailand, as doctors are universally recognized as leaders of health-care professional teams, they are usually promoted to at least PC level 7 or 8, equivalent to a director of a division in the central MoPH office, within 0–12 years (Wibulpolprasert, 1999). In addition, since October 1996, the MoPH has adopted strategies to address the internal brain drain of rural doctors. These include the promotion of rural doctors’ career paths: doctors who serve in rural areas for a long period are promoted to PC level 9, equivalent to the provincial chief medical officer and the deputy director-general of the central department in the MoPH (Wibulpolprasert et al., 2003). Based upon an interview with a key informant involved in evaluating the career promotion of health personnel, it is clear that promoting doctors through technical and performance assessment was not strongly influenced by political interference by their directors or influential staff in the MoPH. This is in contrast to promotion in an administrative career such as the provincial chief medical officer, deputy or director-general, which are much more influenced by political decisions and also restricted by the limited availability of vacant posts. It should be noted that the civil servant reform of 2008 resulted in the modification of mechanisms for career promotion by not using the conventional PC system. The PC was renamed, whereby positions are clustered by type of work, e.g. academic or technical cluster, administrative cluster and supportive cluster. This was to improve the efficacy of civil servants’ performance. Nevertheless, in reality, there has not been a significant change in this mechanism. 120 During the first three years of compulsory rural service, most doctors’ movements are to community and provincial hospitals, mostly in the same province. 4.2.5 Other health workers’ career paths Nurses Nursing careers offer a wide variety of roles and broad scope of responsibility. The Thai Nursing and Midwifery Council reported that, in March 2012, there were 15 558 registered nurses of whom 78.2% were actively working in nursing, most of them were public employees and worked in hospital settings, only 11.0% were employed by the private sector. Out of the total, 3.1% of registered nurses were lecturers in nursing schools, 85% were nurses in the health-care service and 11.9% were nurse administrators. The two main career paths of nurses consist of a professional career path and nursing management career path. Professional career promotion is based on the level of knowledge, qualification, experience and competence. There are several types of nursing careers, each with a different set of responsibilities. Clinical nurse specialists (CNS) include certified nurse anaesthetists, nurse practitioners, infection- control nurses and other nurse specialists in various clinical specializations in hospitals. To gain this type of promotion, a registered nurse is required to have more than two years of experience in nursing and to have completed one year of training in CNS. Further, the APN (Tarn et al., 2008) is a registered nurse who has fulfilled the requirements of a specialized registered nurse, and passed the certification examination for APN or CNS and who continues to study at the doctorate level. The APN residency training programme takes two years. Some nurses want to go into management, supervising others and handling day-to-day administration responsibilities. In general, Bachelor’s degree- registered nurses gain experience as a health-care team member; they have opportunities to be promoted to senior-level positions in nursing management. Not more than 10–15% of total nurses in each hospital can go into the managerial path due to limited vacant posts. The steps involved are in-charge nurse, assistant unit manager, unit manager, senior nurse manager/supervisor, and chief nurse officer or director of the nursing department. Increasingly, however, nurses find that it is important to get a postgraduate degree in nursing management to jump more quickly into high-level positions such as director or chief nurse. A registered nurse working in the public sector for the first six years following graduation is appointed to position level 3–5 (practitioner level); the registered nurse will 121 be further promoted to professional level 6–7 in their seventh to tenth year of experience. In the MoPH, most of the registered nurses finish their career at level 7 due to limited availability of posts: only about 10% of registered nurses became senior professionals (level 8) and a very small number, only 50 registered nurses, are promoted to Chief Nursing Officer or Director of the Nursing Department of a regional or general hospital at an expert level (this is equivalent to level 9). 122 5 Provision of services Chapter summary Thailand has a multilevel health-care system aimed at improving geographical access of the population, in addition to enhancing system efficiency through rational use of services by level and proper referral systems. Public providers, especially hospital beds for acute care, dominate the system. There is at least one health centre in each sub-district, which covers approximately 5 000 people. Most of these health centres were upgraded and renamed as subdistrict health-promoting hospitals in 2010. At the district level, there is at least one district hospital with 30–120 beds covering a population of approximately 50 000. At the provincial level, there is a general hospital covering a population of approximately 600 000 and some general hospitals have been upgraded to regional hospitals for referral in particular regions. Most private hospitals in Thailand operate for profit, primarily catering to high-end and foreign patients. Certain private hospitals participate in public health insurance schemes, although their numbers have declined over time due to less favourable capitation rates. Additionally, the Civil Servant Medical Benefit Scheme (CSMBS) has implemented a programme enabling beneficiaries to undergo elective surgery in accredited private hospitals, with participation fluctuating over the years. Health promotion and disease prevention services are handled by the Universal Coverage Scheme (UCS) for the whole population. In addition, the Thai Health Promotion Foundation fund, financed by additional surcharge of tobacco and alcohol excise tax, supports the tackling of social determinants of health (e.g. alcohol, tobacco and road traffic injuries) and is managed by an autonomous public organization. Primary health care (PHC) under the UCS is delivered through contracting units for primary care (CUP), which have minimum staffing requirements and consist of networks of several health centres/subdistrict health- promoting hospitals and a hospital. In urban settings, a CUP consists of private clinics and a public health centre. Secondary and tertiary care are provided by the hospitals, often on referral up the system (from PHC to district to provincial/regional level). Access to 123 and use of specialized services (e.g. stroke fast track and renal replacement therapy) in hospitals has been increasing over time. An increase in levels of accreditation and lower standardized mortality ratios in networks with accredited provincial hospitals indicate that hospital care quality has been improving. Emergency medical services (EMS) are now effectively universal and fully financed by general tax, both prehospital and hospital accident and emergency services, with patients able to access the emergency department nearest to them at the time of need, irrespective of public or private setting. Prehospital care is divided into first response, basic life support, intermediate life support and advanced life support. Outside of hospitals, medicines are available in private pharmacies, which must be operated by a registered pharmacist, who can dispense “dangerous” and “specially controlled” drugs. Other types of pharmacies operated by a pharmacist or other kinds of health professionals, can sell only ready- packaged drugs that are not classified dangerous drugs or specially controlled drugs. Access to rehabilitation services and assistive devices has increased, but major geographical inequities still remain. Long-term care is traditionally and culturally a family responsibility (children and grandchildren do the caregiving) in Thailand. However, increasing numbers of older people without access to family-based care has meant that State and private provision of long-term care has increased in a variety of ways, from home-based support and paid caregivers to institutional care. Meanwhile, palliative care is an area of growth. Historically, even health-care professionals have been ignorant of the value of certain drugs (especially opiates) in managing palliative care and chronic pain relief and this has only recently been added to various health training curricula. Opiate availability for medicinal use has been growing rapidly in recent years, though morphine consumption per capita is still lower than the global average. There are 485 public mental health outpatient facilities (OPDs) in Thailand with 20 of them in mental hospitals, under the Department of Mental Health, and 465 in public hospitals including regional hospitals, general hospitals, and district hospitals. Other health personnel were recruited to support mental health service provision, prevention, and promotion. However, this is an area that still suffers from stigma. 124 Dental/oral health care is available at all levels of the public health service, but utilization is low (just 9.9% of Thais receive dental services). Additionally, there are regional differences in access to dental care services, with people living in Bangkok having the highest access. Thai traditional medicine (TTM) and other complementary and alternative medicine are fully recognized in Thailand. Demand for TTM providers is increasing in both the public and private sectors. In order to supply this increase, a number of full degree programmes and short courses have been launched. In recent decades, Thailand has emerged as a significant destination for migrants, particularly from neighbouring nations, with a labour migration policy heavily shaped by bilateral agreements. These agreements, including memoranda of understanding (MoUs) and implementation of border employment or national verification (NV), have facilitated both regular and irregular migration, resulting in a diverse migrant workforce that plays a substantial role in contributing to Thailand’s economy, accounting for 4.3– 6.6% of the total GDP. In addressing the COVID-19 pandemic, Thailand established effective response mechanisms, including the Centre for COVID-19 Situation Administration (CCSA) and Emergency Operation Centre (EOC). The country faced multiple waves of the pandemic, employing strategies such as localized lockdowns, ‘Bubble and Seal’ approaches, and flexible testing methods. Thailand extended COVID-19 vaccinations to non-Thais, ensuring equitable access, even for undocumented migrants. Thailand utilizes the Emergency Decree for a whole-of-government approach in emergencies. Effective risk communication and knowledge management are crucial components of disaster response, with the CCSA playing a central role in coordinating communication efforts. Thailand has a national emergency fund and utilizes emergency decrees for flexible financing in crisis scenarios, showcasing financial flexibility and transparency in handling disasters, including diverse allocations for vaccine research, PPE, and economic recovery. 5.1 Public health 5.1.1 Organization and provision of public health services In the past, provision of public health services was solely the responsibility of the MoPH and its facilities. However, there have been continued reforms and evolution since the 1990s. These included the public-sector reform, decentralization of public administration, the UCS managed by the National Health Security Office (NHSO), establishment of the Thai Health Promotion 125 Foundation (ThaiHealth) and the National Health Commission Office (NHCO), and Local Health Security Fund (LHF) initiative. These reforms and initiatives have resulted in increased complexity of the system in handling public health services, as shown in Fig. 5.1. Fig. 5.1 Organization of public health services in Thailand NHSO MOPH MOITHPF NHCO MONRE FDA OPS PHO RH/GH DHO PCU/HC LHF Local Administrative Organizations DH Funding Matching fund Matching fund Community health Community services Sanitation Disease control Provision of services Environment control Social determinants of health National Health Assembly Civic movements Essential Public Health FunctionsPersonal or clinical health promotion and prevention services, i.e. EPI, MCH, FP, dental health, health screening DOH DODC NHSO: National Health Security Office; MOPH: Ministry of Public Health; THPF: Thai Health Promotion Foundation; NHCO: National Health Commission Office; MOI: Ministry of Interior; MONRE: Ministry of Natural Resources and Environment; FDA: Food and Drug Administration; OPS: Office of Permanent Secretary; DOH: Department of Health; DDC: Department of Disease Control; PHO: Provincial Health Office; DHO: District Health Office; RH/GH: regional or general hospitals; DH: district hospital; PCU: primary health-care unit; HC: health centre; LHF: Local Health Security Fund; EPI: Expanded Programme on Immunization; MCH: maternal and child health; FP: family planning. Source: Synthesis by the author Communicable disease control is supported by the Department of Disease Control (DDC) and operated by the MoPH and local governments. The Bureau of Epidemiology is responsible for disease surveillance and outbreak detection. Disease surveillance is routinely performed by public health- care facilities. Health centres and hospitals report patients with specific communicable diseases to the province and central ministry. Outbreak control is primarily managed by the local health authority at the district and provincial levels under close monitoring and support from the DDC, except for some situations (especially emerging diseases) that are directly managed by the central MoPH. 126 There is also a surveillance system for occupational and environmental diseases to detect cases presenting at health-care facilities. The Bureau of Occupational and Environmental Diseases under the DDC is responsible for monitoring and developing policies and strategies on prevention and control of occupational and environmental diseases. For NCDs, surveillance of behavioural risk factors that contribute to chronic diseases is conducted by the Bureau of Noncommunicable Diseases. Basic health prevention and promotion services for the Thai population are covered in the benefit package of the UCS. Apart from the NHSO, the MoPH also plays a role in determining health prevention and promotion services through its governing and performance management functions. These services cover essential programmes for immunization, antenatal and postnatal care, family planning, nutritional surveillance, dental health promotion, routine health check-up, risk and disease screening for diabetes, hypertension, cervical cancer and other diseases. These services are covered by the per-capita budget for health-care facilities with some top-up payments. Most services are provided by hospitals and health centres for the catchment population in each area. However, some private clinics participate in providing these services as well. For community health promotion activities and campaigns, since 2006, the NHSO has provided funding to a Local Health Security Fund, which allows local governments to assess the situation and allocate resources as per local needs (Boonsang et al., 2023). The area-based health promotion and prevention budget is allocated to each region and province and local health-care facilities. These activities cover promotion of health-promoting behaviour such as exercise, healthy diet, safe sex, control of alcohol drinking and smoking, as well as environmental control. ThaiHealth plays the role of an innovative enabler or catalyst to a diverse network of partners actively involved in health promotion activities, with a specific focus on addressing various risk factors for health such as harmful alcohol use, tobacco consumption, unhealthy diets, sedentary behaviour, unsafe sex, road accidents, disasters and infodemics (Pongutta et al., 2019; Sopitarchasak et al., 2015). For 20 years, ThaiHealth funded partners, including organizations, communities, groups of people and individuals who volunteer, to carry out 23 892 projects of which 3582 projects were conducted in 2021 (Thai Health Promotion Foundation, 2021, 2022). In 2021, during the COVID-19 pandemic, ThaiHealth actively collaborated with the MoPH and related agencies to engage in the “COVID-19 prevention campaign”, fostered community capacity and self-reliance during the crisis, treated mental health problems, revitalized social foundation and created a new normal to combat COVID-19 (Institute for Population and Social Research, Mahidol University, 2021). 127 5.1.2 Accessibility of public health services Access to basic health promotion and prevention services such as immunization, family planning and antenatal care is generally high among targeted populations, given the establishment of basic health infrastructure, i.e. district hospitals and health centres covering all districts and subdistricts throughout the country. According to the fifth and sixth national health examination surveys in 2014–2020, there was improvement in access to screening for chronic conditions (diabetes, hypertension and hyperlipidaemia), including improvement in the effectiveness of control of certain conditions, though there is substantial room for improvement (Aekplakorn et al., 2021; Aekplakorn et al., 2014). The coverage of services was somewhat influenced by the targeted payment adopted for particular services. However, this had some negative consequences, crowding out non- targeted prevention and promotion services and increasing the workload of health centre staff (e.g. data entry). 5.2 Patient pathways Due to differences in system design and access conditions of health insurance schemes, patient pathways differ between schemes. According to the capitation payment method adopted by the UCS, its members are automatically assigned to a local CUP. Most of the CUPs are district hospitals that are responsible for service provision in cooperation with a network of health centres or PHC units within the district. Under the UCS, the first point of contact for a patient is expected to be a local health centre or PHC unit; however, patients can directly access the hospital at which they are registered. Bypassing of PHC units by patients who directly access hospital outpatient departments (OPDs) has been decreasing. The ratio of patients accessing a hospital OPD/PHC unit was 1.2 in 2003 and 0.8 in 2011 (National Health Security Office, 2011b). To increase accessibility, there is a policy for UCS members to receive OPD services anywhere in the country. The policy was piloted in four health regions in 2021 and, subsequently, scaled up nationwide in 2022 (National Health Security Office, 2022e). Another initiative to improve patients’ access to health care is the “Take medicine near home” programme launched by the NHSO in 2019. The programme is a medicine delivery system in which patients can pick up medicines from pharmacies located in their communities without going to hospitals, free of charge (National Health Security Office, 2020f). With the advent of the COVID-19 pandemic in 2020, telehealth and telemedicine were also introduced to UCS beneficiaries for easier access to health-care services (National Health Security Office, 2020e). 128 The patient pathway under the Social Health Insurance Scheme (SHI) scheme is similar to that of the UCS, even though all main contractors of the SHI are big hospitals, both public and private, with 100 beds or more. Patients can directly access the OPD in their registered hospitals. However, most contracted hospitals also set up networks with small hospitals and PHC units to ease access and reduce the cost of services provided. Even though SHI patients can directly access OPDs in contracted private hospitals, the hospitals usually have a general OPD as gatekeeper for SHI members and access to a specialized clinic needs referral from the general OPD. Access to specialized clinics in contracted public hospitals is not restricted among SHI members. Patient pathways under the Civil Servant Medical Benefit Scheme (CSMBS) are more flexible than those under either the UCS or SHI. According to the retrospective fee-for-service payment for outpatient services, CSMBS members can easily access any public facility. Bypassing PHC units or district hospitals to go directly to next level hospital is common among CSMBS members. 5.3 Primary/ambulatory care 5.3.1 Organization and provision of primary health care Primary/ambulatory health care is defined as the first point of contact between an individual and the health system. In 2009, it included 10 347 public health centres, 17 671 private clinics, 992 OPDs of public hospitals, and 322 OPDs of private hospitals (Wibulpolprasert et al., 2011b). In 2020, health facilities increased to 10 866 public health centres, 30 904 private clinics, 1092 OPDs of public hospitals, and 382 OPDs of private hospitals (Marshall et al., 2023). The number of outpatient contacts per person per year increased from 3.23 in 2011 to 3.44 in 2021 (National Health Security Office, 2021c). Primary care in Thailand is publicly dominated by the MoPH, with full geographical coverage. All subdistricts had a health centre by the 2000s. A health centre serves 3000–5000 people and is staffed by a team of three to five nurses and paramedics (Tangcharoensathien et al., 2018). Since 2008, in accordance with the Second Decentralization Action Plan, 84 of 9759 public health centres under the MoPH were devolved to TAOs or municipalities. In 2010, the government upgraded these health centres to subdistrict health- promoting hospitals to increase capacity, accessibility and focus on health promotion in response to unmet needs and solve the problem of overcrowded OPDs in MoPH hospitals. However, the shortage of human resources remains a major obstacle to the implementation of this policy. The number of staff per health centre or subdistrict health-promoting hospital increased only 129 slightly from 3.44 in 2011 to 4.38 in 2021 (Strategy and Planning Division, 2011b, 2021c). Contracting unit for primary care and primary health care unit To get funding as a main contractor of PHC for the UCS, health-care providers have to become a contracting unit of primary care (CUP). CUPs have to fulfil certain criteria, especially in terms of human resources. For a catchment population of 10 000, a CUP must have a physician, two registered nurses and eight paramedical staffs (minimum 2 years training). Pharmacists and dentists are only needed per 20 000 population, or they can work half-time for a catchment population of 10 000. Health services provided by a CUP have to be available at least 56 hours per week and a laboratory system for investigations must be available, as well as vehicle(s) for transferring patients. These criteria have different consequences in urban and rural areas. In rural areas, where qualified staff (physician, pharmacist and dentist) are available only in hospitals, health centres or subdistrict health-promoting hospitals have to collaborate with the CUP which is usually is a district hospital to constitute the district health system. In this context, the district health system typically comprises a network of several public health facilities in sub-district level and a CUP and one CUP with its network covers services in each district. In urban settings, where there is a larger number of health-care facilities, there could be several hospitals in the same area and there may be doctors in public health centres and private clinics. A CUP could be a hospital or a public health centre. The network of primary health care in urban areas has variou forms of collaborations among hospitals, public health centres, and private clinics, which called a “warm community clinic”. This network, typically led by one or a few CUPs and their associated networks, provides primary healthcare services across the urban district. Primary care units include public health centres or subdistrict health- promotion hospitals, and private clinics. Primary care units are the most accessible to people working in communities and local clusters. Based mainly in sub-districts, primary care units carry out health promotion, prevention, medical treatment, and rehabilitation services. Provincial public health officers and CUP provided budgetary support, medical material, human resources, and training for the primary care units (International Labour Organization, 2006). 130 In 2021, there were 1215 CUPs and 11 830 primary care units, of which 11 496 primary care units were in the public sector and 334 primary care units were in the private sector (National Health Security Office, 2021c). 5.4 Specialized ambulatory care/inpatient care Specialized ambulatory services and inpatient care are provided mainly in hospital settings. Nearly all specialists work in either public or private hospitals, with only a few working as full-time physicians in their own clinics. However, many public-sector physicians (including specialists) also work part time in private hospitals or their own clinics outside normal working hours. Some specialists also work as general practitioners in their own clinics. For inpatient care, services are available in a variety of both public and private hospitals, either general or specialized. 5.4.1 Organization of services The MoPH owns the majority of hospitals in Thailand and is the backbone of the Thai health system. In 2021, MoPH hospitals had approximately 80% of all hospital beds, which were distributed throughout the country, organized as a multilevel system outside Bangkok (Strategy and Planning Division, 2021c). There is a community hospital in all districts, with 30, 60, 90 or 120 beds, which covers a population of approximately 50 000. At the provincial level, there is a general hospital with 150–500 beds, which covers a population of approximately 600 000. Some general hospitals have been upgraded to regional hospitals with 400–1000 beds and act as referral centres in the region. In 2021, there were 775, 92 and 34 community hospitals, general hospitals and regional hospitals, respectively, while the proportion of beds shared by each type was 43:31:26 (Strategy and Planning Division, 2021c). In general, the majority of community hospitals provide only basic medical care and inpatient services by general practitioners; however, community hospitals with 90 or 120 beds provide more complicated services by specialists in major areas such as internal medicine, general surgery, obstetrics and paediatrics. General hospitals provide secondary to tertiary care and are the referral centres within the province. Regional hospitals provide tertiary care and some of them have been upgraded to centres of excellence for particular services, e.g. cardiac care, cancer and trauma. Hospital services are also provided by some other ministries such as the Ministry of Interior, Ministry of Defence, and Ministry of Justice. These were initially intended to provide services to their own specific populations: however, they are accessible to the public. Universities with a faculty of medicine also have teaching hospitals and act as referral centres that provide 131 tertiary care. A few provincial administrative offices (PAOs) and municipalities also have their own hospitals. In 2021, there were 8161 intensive care beds in 496 big hospitals, accounting for 4.9% of total beds. However, only 3.8% of MoPH hospital beds were intensive care beds, while 6% of beds in other public hospitals and 7.7% of beds in private hospitals were intensive care beds (Strategy and Planning Division, 2021c). Private hospitals Almost all private hospitals in Thailand are private for-profit ones and a few of them are also on the stock market and target high-end populations and foreign patients. Private hospitals account for approximately 20% of total hospitals and beds and all of them are located in big cities like Bangkok and its vicinity, and district capitals in the provinces. Some private hospitals are registered as main contractors of the public health insurance schemes UCS and SHI. However, the number of private hospitals under these two schemes has been declining over time, from 49 and 92 private hospitals, which were the main contractors of the UCS and SHI in 2010, to 31 and 79, respectively, in 2020, as shown in Table 5.1. The less attractive capitation rate paid by the schemes might explain the decline in the number of private main contractors of these two schemes. Private hospitals under the public schemes are usually those of medium size, i.e. those with 100 beds or more, targeting lower- to middle-income populations. Moreover, the CSMBS has been piloting a programme to allow CSMBS beneficiaries to obtain elective surgery in accredited private hospitals. The number of the private hospitals participating in the direct billing project (for elective surgery) under the CSMBS increased from 26 in 2010 to 124 in 2016 and decreased to 110 in 2021. Table 5.1 Number (and percentage) of private hospitals providing services under different health insurance schemes, 2010–2021   2010 2012 2014 2015 2016 2018 2020 2021 Number (%) of private hospitals under UCSa 49 (19%) 40 (12%) 36 (11%) na 39 (12%) 35 (11%) 31 (8%) 28 (7%) Number (%) of private hospitals under SHIb 92 (35%) 89 (28%) 85 (26%) 84 (26%) 82 (26%) 78 (24%) 79 (21%) na Number (%) of private hospitals providing elective surgery for CSMBSc 26 (10%) na na 96 (30%) 124 (39%) na na 110 (27%) Total no. (%) of private hospitals d 261 (100%) 321 (100%) 321 (100%) 321 (100%) 321 (100%) 321 (100%) 382 (100%) 403 (100%) 132 Sources: a (National Health Security Office, 2010, 2012c, 2014, 2015, 2016b, 2018, 2020b, 2021c) b (Social Security Office, 2021b); c (Comptroller General Department, 2015, 2021; Hfocus, 2016) d (Strategy and Planning Division, 2011a, 2012b, 2014, 2015, 2016, 2018a, 2020, 2021c) Centres of excellence After the introduction of the UHC policy in 2002, the NHSO collaborated with the MoPH to develop centres of excellence to tackle high-burden diseases and those with a high mortality rate, i.e. cardiac diseases, trauma and cancer. Some tertiary and secondary public hospitals were chosen to be upgraded to centres of excellence to ease access to specific specialized care for patients in rural areas. Table 5.2 shows the number of hospitals being upgraded to centres of excellence. Table 5.2 Number of centres of excellence by category and level Cardiac centrea Trauma centre Cancer centre Level 1 2 35 31 Level 2 12 Level 3 15 Level 4 33 Note: a Cardiac centres have been classified into four levels: level 1 provides all cardiac procedures, level 2 provides most of the cardiac procedures, level 3 provides at least cardiac catheterization and a few open-heart surgeries, level 4 can provide echocardiography and exercise treadmill stress test. Source: (National Health Security Office, 2011a) In addition to Table 5.2, new effective interventions for treating specific conditions have been rolled out across public hospitals, e.g. stroke fast-track in 36 public hospitals and ST segment-elevated myocardial infarction (STEMI) fast-track in 243 public hospitals (data not available for private hospitals). Relationship between secondary, primary and social care Even though the health system in Thailand has been designed as a multilevel system, district, provincial and regional hospitals not only provide secondary and tertiary care to the people in their catchment areas, but also provide PHC to people within the subdistrict where they are located. Moreover, following the introduction of the UCS, MoPH hospitals have been contracted as CUPs to provide essential health services to people residing in the district, with UCS budgets channelled through CUPs. Health centres located in the district have been recruited as PHC networks of the CUPs for providing both personal care and community services. This has resulted in greater involvement and 133 collaboration between the hospital and health centres, including financial and technical support (Srithamrongsawat, 2010). While there are greater demands for chronic, intermediate, and long-term care, the service delivery system in hospitals does not sufficiently support patients with disabilities or ease the continuity of both medical and social care within communities (Vichathai et al., 2009). However, continuity of care for those needing intermediate and long-term care is improving. NHSO established the Local Health Security Fund (LHF) in 2006 to organize activities for health promotion and disease prevention in local areas. It is a matching fund between the NHSO and local government organizations, including TAOs and municipalities. In 2006, the NHSO added long-term care services for dependency persons in the LHF with THB 6 000 per capita without co-financing. In 2010, NHSO established the Provincial Rehabilitation Fund (PRF) for rehabilitation financial management in provincial level. It is a matching fund between the NHSO and PAO. It is expected to be a better financing system for integrative health and social care for persons with disabilities (PWD) and older people. In 2022, a new benefit package was added to provide diapers for frail elderly people who have a Barthel Activity of Daily Living index equal to or lower than 11 and a care plan for long-term care management. The benefit package is funded by both the LHF and PRF (National Health Security Office, 2022e). The MoPH developed a service plan for service provision of primary, secondary and holistic health care in 2012 (Hfocus, 2012), which was revised to the service plan for primary health care and district health systems in 2017 (Health Administration Division, 2016). The service plan for intermediate care and palliative care was included in 2019 (Health Administration Division, 2019; Hfocus, 2017). The service plan aims to enhance health-care quality, capacity, and efficiency by creating a networked health-care system instead of expanding stand-alone hospitals. It emphasizes seamless coordination among primary, secondary, tertiary, and specialized centres to reduce congestion and allocate resources effectively (Nursing Division, 2018). 134 5.4.2 Access to secondary and tertiary care Access to secondary and tertiary care of various specialized services has improved under the UCS (Table 5.3). Table 5.3 Utilization of specialized hospital services within the UCS, 2011–2021   2011 2013 2015 2016 2017 2019 2021 Heart transplant 9 56 80 78 106 112 Liver transplant 22 156 189 224 295 354 STEMI fast-track, thrombolytic therapy 3 306 3 380 3 846 3 955 4 503 4 474 3 644 Stroke fast-track, thrombolytic therapy 717 1 374 2 557 2 901 3 861 6 326 6 808 Renal replacement therapy 24 545 42 090 44 468 49 047 53 265 60 202 69 208 Renal transplant 86 198 202 209 225 110 Antiretroviral therapy for HIV/ AIDs (included in UCS, CSMBS, SHI) 225 272 240 697 258 039 238 183 251 476 271 704 289 116 Cataract 122 064 157 498 168 726 154 561 127 009 134 346 93 945 Haemophilia 1 171 1 309 1 453 1 158 1 131 na na Cleft lip & cleft palate 2 603 251 1 308 1 277 1 290 1 264 999 STEMI: ST elevated myocardial infarction Source: (National Health Security Office, 2021c) 5.4.3 Quality of services The Thai Hospital Accreditation (HA) programme began as a research and development (R&D) project under the Health Systems Research Institute and has grown from just 35 hospitals in 1997 to over 1 000 hospitals in 2018. The International Society for Quality in Healthcare (ISQua) certified the Thai HA standards, the organization, and the surveyor training programme in 2010, 2013, and 2016, respectively. Hospitals must continually enhance their health-care processes and outcomes, assess against standards, and demonstrate improvement to gain accreditation. A study conducted in 2020 showed that networks with HA-accredited provincial hospitals had significantly lower stroke and sepsis standardized mortality ratios (SMRs) (Sriratanaban et al., 2020). As such, there is an indication that the quality 135 of service provided by hospitals has improved, as shown by the increasing proportion of hospitals being accredited (Fig. 5.2). However, HA alone is not enough to determine the quality of service improvement. There is a variation in the proportion of well-controlled cases of certain conditions such as hypercholesterolaemia, hypertension, diabetes and anaemia (Aekplakorn et al., 2009; Aekplakorn et al., 2021; Aekplakorn et al., 2014) (Fig. 5.3). Fig. 5.2 Number of hospitals under the UCS being accredited under the Hospital Accreditation Programme 2004–2020 6.74 15.82 22.58 23.48 39.98 45.09 55.19 79.61 85.28 16.18 20.81 48.22 65.59 53.34 43.68 37.36 11.28 5.09 26.45 54.73 25.43 10.02 4.26 0.85 1.04 0.94 1.11 50.62 8.64 3.76 0.91 2.42 3.49 3.21 3.2 3.24 6.89 3.21 4.98 5.46 0 10 20 30 40 50 60 70 80 90 100 2004 2006 2008 2010 2012 2014 2016 2018 2020 Final HA Step 2-HA Step 1-HA Under development Under assessment Source: (National Health Security Office, 2021c) 136 Fig. 5.3 Effectiveness of treatment of patients with chronic conditions 2008, 2014 and 2019–2021 72.7 61.7 62.5 50.3 44.7 48.8 31.2 43.1 30.6 90.2 94.6 89.8 7.2 5.9 5.6 8.7 6.1 3.5 3.3 2.7 13.9 3.3 2 3.8 5.4 4.7 5.4 20.7 19.5 25 37 30.6 29.2 4 1.6 3.414.8 27.7 26.5 20.9 29.7 22.6 28.5 23.5 26.3 2.6 1.9 2.9 0 10 20 30 40 50 60 70 80 90 100 2008 2014 2020 2008 2014 2020 2008 2014 2020 2008 2014 2020 Hypercholesterolemia Hypertension Diabetes Anaemia Not diagnosed Diagnosed but not treated Treated but uncontrolled Treated and controlled Sources: (Aekplakorn et al., 2009; Aekplakorn et al., 2021; Aekplakorn et al., 2014) An additional measure of service quality is the effective coverage of specific NCDs such as diabetes. A study conducted in 2022 showed an improvement in effective coverage of diabetes mellitus (DM) from 8.1% in 2016 to 11.7% in 2019 and for hypertension (HT) from 11.3% in 2016 to 15.7% in 2019. These data indicate that although disease detection rates may be high, effective coverage, while improving, remains relatively low in Thailand (Rajatanavin et al., 2022). In addition to these factors, the NHSO annual report highlights improved consumer satisfaction, with 91.86% giving the highest score (7–10) in 2016, which increased to 97.69% in 2022. This demonstrates a positive trend in how beneficiaries perceive the health-care services they receive under the UCS (National Health Security Office, 2022e). However, challenges persist. While there are no published data on average waiting times at MoPH hospitals, a study on colorectal cancer patients in Thailand revealed that over 25% of cancer patients have to wait more than 137 one month to start treatment. This is despite the MoPH’s goal to schedule cancer operations within four weeks of clinical or radiological staging (Lohsiriwat et al., 2020). Moreover, adverse events in Thailand’s health-care system remain a concern. A study conducted in 2023, using data from 2016 to 2020 from the NHSO’s inpatient department (IPD) e-claim database, found that the estimated prevalence of medical harm in Thailand was approximately 7% among hospitalized patients under the UCS. This medical harm has a significant economic impact, costing approximately THB 9.6 billion annually, which was around 5.5% of the UCS budget in 2021. Infections, ulcers, and complications were identified as the leading causes of medical harm in Thai inpatient populations (Luankongsomchit et al., 2023). 5.5 Emergency care 5.5.1 Evolution of Thailand’s emergency medical systems In 1993, Khon-Kaen province pioneered an integrated prehospital and hospital emergency service model, later replicated across provinces. Funding constraints limited incremental development until the 2002 UHC policy, which allocated funds for emergency medical infrastructure, staff training, and service payment. The 2008 Emergency Medical Act led to the establishment of the National Institute for Emergency Medicine (NIEM), transferring the policy and service provision roles from the NHSO to NIEM. According to the Act, the NIEM is responsible for system development, including the emergency medicine master plan, system structures, service quality and standards, training programmes, education of emergency medical personnel and accreditation of emergency medical service agencies, service payment, research and development. 5.5.2 Situations of emergency patients In 2022, 1 808 799 patients received emergency medical services at public health facilities. The number of emergency patients fluctuated between 1.6 and 1.8 million patients in 2017–2022. According to data collected in the Information Technology for Emergency Medical Service (ITEMS), sudden illness related to heart diseases, i.e. stroke and acute myocardial infarction; road traffic accidents and difficulty in breathing were ranked as the top three leading causes of medical emergencies in Thailand. In 2022, vehicle accidents caused injuries to over 435 000 people. Such accidents were more common in the more industrialized Eastern region. 138 Vehicle accidents were estimated to cost THB 545 435 million in economic loss, or 6% of GDP on average (O-charoen, 2017). The need for emergency medical services has been increasing considerably in the four types of prehospital services – first response (Gilmore et al.), basic life support (BLS), intermediate life support (ILS) and advanced life support (ALS) services (Fig. 5.4) (National Institute for Emergency Medicine, 2022b). Fig. 5.4 Number of cases receiving prehospital services, 2017–2022 253 427 288 301 313 852 343 818 422 548 397 937 310 470 355 946 390 429 388 373 395 616 408 352 989 631 1 025 078 1 064 608 1 013 792 964 359 977 256 26 157 25 728 25 317 24 225 25 476 25 855 0 200 000 400 000 600 000 800 000 1 000 000 1 200 000 1 400 000 1 600 000 1 800 000 2 000 000 2017 2018 2019 2020 2021 2022 N um be r o f c as es ALS BLS FR ILS FR: first response; BLS: basic life support; ILS intermediate life support; ALS: advanced life support Source: (National Institute for Emergency Medicine, 2022b) 5.5.3 Prehospital services People can access emergency medical services by calling 1669. Calls are channelled to a dispatch centre, where they are managed by dispatchers who triage the call based on the patient’s medical condition through the criteria- based dispatch (CBD) system. Most of the 82 dispatch centres in Thailand are situated at provincial hospitals, although some have been transferred to local administrative organizations. All centres are managed by trained nurses, capable of performing emergency medical triage and coordinating service provision from emergency medical (EM) units (Fig. 5.5). 139 Fig. 5.5 Thailand’s emergency medical operation Cost Subsidize General EMS operation process Reimbursement Accident or medical emergency Medical control or protocols On-scene care consult information command response dispatch Transfer To definitive care and care during transit R ep or t o r re qu es t ad di tio na l re so ur ce s advise instruction coordinate provide information Social services Command and control centre 1 CCC/ 1 province Public Police Volunteer Network FR ILS ALS Special Unit BLS 1-6-6-9 1 2 4 5 6 7 3 EM: emergency medical; FR: first response; BLS: basic life support; ILS intermediate life support; ALS: advanced life support Source: (Pangma, 2012) Access to prehospital care is free for all Thais. The NIEM has set the guidelines and paid for prehospital care by accredited public and private ambulance services. Payment rates are capped at THB 350, 500, 750 and 1000 per service for first response, basic life support, intermediate life support and advanced life support, respectively. Payment rates vary based on the assessment results of the patient’s severity level at the incident point. The NIEM also regulates air and water prehospital services with strict criteria for efficient utilization of resources (National Institute for Emergency Medicine, 2022a). All EM units (both EM operation units and EM direction units) must be registered and accredited by the NIEM and the Thailand Emergency Medical Service Accreditation (Wright et al.) or by licensing offices designated by 140 the NIEM. The licensing offices are contracted by the NIEM to manage operational functions, for example, service zoning, quality control and auditing, service payment and service information systems (National Institute for Emergency Medicine, 2021). In October 2022, there were 8869 EM operation units providing prehospital services in Thailand. The majority of them were operated by local government organizations (Fig. 5.6). Within these units, there were 91 709 EM personnel. Fig. 5.6 EM operation units (percentage) in Thailand 5384 (60.7%)1732 (19.5%) 1130 (12.7%) 623 (7.0%) Local Government Organizations Public hospitals Volunteer Organizations Others Source: data in 2022 from the Information Technology for Emergency Medical Service (ITEMS) 5.5.4 Hospital emergency service The hospital emergency service has applied clinical practice guidelines, fast- track systems for particular cases, e.g. stroke and myocardial infarction, and undertaken trauma registry and audit. The challenges were the insufficient numbers of physicians and nurses for the increase in service need, lack of effective teams working and coordinating both within and outside the hospitals and restricted operating space (Suriyawongpaisarn, 2009). Hospital EM services are covered by the three public insurance schemes and the Motor Accident Victims Protection Insurance, which covers all vehicle owners purchasing insurance for injuries or death caused by their vehicles. In 2017, the government introduced Universal Coverage for Emergency Patients (UCEP), ensuring free, high-quality emergency care for up to 72 hours at any hospital (public or private). Hospitals apply a single medical criterion called Emergency Severity Index (ESI) through the pre-authorization 141 (PA) programme and deliver appropriate emergency medical care. During this time, the patient can be transferred to their registered hospital if ongoing inpatient treatment is required. The fee schedule has been used as a provider payment method for hospital emergency services (National Health Security Office, 2020g). According to the Road Accident Victims Protection Act B.E. 2535 (1992), individuals injured in motor vehicle accidents requiring emergency care can seek reimbursement for health-care services up to a maximum of THB 30 000. In cases where the patient suffers severe damage resulting in disability, the preliminary compensation payment is capped at THB 35 000 (Royal Thai Government Gazette, 1992, 2009). 5.5.5 Challenges for systems development Despite progress, several challenges still persist, including regional disparities in EMS coverage, supply–demand imbalances, concerns over service quality, and issues related to ambulance safety (Pochaisan et al., 2021). The establishment of EM units should be considered on the basis of economies of scale, coverage and care quality. The shift from first response to basic life support may be financially driven, requiring evidence-led recommendations from the NIEM for accountability and efficiency. Investment in hospital emergency services infrastructure, staff training, and fast-track programmes for stroke and acute STEMI cases is crucial. These fast-track programmes have shown success in both prehospital and hospital service system management due to hospital leadership and the effective cycle of plan–do–check–act (Suriyawongpaisarn, 2009). Success in these areas should drive overall system development. 5.6 Pharmaceutical care 5.6.1 Pharmaceutical industry The pharmaceutical industry in Thailand consists of local production, importation, and exportation. Most of the local production, more than 90% in terms of value, is used for consumption in the country. The export of pharmaceutical products, although low, has slightly increased. Most export destinations are neighbouring countries such as Myanmar, Cambodia, and Lao People’s Democratic Republic (Department of Trade Negotiations, 2020). In 2020, the total value of modern pharmaceutical production and importation was THB 210 billion, of which approximately 30% is from local production and 70% from importation, indicating high consumption of imported medicines. 142 The rising consumption of imported medicines was evident from 2005 then started to stabilize from 2009 (Fig. 5.7). Fig. 5.7 Value of imported and domestic production medicines, 1987–2020 69 72 72 72 70 70 70 68 63 64 59 63 57 56 54 55 51 51 44 41 44 36 35 32 37 31 33 34 32 32 32 32 32 33 0 10 20 30 40 50 60 70 80 0 20 000 40 000 60 000 80 000 100 000 120 000 140 000 160 000 19 87 19 89 19 91 19 93 19 95 19 97 19 99 20 01 20 03 20 05 20 07 20 09 20 11 20 13 20 15 20 17 20 19 % D om es tic p ro du ct io n TH B ah t ( M ill io n) Domestic production (million Baht) Import (million Baht) % domestic production Note: the graph shows ex-factory prices of modern human medicines Source: (Medicine Regulation Division, 2022) As of June 2022, there are 176 GMP-certified modern pharmaceutical manufacturing facilities in Thailand (Food and Drug Administration, 2022). Classified by ownership, nine facilities are government-owned or stock- based pharmaceutical manufacturing facilities. The remaining facilities are privately owned, mostly by Thais, with foreigners owning or holding the major shares of nine facilities (Nimkulrat et al., 2020). In 2011, Thailand allocated a modest portion of its GDP, approximately 0.37% (THB 40 870 million), towards R&D. However, this allocation increased significantly to 1.33% (THB 208 009 million) in 2020 (Office of National Higher Education Science Research and Innovation Policy Council, 2017, 2022). Until the early 2010s, pharmaceutical manufacturers did not give much importance to R&D both in technology and personnel. On the one hand, there was insufficient support from government policies, while on the other hand, most 143 of the Thai-owned private companies focused on the development of drug formulations to improve drug properties rather than developing new drugs. In the past ten years, circumstances have changed dramatically as many pharmaceutical companies have set up R&D departments with increased budgets. However, the number of new drug formulations is limited due to various reasons, including the unpreparedness of the industrial sector and the lack of clear guidelines for the registration of new drugs produced in Thailand. To address these challenges, the government has collaborated with the private sector to support R&D in the pharmaceutical industry. This includes the establishment of agencies that provide services for conducting bioequivalence studies and supporting the development of new drugs. Additionally, clear policies, guidelines, and procedures have been laid down to promote the development of new drugs (Nimkulrat et al., 2020). The R&D budget has seen a substantial increase, specifically in the area of vaccine development, in response to the COVID-19 pandemic. For instance, the budget allocated for vaccine development by the National Vaccine Institute (NVI) increased from THB 11.3 million to THB 2966.1 million in 2019 and 2021, respectively. However, it decreased to THB 487.4 million in 2022 (National Vaccine Institute, 2019, 2021, 2022). 5.6.2 Distribution channels In the past, domestic manufacturers and small importers frequently handled their own logistics, while large importers, particularly multinational pharmaceutical companies, often relied on third-party outsourcing. However, currently, there is a growing trend among domestic manufacturers and small importers to also utilize third-party services to minimize administrative costs (Nimkulrat et al., 2020). Mail ordering of medications with the use of telemedicine from hospitals to patients has become more popular. It was used to provide services without getting in touch during COVID-19. After the pandemic, it was found to help decrease congestion in public hospitals. Patients also felt it was more convenient if they did not need to come to hospitals frequently (Soonthorn et al., 2022). 5.6.3 Provision of pharmaceuticals to the public Outlets for pharmaceuticals include hospitals, both public and private, clinics and pharmacies. Recently, convenient stores can legally sell OTC drugs as a response to people’s self-medication behaviours. Online sales of medications have become more popular, especially during the COVID-19 pandemic, but they are illegal. 144 Modern medicines for human consumption can be sold in two types of pharmacies. A Type I pharmacy, operated by a registered pharmacist, can sell all medicines, including dangerous drugs that need to be dispensed by a pharmacist and specially controlled drugs that require a prescription. A Type II pharmacy, operated by a pharmacist or other kinds of health professionals, can sell only ready-packaged drugs that are not classified dangerous drugs or specially controlled drugs. In 2022, there were 20 542 pharmacies categorized into 18 396 and 2146 Type I and Type II pharmacies, respectively (Medicine Regulation Division 2022). Due to the increasing number of pharmacists, the FDA is focusing on promoting Type I pharmacies and no longer allowing new registrations for Type II pharmacies. As a result, the number of Type I pharmacies has been growing steadily, while the number of Type II pharmacies has been declining. Furthermore, in 2015, the Pharmacy Council of Thailand introduced a voluntary programme to enhance the qualifications of Type I pharmacies and certify them as “quality pharmacies” (Pharmacy Council of Thailand, 2023). Up to 2022, there were 1526 quality pharmacies in the registry. These quality pharmacies have collaborated with the NHSO to pilot a new benefit package for 16 common conditions that can be treated by a certified community pharmacy (National Health Security Office, 2022c, 2023a). Pharmacies are an important source for Thai people to purchase medicines for their minor illnesses. In rural areas, medicines such as antibiotics, nonsteroidal ani-inflammatory drugs (NSAIDs) and steroids are sold illegally in corner shops (Booddawong B et al., 2022). 5.6.4 Access to medicines In Thailand’s public health system, access to medicines faces distinct challenges across various pharmaceutical product categories, each posing its unique set of issues. Patent drugs One of the pressing issues in Thailand’s health-care system is the differing provider payment methods among the three public schemes, which notably influence medicine prescribing patterns, particularly for expensive medications outside the national list of essential medicines. For instance, a study found that among the hospitals visited by CSMBS members, hospitals with relatively higher expenditure prescribed a lower share of drugs from the NLEM. The fee-for-service payment system within the CSMBS health-care scheme leads to the ordering of more diagnostic tests and prescriptions of more medications during outpatient visits, effectively resulting in a higher level of service intensity for patients, even though there are no significant 145 official differences in outpatient benefits between the UCS and CSMBS (Patcharanarumol et al., 2018). To tackle this challenge, Thailand has established a system of centralized purchasing and distribution for costly medicines like HIV drugs and those in the National Essential Medicines E2 list as well as some types of vaccines, enhancing accessibility and affordability. Generic medicines and orphan drugs Certain types of medications, such as antitoxin, antidote, and orphan drugs, face limited production and availability due to their low demand and unprofitability for the pharmaceutical industry. To address this issue, Thailand has adopted measures such as tax exemptions and expedited registration processes for manufacturers and importers dealing with orphan drugs, aiming to encourage their production and widespread availability. Additionally, the Toxicology Center at Ramathibodi Hospital stocks and provides access to antitoxin, addressing the scarcity of these critical medications. Similar strategies are applied to boost the accessibility of generic medicines, ensuring that essential medications are readily accessible to the population. Thailand once considered compulsory licensing as a solution. However, this approach is no longer in use due to adjustments made by Indian manufacturers to comply with World Trade Organization (WTO) regulations, preventing them from producing generic drugs with unexpired patents (Chokevivat, 2020; Wibulpolprasert et al., 2011a). Patient access programmes Patient access programmes are arrangements among patients, hospitals, and multinational pharmaceutical companies to provide conditional access to a specific group of medicines. The majority of them (>90%) are innovative cancer drugs. However, the programmes are controversial because pharmaceutical companies design and manage the arrangements and collect medical records directly from patients. Arrangements for a specific drug may be different among hospitals. It is also found that medicines under the programmes have been delayed in being proposed for inclusion in the National List of Essential Medicines (NLEM) (Suchonwanich et al., 2020). 5.6.5 Price control Thailand lacks a well-established legislative measure for pharmaceutical price control, with retail prices influenced by market dynamics. Although pricing is under the Ministry of Commerce, drug prices vary across health- care settings, with retail prices up to 15% higher than in public hospitals, and even higher mark-ups in private hospitals and clinics. 146 Recognizing the cost–inefficiency of expensive medications, the health- care system has effectively introduced price negotiation procedures for the inclusion of drugs in the NLEM. Within the capitation payment system, providers lack incentives to prescribe costly medications to beneficiaries. Consequently, the NHSO initiated a special access programme involving financial strategies and centralized procurement to engage in price negotiations for medicines with restricted availability, including antidotes, clopidogrel, and exceedingly expensive drugs. The prices of medicinal products are regulated only when they are included in the NLEM. While this regulation applies to public hospitals, private hospitals can set their own prices, as long as they do not exceed the distributor-defined maximum. Private hospitals have exhibited resistance to disclosing drug prices in the past. In 2019, a law was enacted mandating private hospitals to disclose this information. 5.6.6 Pharmaceutical consumption The proportion of drug spending on health expenditure has been increasing continuously. It increased from 42.6% in 2015 to 46.4% in 2018 or THB 180.585 billion in retail prices. 5.6.7 Current challenges and reform plans The problem of antimicrobial resistance (AMR) poses a major threat to Thai public health in terms of mortality and economic loss. It was estimated that each year, there are 38 000 deaths due to resistant infections in an infected population of 100 000. This causes an economic loss of THB 40 billion per year (Phumart et al., 2012). Thailand implemented a National Strategic Plan on AMR 2017–2022. At the end of the implementation phase, resistance rates of leading pathogens such as Acinetobacter baumannii and Klebsiella pneumoniae were still high and continuing to increase. Irrational use of antimicrobials both in humans and animals is still high. More actions are needed both at the policy level and in public participation. In February 2021, the Thai Cabinet approved the National Drug Policy and National Drug Development Strategy for 2020–2022, aiming to ensure that all Thai people have access to affordable, quality essential medicines, and that the country has a sustainable drug supply (National Drug Information, 2021). The challenges are its implementation and monitoring and evaluation. 5.7 Rehabilitation/intermediate care Rehabilitation care in Thailand primarily focuses on restoring functional abilities for independent living and social participation. Post-acute 147 rehabilitation care is included in the acute treatment benefit package, while subacute rehabilitation or intermediate care is covered under the “rehabilitation benefit package”. These packages are applicable to individuals with disabilities, the elderly, and patients transitioning from the acute phase to the subacute phase. They are available for Thai nationals for both individuals covered under the UCS and those not covered under the UCS as well (National Health Security Office, 2012a). Thus, subacute rehabilitation care requires a functional assessment of the individual and goal-setting in either a short- or long-term care plan. The Barthel index has been used for this assessment in some provinces as an R&D pilot together with rehabilitation impairment category (RIC), which is closely related to the disease diagnosis by the International Classification of Disease (ICD) (Kheawcharoen et al., 2007). Additionally, the International Classification of Functioning, Disability and Health (ICF) has been conceptually utilized in community and PHC approaches to communicate and link health and social rehabilitation care for persons with disabilities. The ICF coding system is in the trial phase. 5.7.1 Organization of services Structurally, there is a rehabilitation department in every provincial and regional hospital, and there are a few physiotherapists working in multidisciplinary teams with a community nurse and family or general physician in district or community hospitals. In 2021, there were 5722 physiotherapists working in different settings; 4.19 per institution on average (Strategy and Planning Division, 2021c). Most rehabilitation personnel are concentrated in hospitals affiliated with a local government organization, an independent organization, and other ministries (Fig. 5.8). In 2019, the MoPH developed a service plan for intermediate care (IMC) which in the initial phase focuses on patients with stroke, traumatic brain injury and spinal cord injury. The service plan has driven the establishment of a seamless care system among centres of excellence, tertiary care, secondary care, and primary care across all provinces (Tejativaddhana et al., 2023). The IMC is transitional care between the post-acute and clinically stable phases, which can be carried out at home or in the community using a multidisciplinary approach (Health Administration Division, 2019). In 2018, intermediate beds or wards were available in 39.7% of district hospitals and small general hospitals, and this availability increased to 94% in 2021 (Fig. 5.8). In 2022, 83% of patients with stroke, traumatic brain injury, spinal cord injury or fractured hip who received IMC were followed up for 6 months or until they had a Barthel index score of 20 before 6 months (Ministry of Public Health, 2022b). 148 Fig. 5.8 Average number of physiotherapists by hospital affiliation, 2021 3.71 7.45 8.11 13.38 4.17 4.19 0 2 4 6 8 10 12 14 16 MOPH Other ministries Independent organization Local goverment Private Nationwide N um be r o f p hy si ot he ra pi st s pe r h os pi ta l Source: (Strategy and Planning Division, 2021c) 5.7.2 Availability and accessibility of services Inadequacy of rehabilitation services may cause permanent disability in patients, shifting the burden to families (Riewpaiboon et al., 2011; Riewpaiboon et al., 2009). In the community, there are health volunteers working collaboratively with social development and human security volunteers to improve access to services and the quality of life of persons with disabilities (PWD) and older people. They utilize resources under the Empowerment of Persons with Disabilities Act 2550 B.E. (2007) and the Elderly Act B.E. 2546 (2003). These include a living allowance from the local authority office, travelling assistance, and home modification (Royal Thai Government Gazette, 2003, 2007b). An assessment study in 2009 showed that most stroke survivors are still unable to perform activities of daily life on the day of discharge from provincial and regional general hospitals (Vichathai et al., 2009). The average length of stay of patients with acute stroke in general hospitals was only 7.9 days (Sa-ringkan et al., 2021). They were commonly referred back to a community hospital close to where they lived, but most did not go on to attend rehabilitation care at the hospital due to difficult and costly transportation. There was consistent inadequacy of rehabilitation staff in providing outreach or home-based rehabilitation care, particularly at the district and lower levels. However, recent years have seen an increase in physiotherapists at district and subdistrict levels, focusing on subacute and non-acute health care. Nurses were also additionally trained in rehabilitation. 149 Community-based rehabilitation was a common approach and conducted in tandem with family medicine practice. Assistive devices such as wheelchairs, prostheses, orthoses, other mobility aids, hearing aids and visual aids are included in the rehabilitation benefit package of the UCS and are provided, which addresses needs at the provincial level. However, long-term maintenance services are rather inadequate. There are some sporadic community development wheelchair and prosthetic workshops, which are usually collaborations between a hospital, PWD self-help group and NGO, with support of the NHSO. Rehabilitation care financing for UCS increased from THB 4 per capita in 2004 to THB 18.73 per capita in 2022 (National Health Security Office, 2022e). About 30% of the annual budget is targeted for development of rehabilitation services. The remaining 70% is allocated for hospital services reimbursement, including both rehabilitation services and assistive devices. A pilot decentralization initiative started in 2010 between the NHSO and Provincial Administrative Organization (PAO). It is expected to be a better cofinancing system for integrative health and social care for PWD and older people. In 2022, 58 out of a total of 76 PAOs participated (National Health Security Office, 2022e). The SHI covers rehabilitation care but faces issues with a retrospective fee- for-service reimbursement system, hindering access. The majority of those with disabilities quit work and have less cash to pay upfront; moreover, they also have difficulty in travelling to claim reimbursement for their payments. The CSMBS does not specifically mention rehabilitation for restoring functional ability, but as a part of the treatment process of disease. However, the costs of rehabilitation care could be reimbursed. Thailand’s national disability statistics show that, in 2017, 5.5% of the population had some kind of disability or impairment, increasing to 6.0% in 2023 (National Statistical Office, 2017, 2022a). As of March 2022, there were 2 180 178 (1 136 836 male and 1 043 342 female) PWD legally registered with the Ministry of Social Development and Human Security (Department of Empowerment of Person with Disabilities, 2023). To access health care, particularly rehabilitation care, 1 292 496 legally registered PWD were registered with the UCS in 2022 (National Health Security Office, 2022e). The average percentage of UCS-registered PWD is about 2.74% of the total UCS population, ranging from 1.1% in region 4 (Saraburi) to 9.21% in region 1 (Chiang Mai) (Fig. 5.9). This implies that more people who 150 are in need of rehabilitation care could access it by right. Geographical disparities persist, with uneven access due to varying capacity for provision of rehabilitation service. Fig. 5.9 Number and percentage of UCS-registered persons with disabilities, 2022 3.6% 3.2% 3.2% 2.3% 2.4% 2.0% 2.9% 2.9% 3.6% 3.3% 2.0% 2.2% 2.1% 0% 1% 1% 2% 2% 3% 3% 4% 4% 0 20 000 40 000 60 000 80 000 100 000 120 000 140 000 160 000 180 000 200 000 Re gi on 1 Ch ia ng M ai Re gi on 2 Ph its an ul ok Re gi on 3 N ak ho n Sa w an Re gi on 4 Sa ra bu ri Re gi on 5 Ra tc ha bu ri Re gi on 6 Ra yo ng Re gi on 7 Kh on K ae n Re gi on 8 Ud on T ha ni Re gi on 9 N ak ho n Ra ts ha si m a Re gi on 10 U bo n Ra tc ha th an i Re gi on 11 S ur at T ha ni Re gi on 12 S on gk hl a Re gi on 13 B an gk ok Pe rc en ta ge o f U CS -r eg is te re d w tih d is ab ili tie s N um be r o f U CS -r eg is te re d w tih d is ab ili tie s UCS-registered PWD % UCS-registered PWD Source: (National Health Security Office, 2022e) As a result of improved access to health care by PWD, service utilization in terms of the number of persons and visits for rehabilitation care increased markedly (Fig. 5.10); however, the distribution is uneven across health regions. 151 Fig. 5.10 Rehabilitation service use as persons and visits by region, 2021 and 2022 0 50 000 100 000 150 000 200 000 250 000 300 000 350 000 400 000 450 000 Re gi on 1 Ch ia ng M ai Re gi on 2 Ph its an ul ok Re gi on 3 N ak ho n Sa w an Re gi on 4 Sa ra bu ri Re gi on 5 Ra tc ha bu ri Re gi on 6 Ra yo ng Re gi on 7 Kh on K ae n Re gi on 8 Ud on T ha ni Re gi on 9 N ak ho n Ra ts ha si m a Re gi on 10 U bo n Ra tc ha th an i Re gi on 11 S ur at T ha ni Re gi on 12 S on gk hl a N um be r o f s er vi ce No. of service (person) 2021 No. of service (visit) 2021 No. of service (person) 2022 No. of service (visit) 2022 Source: (National Health Security Office, 2021c, 2022e) Physiotherapy focused on mobility and ambulation were most commonly provided, followed by psychotherapy, behaviour therapy, activity therapy, and hearing rehabilitation. Early intervention, visual rehabilitation, speech rehabilitation and phenol block were very few (Fig. 5.11). The setting where rehabilitation services are provided is concentrated under the MoPH. The average number of visits to the rehabilitation care programme was about three visits per person per year, which seems rather low for ensuring improvement of functional outcomes. 152 Fig. 5.11 Number of visits by type of rehabilitation services, 2020 and 2022 1 10 100 1 000 10 000 100 000 1 000 000 10 000 000 Ph ys ic al th er ap y Ps yc ho th er ap y Be ha vi or th er ap y Ac tiv ity th er ap y H ea rin g re ha bi lit at io n Ea rl y in te rv en tio n Vi su al re ha bi lit at io n Sp ee ch re ha bi lit at io n Ph en ol b lo ck N um be r o f v is its No. of service (visit) 2020 No. of service (visit) 2021 No. of service (visit) 2022 Source: (National Health Security Office, 2022e) Provision of assistive devices has been increasing (Table 5.4). In recent years, the ratio of the number of devices per person is stable from 1.22:1 in 2020 to 1.23:1 in 2021 and 1.24:1 in 2022. This might imply more effective distribution of devices to needy persons, i.e. better access to this kind of rehabilitation service. However, great variation in service utilization was found by region. 153 Table 5.4 Number of PWDs receiving assistive devices and number of devices by region, 2020–2022 Region 2020 2021 2022 No. persons No. devices No. persons No. devices No. persons No. devices Region1 Chiang Mai 3 085 4 413 2 535 3 996 3 896 5 157 Region2 Phitsanulok 1 670 1 916 1 445 1 566 1 861 2 023 Region3 Nakhon Sawan 1 543 1 589 1 321 1 429 1 767 1 927 Region4 Saraburi 2 562 3 082 1 885 2 343 2 782 3 567 Region5 Ratchaburi 1 806 2 019 1 618 1 763 1 756 1 959 Region6 Rayong 2 156 2 598 1 619 1 939 2 203 2 721 Region7 Khon Kaen 3 736 5 209 3 763 5 413 4 070 6 515 Region8 Udon Thani 3 019 4 101 2 998 3 706 2 974 3 653 Region9 Nakhon Ratshasima 3 074 3 382 2 667 2 938 3 136 3 438 Region10 Ubon Ratchathani 2 549 2 848 2 236 2 482 2 355 2 672 Region11 Surat Thani 1 071 1 268 1 057 1 223 1 043 1 236 Region12 Songkhla 1 926 2 181 1 710 1 952 2 159 2 383 Total 28 197 34 606 24 854 30 750 30 039 37 289 Source: (National Health Security Office, 2020b, 2021c, 2022e) In summary, improved access to rehabilitation services and assistive devices has been observed, even though geographical inequity remains. However, for some specific population groups, there are other kinds of barriers such as physical for people with mobility disorders, language for the deaf, and information access for the blind. Ramps, accessible toilets and car parks are the minimal access concerns of nearly all hospitals and health centres, but the quality of this physical access is sometimes inadequate. To reduce the communication barrier for the deaf, the NHSO supported training in basic sign language for health-care providers; however, this was discontinued as it was not effective for various reasons. A sign language interpretation service has been developed by the Ministry of Social Development and Human Security (MSDHS). For information access for the blind, there is no specific intervention in the health system, but there is concern and action in the wider social context of Thailand. 5.7.3 Current problems and challenges The major challenges in recent years have come from the increasing need for rehabilitation care for the ageing population and increasing prevalence of chronic disabling health conditions either from injuries or diseases. The 154 current acute-oriented health system has little space for subacute labour- intensive rehabilitation care, which requires more time. While tertiary health-care settings have more rehabilitation personnel, most PWD who are in need of rehabilitation services live in rural communities. Redistribution of rehabilitation personnel and redesigning of health-care facilities at the secondary level are challenges for future reform plans. 5.8 Long-term care and informal care 5.8.1 Situation of care needs Long-term care (LTC) is a range of medical and/or social services designed to help people with disabilities or chronic care needs. Services may be short- or long term and may be provided in a person’s home, in the community, or in residential facilities (e.g. nursing homes or assisted living facilities). Most of the people in Thailand who need LTC are senior citizens. The rapidly growing number of older people in Thailand and PWD, including patients with chronic conditions who need continuity of care, indicate the need for development of the LTC system. It was projected that the number of older people with severe- to-profound dependency levels would increase from 40 000 men and 60 000 women in 2004 to 110 000 and 170 000, respectively, in the following 20 years (Table 5.5) (Srithamrongsawat et al., 2009). Table 5.5 Projection of the number of various dependent levels of older people, 2004–2024 (millions) Limit in activity of daily living Male Female 2004 2009 2014 2019 2024 2004 2009 2014 2019 2024 None 2.36 2.87 3.55 4.42 5.35 2.51 3.46 4.49 5.67 6.91 Mild 0.33 0.37 0.44 0.53 0.64 0.68 0.69 0.75 0.88 1.03 Moderate 0.2 0.21 0.24 0.29 0.35 0.37 0.32 0.35 0.41 0.48 Severe 0.03 0.04 0.05 0.06 0.07 0.04 0.05 0.06 0.08 0.1 Profound 0.01 0.02 0.03 0.04 0.04 0.02 0.03 0.04 0.05 0.07 Total number of elderly (millions) 2.93 3.51 4.31 5.34 6.45 3.62 4.56 5.7 7.09 8.58 Source: (Srithamrongsawat et al., 2009) In Thailand, most older individuals requiring LTC receive informal assistance from the family. The Second National Plan on the Elderly (2002–2021), initiated in 2001, emphasizes LTC strategies, including promoting family- based care, offering health and social services in the home/community and institution, developing housing options, and environmental adaptation to fit in with the activities of older people (Chen et al., 2009). Since 2009, local governments have prioritized home/community services to support 155 older individuals and their caregivers, aligning with the Plan’s shift towards emphasizing home- and community-based services to facilitate independent living. (Kespichayawattana et al., 2008; National Comittee on Ageing, 2020). Two main ministries are responsible for providing the services mentioned above – the MoPH and the Ministry of Social Development and Human Security (MSDHS). According to the 2017 Disability Survey, 498 628 older persons faced a great deal of difficulties/problems in carrying out at least one daily routine activity such as eating, bathing, face washing/teeth brushing, dressing, and excretion and cleaning after excretion. Approximately 457 241 persons, or 91.7%, had caregivers. Most caregivers were their family members (84.9%). However, some caregivers did not stay with their families, such as relatives, nurses/health service officers, and special caregivers (National Statistical Office, 2017). In 2006, the Local Health Security Fund (LHSF) started as a matching fund between the NHSO and 888 local government organizations, including TAOs and municipalities. The Fund supports long-term care services for dependent persons from all schemes. In 2022, the number of local government organizations participating in the Fund increased to 7 774, and the fund for services of dependent people in communities was THB 990.11 million. The number of beneficiaries rose from 80 826 in 2016 to 201 291 in 2022 (National Health Security Office, 2022e). The per capita spending from the NHSO is THB 45 for UCS members and non-UCS members, and local government organizations contribute 30–60%, according to their size. In 2016, long- term care services for dependent persons were added to the Fund with an additional THB 6 000 per capita from the NHSO (without co-financing). Initially, some local authorities did not utilize their budget, but the unspent fund reduced from THB 4 289.30 million in 2017 to THB 2 770.85 million in 2022. Local authorities can also utilize budget from other funds, including the Provincial Rehabilitation Fund, to integrate long-term care services in their area and to make the services stronger and more efficient (National Health Security Office, 2022e; Noree et al., 2020). 5.8.2 Organization of long-term care There are several forms of welfare systems and services provided by governments, the private for-profit sector, and NGOs. However, the government puts more emphasis on empowering independent older persons to live within their communities and provides residential homes for independent older people who have no carer at home. The majority of services for older people with some degree of dependency are mainly 156 provided by private for-profit providers. Table 5.6 presents available services for both independent and dependent older people in Thailand. Table 5.6 Available welfare services and care assistance for Thai elderly persons Elderly/PWD caregiving system/providers Responsible organization 1. Informal care 1.1 Home- and community-based care 1.1.1 Home care volunteers • Department of Older Persons (Ministry of Social Development and Human Security) 1.1.2 Older persons’ clubs Senior Citizens Council of Thailand under the patronage of her Royal Highness Princess Srinagarindra 1.1.3 “Home care peer group” volunteer project Senior Citizens Council of Thailand under the patronage of her Royal Highness Princess Srinagarindra 1.1.4 Community welfare funds for the elderly Community Organizations Development Institute 2. Formal care 2.1 Home- and community-based care 2.1.1 Home health care by health practitioners MoPH 2.1.2 Paid caregivers Private sector, profit-making organizations 2.1.3 Personal assistants MSDHS 2.2 Institutional care 2.2.1 Residential homes for older persons MSDHS, BMA, PAO 2.2.2 Elderly care centres • LTC hospitals Private for-profit and public organizations • Centre for living assistance (day care) Private for-profit and public organizations • Nursing homes Mainly private for-profit • End-of-life care Private for-profit and public organizations MSDHS: Ministry of Social Development and Human Security; BMA: Bangkok Metropolitan Administration; PAO: Provincial Administration Organization; LTC: long-term care Source: Synthesis by the author Government agencies still serve as the main mechanism for initiating and arranging models of services or activities for older people and care for PWD. Most LTC in Thailand is informal. There are many forms/models of elderly care as detailed in the following. 157 Informal care 1. Home care for older people and persons with disabilities This project was initiated and has been carried out by the MSDHS since 2002 with the objectives of building the care system and protecting the rights of older persons in the community. The project is undertaken through interaction between the public and community members, so that they can take part in caring for older people and PWD in their own communities. The project targets those without caregivers who encounter social problems and enables them to access home-based care provided by volunteers/field workers and to access public services. More importantly, it supports them so that they can live with their families in the community and have a good quality of life. On 10 April 2007, the Cabinet adopted a resolution extending the home care project to cover all areas of the country. In 2021, there were 13 387 home care volunteers (Foundation of Thai Gerontology Research and Development, 2023). 2. Home care peer group volunteer project In addition, there is a home care project in the form of a peer group carried out by the Senior Citizen Council of Thailand under the royal patronage of Her Royal Highness Princess Srinagarindra. This project has 76 provincial branches all over the country in collaboration with provincial health offices (Foundation of Thai Gerontology Research and Development, 2021). The concept is to train members of elderly persons’ clubs to become home-care volunteers, supervised by the local community hospital. Volunteers visit the dependent older persons twice a week. Formal care 1. Home-based and community-based care Home health care (HHC) The Department of Health and MoPH initiated the home health care (HHC) project in 2005, collaborating with hospitals to provide integrated health care at home for older persons. Expanded in 2006–2007 to all MoPH hospitals, the project aims to develop HHC, strengthen family and community caregiving, and enhance preventive health measures, reducing the burden on hospitals. Since 2014, PHC services for the elderly have been fundamental, with a focus on elderly-centred health services (Department of Medical Services, 2014). The Integrated Care for Older People (ICOPE) Framework, along with the “Every Thai Family has Three Doctors” policy and the concept of “integrated people-centred health services”, aims to establish seamless elderly care in the community through pilot projects in seven provinces (Department 158 of Health Service Support, 2020; Foundation of Thai Gerontology Research and Development, 2021). Health services involve collaboration with VHVs through PHC facilities, with 1 039 729 volunteers in 2021 (Foundation of Thai Gerontology Research and Development, 2023). Social services are primarily provided by local governments, supported by the MSDHS and Ministry of Interior (MoI), but the integration of health and social services lacks systematic organization (Foundation of Thai Gerontology Research and Development, 2023). Paid caregiver (CG) The demand for formal LTC is rising due to an ageing population, increase in chronic disabling conditions, and urbanization (Kespichayawattana et al., 2008). Primarily available in urban areas, formal LTC is sought by families when they are unable to provide care for dependent members, often hiring caregivers (CG) when family members work outside the home. In 2016, the NHSO allocated funding for CGs from the LHSF through local government organizations, enhancing home LTC quality (Kitreerawutiwong et al., 2018; National Health Security Office, 2016a). CGs, mainly VHVs, undergo a 70-hour or 420-hour training course conducted by the Department of Health, MoPH, after which they can work in the private sector as well. Their job is to visit and assist elderly and dependent patients with daily activities such as bathing, eating, dressing, taking medication, screening, and providing primary health-related procedures, according to the care plan designed by the care managers (Noree et al., 2020). In 2021, there were 94 968 caregivers (Foundation of Thai Gerontology Research and Development, 2021). In communities where local administrative organizations collaborate with health centres or subdistrict health-promoting hospitals for LTC management, CGs receive THB 600 per month for 1–4 dependent cases and THB 1500 baht for 5–10 cases. The LHSF allocates THB 5000 per person per year to health-care facilities based on registered dependent patients. In areas where local governments establish their own elderly quality-of-life development centres for LTC, they can set remuneration rates, ensuring that the rate is not below the local minimum wage (Noree et al., 2020). Care centres Care centres offering assistance to older individuals, PWD, and those with chronic diseases at home have gained popularity, especially in urban areas like Bangkok. Most elder care training schools, managed by medical or nursing professionals, also function as companies, connecting students with job opportunities. The schools also act as intermediaries among workers, 159 older people/PWD and families. The exact count of these caregiver centres is uncertain due to a lack of systematic registration. Government ministries have initiated steps to regulate formal LTC businesses. The MoPH outlined regulations in January 2010, categorizing businesses providing home health care for older persons as controlled businesses according to the Public Health Act, B.E. 2535 (second edition in 2017). However, local governments are responsible for enforcement, and implementation is pending. In October 2009, the MSDHS introduced a regulation for paid personal assistants aiding PWD, funded by the government at THB 50/hour for 6 hours/day, which was initiated nationwide in 2011. 2. Institutional care Residential care The Department of Social Development and Welfare of the MSDHS takes care of residential homes for older people and PWD. In 2003, there were 13 elderly care institutions and social service centres under the Department of Social Development and Welfare, transferred to the PAOs (Department of Local Aministration, 2022). There were 11 protection homes run by the Department of Social Development and Welfare for the destitute, which included older people along with destitute persons (Miankerd, 2020). In 2015, the Department of Older Persons was established, affiliated to the MSDHS, to promote elder potential, welfare and the right to protection. The Department of Older Persons takes direct charge of 12 residential homes for older people (Department of Older Person, 2023). The Department of Older Persons provides development and rehabilitation services for the elderly in collaboration with other related private and public agencies. These LTC services include health care, rehabilitation, education, social care, and occupation. Services have been provided in all 12 residential homes. Institutional care in other forms Public and private hospitals, along with private nursing homes, provide institutional LTC. Private hospitals offer general care with teams of medical professionals, including physicians and nurses. Nursing homes provide 24/7 care, covering daily routines, movement, socializing, mental health, medical support, meals, and accommodation. Regulated by the MoPH since 2020 (Ministry of Public Health, 2020), there were 729 licensed elderly care facilities in 2023. Out of these, 269 facilities (36.9%) were located in Bangkok, 141 facilities (19.3%) in the Central region, 91 facilities (12.4%) in the Western region, 75 facilities (10.2%) in the Eastern region, 88 facilities 160 (12.0%) in the Northern region, 39 facilities (5.3%) in the North-eastern region, and 26 facilities (3.6%) in the Southern region (Department of Health Service Support, 2023). The majority (97.9%) were nursing homes, mainly run by private hospitals and religious NGOs, followed by residential homes for older persons (1.8%), and centres for living assistance (day care) (0.2%). Since there is no specific ministerial regulation on nursing homes, a nursing home can be registered under the ministerial regulation of acute hospitals. Private hospitals with facilities to treat acute illnesses can immediately turn some beds into long-stay care service. Consequently, data on the total number of nursing homes and their capacity are not available from registration. Quality accreditation of nursing home services is currently crucial (Kespichayawattana et al., 2008). The first public nursing home, Chiangmai Neurological Hospital, established in 2009, caters to both independent and dependent older persons and those with stable chronic conditions. Service charges vary according to the dependency level and room type, with a capacity for 20 beds for out- and inpatients. 5.8.3 Challenges for system development For home- and community-based care, no definite and systematized data are available to monitor the quantity and quality of services provided. The services are reported within the regular health service activities such as home health care, services for people (not specifically for frail elderly persons/PWD) by VHV or health personnel. Social care is reported separately by the MSDHS. These are the challenging issues of integration with health and social LTC. There has been an increasing number of public residential homes and private nursing homes to respond to the needs of older people and people with chronic disease. Of the older persons in such residential homes, over 50% were dependent and needed more intensive health care in LTC, which is currently very limited. 5.9 Palliative care 5.9.1 Organization of services Palliative care in Thailand has evolved, with a focus on late-stage cancer patients due to declining HIV/AIDS cases. Thailand’s palliative care system has been improving. In the four-part typology developed by the International Observatory on End of Life Care, Thailand’s palliative care system was categorized as Group 3: localized hospice-palliative care provision, in 2006, 161 and in Group 4a: palliative care at the preliminary stage of integration, in 2017 (Clark et al., 2019). Thailand is moving forward to Category 4b: palliative care services at an advanced stage of integration. Initiatives include enhancing accessibility, multidisciplinary services, drug availability, and educational efforts. Palliative care in Thailand was developed mainly in response to the needs of HIV/AIDS and cancer patients. It is offered by faith-based community facilities (e.g. Camillian Social Centre, St Clare’s Hospice and Mercy Centre) and hospitals. The temple of Wat Phrabat Nambu provides supportive care to those who are dying. Hospital-based care, mainly for cancer patients, is provided by both public (MoPH hospitals) and private institutions. Hospitals provide both inpatient-based services and community care. Home- care programmes, initiated in 1998 by the National Cancer Institute and regional cancer centres, emphasize pain management and support (Wright et al., 2010). The MoPH developed palliative care guidelines in 2007, revised in 2020 (Department of Medical Services, 2020), and a service plan in 2017, with progress indicators (Hfocus, 2017). By 2018, 92.15% of MoPH hospitals offered palliative care. Opioid use in palliative care patients was 35.77% in 2020, decreasing to 34% in 2021 (Ministry of Public Health, 2018, 2021b). Additionally, in 2021, home-based continuity palliative care reached 39.48% of palliative care patients (Ministry of Public Health, 2021a). The NHSO started covering palliative care expenses in 2014, with patient numbers rising from 9477 in 2014 to 51 441 in 2022 (National Health Security Office, 2014, 2022e). The Healthcare Accreditation Institute (HAI) introduced palliative care indicators in 2006 such as pain management and psychosocial/ spiritual care, and expanded in 2022 to include care coordination and advance care planning and care at the terminal phase (Healthcare Accreditation Institute, 2010, 2018, 2022). During 2020–2022, the NHCO developed a national advance care plan (APC), including the consent for a living will according to section 12 of the National Health Act 2007 (National Health Commission Office, 2020 ) (National Health Commission Office, 2022c). 5.9.2 Access to palliative care Historically, opioid availability for pain management faced obstacles due to strict government controls and limited professional education fostering opioid phobia (Wright et al., 2010). Opioid analgesic sales in Thailand increased from 6.10 mg morphine equivalent per 1000 inhabitants per day 162 (MME per 1000 day) in 2015 to 6.94 MME per 1000 day in 2019. It remained significantly below the global average of 29.51 MME per 1000 day (Ju et al., 2022). Opioid analgesic consumption statistics indicate progress but underscore ongoing challenges. The rigid prescription system required patients to travel to hospitals, impacting accessibility (Wright et al., 2010), especially for immediate-release morphine (Thongkhamcharoen et al., 2013). At the implementation level, access to opioids was limited by restrictions on exchange of opioids among hospitals, which hindered the management of expired drugs and caused temporary shortages (Jaroonwattana, 2020). A survey conducted in 14 Thai hospitals revealed that 18.7% of palliative care inpatients met the criteria for having a life-limiting illness (Pairojkul, 2021). Among them, 55% had cancer and 44.4% had non-cancer-related illnesses. Surprisingly, only 17.3% of these patients received the hospital- based palliative care programme, with cancer patients more likely to receive palliative care consultations compared to non-cancer patients (22.7% versus 11.9%). While cancer patients received palliative care in regional hospitals, in rural areas they relied on community-based services. The capitation and DRG-based payment system of the UCS influenced hospital practices to contain costs and reduce inpatient beds for palliative care, leading to the development of community palliative care networks. In 2021, the NHSO introduced guidelines for home-based palliative care and morphine payment in response (National Health Security Office, 2012b). The NHSO developed the payment for home-based palliative care services and cost of opioids until the patients’ passing away or not more than 6 months (National Health Security Office, 2021a, 2022b). Educational efforts, particularly in medical and nursing schools, focused on fostering appropriate attitudes toward end-of-life care. The palliative care curriculum of the Faculty of Medicine at Prince of Songkhla University was designed with the inclusion of workshops on Dharma, healing workshops and “peaceful death” (Wright et al., 2010). From 2010 to 2020, intensive palliative care education efforts expanded, resulting in a network of services (Pairojkul, 2021). In 2019, a fellowship training programme was established. These initiatives underscore the commitment to enhancing the skills and knowledge of palliative care among health-care professionals, contributing to the expansion of services. The right to die without resuscitation, acknowledged in section 12 the National Health Act, 2007 (National Health Commission Office, 2007), led to guidelines and regulations in 2010 (National Health Commission Office, 2010). The dying person must express their wish to use this action when they 163 are conscious by self-completing or getting an assistant to help complete the form. A contentious issue, the right to die, prompted the addition of an advance care planning (ACP) indicator in the MoPH’s 2022 service plan (Strategy and Planning Division, 2022a). The NHCO developed a national ACP form to facilitate end-of-life care decisions. The integration of ACP into the service plan reflects a commitment to addressing ethical concerns and ensuring patient autonomy (National Health Commission Office, 2022c). Comprehensive research on this topic is needed, looking at different disciplines to help develop informed implementation. 5.10 Mental health care 5.10.1 Organization of mental health services The Department of Mental Health (DMH) is the national mental health authority. It provides advice to the government on mental health policy and legislation, sets the standard of care, and develops and transfers mental health technologies to all stakeholders. Mental health services are organized according to catchment areas. In 2022, there were 485 public mental health outpatient facilities in Thailand – 20 of them are in mental hospitals, under the DMH (Department of Mental Health, 2023b), and 465 public hospitals, including regional hospitals, general hospitals, and district hospitals, where mental health services are available, under the Office of the Permanent Secretary (OPS). Acute mental care services were available in 213 public hospitals under the OPS. Mental health- care services in the community were available in 374 primary care clusters (PCCs) (Department of Mental Health, 2016, 2022a). The majority of patients were diagnosed with addiction, schizophrenia, depression, anxiety and attention deficit hyperactivity disorder (ADHD) (Department of Mental Health, 2021b). In 2022, mental health assessment of the Thai people showed that 12.4% had a risk of depression, followed by 10.5% with high stress and 7% at risk of suicide (Thai Health Promotion Foundation, 2022a). 5.10.2 Mental hospitals There are 20 mental hospitals under the DMH, which have 6.6 beds per 100 000 population. There are 995 beds in four mental hospitals located in Bangkok and 900 beds in two mental hospitals located in Bangkok’s vicinity (Department of Mental Health, 2021a). 164 The number of psychiatric patients decreased by around 9% among admission cases, outpatient visits and outpatient cases during the COVID-19 pandemic in 2020 and 2021, compared with the number of patients in 2019 (Table 5.7). Table 5.7 Number of psychiatric patients, 2017–2022 2017 2018 2019 2020 2021 2022 Inpatients (admission cases) 98 992 95 885 97 720 87 919 77 077 80 020 Total outpatient visits 1 102 470 1 149 645 1 172 784 1 080 512 1 080 303 1 129 404 New outpatient cases 79 379 87 150 86 944 78 844 86 590 71 394 Source: (Department of Mental Health, 2022b) 5.10.3 Mental health in primary health care Both physician-based and non-physician-based PHC clinics exist in the country. Assessment and treatment protocols – the Clinical Practice Guideline (CPG) – have been introduced in the majority of physician-based PHC clinics. Few physician-based PHC clinics make referrals to a mental health-care professional, because having contact with mental health staff is still considered a stigma. Conversely, it is estimated that non-physician- based PHC clinics refer on average at least one case per month to a higher level of care. Community mental health services for chronic psychiatric patients have been included in the benefit package of the NHSO since 2016. The services consist of individual care planning and monthly home visiting. The home visit aims to follow up on ten aspects; mental health condition, drug administration, caregiver, alcohol or drug usage, daily tasks accomplishments, employment status, familial relationships, living environment, communication, and basic learning skills (National Health Security Office, 2021a). The services are provided by a network of health-care providers in primary care units, and in secondary or tertiary care units, including psychiatric hospitals, provincial hospitals and regional hospitals. In 2022, 10 723 patients received services in 958 primary care units, and 118 secondary or tertiary care units (National Health Security Office, 2022e). 5.10.4 Access to mental health services Patients who were physically restrained or secluded at least once in a psychiatric inpatient unit or mental hospital were estimated to be between 2% and 5% in both kinds of facilities. There are no records of involuntary admissions. However, it is estimated that the percentage was high because 165 almost all admissions are forced by the police or families. The number of beds in mental care hospitals ranged from 4362 to 4368 between 2019 and 2022. Out of these, 995 beds were located in Bangkok, while the remaining 3373 beds were distributed across other provinces. In terms of density, the number of mental care hospital beds per 100 000 population in Bangkok was the highest at 18.2, compared to the national average of 6.5 in 2022. This disparity creates inequitable access to care for rural residents (Department of Mental Health, 2022a). In 2022, of the estimated 1.36 million individuals aged 15 years and above suffering from depression, 90.59% (1.23 million) could access mental health services (Department of Mental Health, 2022c). In addition to psychiatric treatment, the DMH also provides a hotline 1323 for mental health consultation services and suicidal rescue. In 2023, there were 15 lines with 50 psychologists making the hotline available 24 hours, including communication via chat through the line application. These services were offered to people in all schemes free of charge (Department of Mental Health, 2023a; Hfocus, 2023a). This prevention strategy has been extended all over the country. 5.10.5 Human resources in mental health care Usually psychiatrists, psychologists and social workers work 25% of their time in inpatient and 75% in outpatient departments. Occupational therapists work only for inpatient departments, providing services until the patient’s discharge. The total number of human resources working in mental health- care facilities per 100 000 population is 4.95. In terms of staff-to-bed ratios, there are 0.05 psychiatrists, 0.44 nurses, 0.04 psychologists, 0.03 social workers or occupational therapists, and 0.25 other mental health workers per bed in mental hospitals. There is a clear shortage of psychologists and psychiatrists in Thailand, resulting in limited time devoted to each patient. Additionally, human resources in mental health care are concentrated in the main cities, which limits access to mental health services by rural users (Department of Mental Health, 2021a). 5.10.6 Financing of mental health services In addition to financing through the UCS, approximately 2.03% of MoPH health-care expenditure in 2021, or THB 2.9 billion, was directed towards mental health services. Of all the expenditure on mental health, 67.2% was directed towards human resources and 23.4% towards operating costs (Department of Mental Health, 2021a). 166 5.10.7 Challenges The ratio of human resources per hospital bed is low for all professional groups. The majority of beds are still located in mental hospitals. Access to mental health-care facilities is uneven across the country, favouring those living in or near the main cities. In terms of support for child and adolescent mental health, a psychosocial care system has been established in schools. Many primary and secondary schools have school-based activities to promote mental health and prevent mental disorders, and the existence of psychosocial care is one of the quality assessment criteria for schools by the Ministry of Education. However, psychosocial support in schools is mainly delivered by general teachers and only a few schools have part- or full-time mental health-care professionals. 5.11 Dental care 5.11.1 Organization of dental services Thailand’s oral health structure is a public–private mix, half of the dentists work in the private sector. In 2017, there were 16 102 dentists in Thailand with 78.8% practising in the health system. Among all active dentists, 44% are working in the MoPH, 5% in other government organizations, and 51% in the private sector. Thus, the private sector plays an important role in providing oral health services, especially in Bangkok and municipality areas. Thailand has a total of 6160 private dental clinics (as of August 2022). Of the total dental clinics, almost 30% or 1796 dental clinics are located in Bangkok. The majority of dental clinics are individually owned by dentists (Department of Health Service Support, 2022). In the public sector, the main provider is hospitals under the MoPH. Oral health services are available at all levels of health-care facilities, including 10 179 health centres at the subdistrict level, 775 district hospitals, 92 provincial hospitals, and 34 regional hospitals located countrywide. In 2021, the workforce consisted of 6013 dentists providing oral health promotion and disease prevention (PP) services and oral health treatment at secondary and tertiary levels, while 6221 dental nurses (who were not permitted to work in the private sector) mainly conduct PP services and basic treatment at the PHC level in community and health centres (Strategy and Planning Division, 2021b). The Bureau of Dental Health is the key institute responsible for technical support and monitoring of the PP programme. The programme covers all age groups, including pregnant women, preschool children, schoolchildren, adults, and seniors. It conducts an oral health programme for school 167 students (brushing after lunch, healthy snacks and banning carbonated drinks in school), a programme on healthy workplaces, an oral health promotion project in elderly clubs and proposes a tax on sugar sweetened beverages (SSBs). The Strategic Oral Health Plan of Thailand 2012–2016 and Thailand Oral Health Plan for the Elderly 2015–2022 are the core plans for driving the national oral health agenda. Accordingly, the Oral Health Service Plan Committee acts as a body to drive the oral health service system in the MoPH. The Committee comprises oral health personnel from all organizations of the MoPH, the Dental Council and education institutes. The Thai Dental Council is the main actor in regulating registration and the license to practise dentistry. According to the Dental Profession Act (No. 2) B.E. 2559 (2016), there is a relicensing process every 5 years for dentists graduating after 12 November 2016. 5.11.2 Access to dental care services The Health and Welfare Survey by the NSO in 2021 revealed that the overall Thai population’s access to oral health services increased from 9.6% in 2017 to 9.9% in 2021, but there was a drop in 2019 due to the COVID-19 pandemic. People living in the Bangkok Metropolis, where there is a concentration of oral health-care facilities and oral health personnel, had the highest accessibility to dental care services (14.9% in 2021) compared to other regions. The Central region had the lowest accessibility to dental care services (8.7% in 2021) (Fig. 5.12). Fig. 5.12 Accessibility to dental care services by region, 2017–2021 9.6 15.8 7.5 10.2 8.6 9.8 8.4 13.3 7.8 7.7 7.7 7.3 9.9 14.9 8.7 8.9 9.3 9.7 0 2 4 6 8 10 12 14 16 Total Bangkok metropolis Central North Northeast South % Region 2017 2019 2021 Source: (National Statistical Office, 2021a) 168 However, the survey in 2021 demonstrated that the proportion of Thais accessing oral health services from the public sector is almost the same as the private sector. Private clinics were the main providers of oral health services, accounting for 38.6%, while the general/regional hospital and health centre/PCU were the major providers from the public sector, with 14.9% and 14.4%, respectively (Fig. 5.13). Fig. 5.13 Percentage of dental care institutes, 2021 14.4% 12.5% 14.9% 1.4% 3.0%4.2% 38.6% 8.2% 2.7% Health centre/PCU Community hospital General/Regional hospital University hospital Other public hospital Private hospital Private clinic School Others Source: (National Statistical Office, 2021a) Most of the oral health procedures in the last visit were curative services, which were scaling/periodontal treatment (29.8%), extraction (23.0%), and filling (16.5%) (Fig. 5.14). Fig. 5.14 Types of dental care services, 2021 29.8 16.5 1.8 23.0 0.8 2.5 4.9 13.8 6.1 0.8 Scaling/Periodental treatment Filling Root canal treatment Extraction Sealant Dental prosthetics Orthodontic treatment Oral examination Fluoride Others/Cannot remember Source: (National Statistical Office, 2021a) 169 Around 0.9% of the population had unmet oral health needs. The main reasons for not seeking oral health services were no time for treatment and prolonged waiting time. Oral health status The Eighth National Oral Health Survey of Thailand in 2017 reported the oral health status of each age group. Oral conditions that are the most prevalent are mainly dental caries in children, periodontal diseases in adults and edentulous state (tooth loss) in the elderly. The mean decayed, missing and filled teeth in primary dentition (DMFT) was 2.8 and 4.5 between the ages of 3 and 5 years, respectively, with a prevalence rate of 52.9% and 75.6%. Schoolchildren aged 12 years and adolescents aged 15 years had DMFT of 1.4 and 2.0, respectively, with a prevalence rate of 52.0% and 62.7%, respectively. The working age group, aged 35–44 years, had several untreated oral diseases; 85.3% of working-age group people had lost an average of 3.6 teeth per person, 43.3% had untreated dental caries, 62.4% had gingivitis and 25.9% had periodontal pockets. If they do not receive proper oral health treatment, the problems will continue to worsen in the elderly. Tooth loss is a major oral health problem among the Thai elderly. The survey revealed that 56.1% of the elderly aged 60–74 years had at least 20 remaining natural teeth, with an average of 18.6 teeth per person. In the elderly aged 80–85 years, only 22.4% had at least 20 remaining natural teeth, with an average of 10 teeth per person. Occlusion was clearly reduced, which greatly affected the quality of life due to poor mastication. 5.11.3 Dental service financing The oral health benefits package among the three main health public insurance schemes covered essential oral health services, including prevention and promotion (PP), curative and rehabilitation services throughout the life-course. However, the oral health benefits package and payment mechanisms might be different among insurance schemes, resulting in different patterns of dental care utilization and cost sharing (Table 5.8). Thai people can use the oral health services provided by the health insurance scheme; as a result, in 2021, 60.7% of Thais who accessed oral health services did not have to pay out of pocket (OOP). For those who paid OOP by themselves, the average expenditure at the last visit of oral health services was THB 513. 170 Table 5.8 Oral health benefits package within the three main public health insurance schemes Universal Coverage Scheme (UCS)a Civil Servant Medical Benefit Scheme (CSMBS)b Social Health Insurance Scheme (SHI)c Advance treatment Pulpotomy/Pulpectomy, vital pulp therapy, cleft lip/palate - Implant-supported denture Root canal treatment, stainless steel crown, crown/ bridge Impacted tooth, removable prosthesis Basic treatment Filling, scaling, extraction Oral health promotion & disease prevention (PP)d Pregnant woman − oral health examination − polishing & cleaning Preschool children − oral health examination − fluoride application Schoolchildren & adolescents − oral health examination − fluoride application − dental sealant Working age and elderly − Oral potentially malignant disorders & cancer screening − fluoride application Sources: a (National Health Security Office, 2022a) b (Comptroller General Department, 2016) c (Social Security Office, 2017) d (Royal Thai Government Gazette, 2022b) Funding for oral health services from the UCS is bundled with outpatient budgets to contracted hospitals. In addition, in 2020, the NHSO introduced additional payment methods, and a fee schedule for PP services among schoolchildren and pregnant women. The total expenditure for oral health PP services in 2020 was THB 1.192 billion, including THB 40 million for oral health examination and polishing and cleaning in pregnant women, THB 285 million for fluoride application in children aged 4–12 years and THB 867 million for dental sealant in children aged 6–12 years. Beneficiaries of the CSMBS and SHI are reimbursed on a fee-for-service basis. Moreover, SHI covers oral health costs of only THB 900 per year. In 2015, the CSMBS budget for oral health services was THB 1.17 billion or 171 1.76% of the total CSMBS health expenditure. SHI’s budget for oral health services in 2020 was THB 1.988 billion for 3.3 million visits. 5.11.4 Challenges Impact ofCOVID-19 on oral health services The COVID-19 pandemic has impacted all aspects of the oral health-care system on both patients and oral health services in terms of the number of services, type of services and the way in which services are delivered. Early in the pandemic, the MoPH had developed policies and operational guidelines for health facilities that recommended dental practices and implemented restrictions whereby dental professionals should provide only emergency care, and all treatments that generated aerosols were postponed. Dental professionals from the MoPH, the Dental Council, the Dental Association, and the private sector collaborate and created several versions of the guidelines for dental practice during the COVID-19 pandemic adapted to the COVID-19 situation in Thailand. Dental treatments should have high standards of care and infection control by following proper recommendations. Use of personal protective equipment (PPE), patient screening, hand hygiene practices, mouth rinsing, disposable instruments, and of a rubber dam, reducing the use of ultrasonic instruments, treating suspected or confirmed COVID-19 patients in separate rooms, and disinfection of inanimate surfaces help in protecting clinicians and patients. Although COVID-19 disrupted the development of the oral health-care system, it accelerated the digital transformation of the oral health system. During the pandemic, teledentistry and digital technology have been developed to maintain oral health services, especially among remote and vulnerable populations, including for consulting, screening, monitoring oral health status and increasing oral health knowledge. Socioeconomic inequality in oral health status An analysis of Thailand’s National Oral Health Survey was conducted in 2019. They used the age group of 35–44 years to represent the working age population. The study found that people with a lower education showed a higher odds ratio for having untreated dental caries before and after controlling for related variables, suggesting worse oral health. Another study in Thai adults aged 15–75 years showed that reports of poor oral health status of the lower socioeconomic group were more common than in their counterparts in higher socioeconomic groups (Tewarit Somkotra, 2011).  172 Both studies indicated that policy-makers need to focus on groups with poor reported oral health status and consider strategies for improvement. 5.12 Complementary and alternative medicine 5.12.1 Overview Thais have recognized Thai traditional medicine (TTM) for its role in remedying illness and in well-being. TTM has been developed along with the Thai culture and transferred from generation to generation. The government has been providing strong support for TTM, including laws, financing, infrastructure development, and a role in the country’s economy. In 2002, the Department for Development of Thai Traditional and Alternative Medicine was established, with the goal of integrating Thai traditional medicine and alternative medicine into the national health-care service systems. Since 2007, there has been an increase in the utilization of TTM services, including herbal medicines, facilitated by a financial mechanism that allows reimbursement from the benefit packages provided by the NHSO (National Health Security Office, 2008). In 2015, the MoPH included TTM and complementary medicine as one of the service plans (Ministry of Public Health, 2016). In 2017, the name of the department was changed to the Department of Thai Traditional and Alternative Medicine (DTAM). 5.12.2 Policy on TTM TTM was first mentioned in the Fifth National Economic and Social Development Plan 1982–1986 and has been adopted and addressed in every National Health Development Plan thereafter. The stated extent of TTM in the national plan has gradually expanded, from merely promoting the use of herbal medicine to the level of ensuring the quality and accessibility of TTM at all levels of public health-care facilities and community self-care. In order to achieve a sustainable health system, the Plan covers the development of (1) human resources, (2) services, (3) herbal medicine, and (4) Thai folk wisdom protection (Petrakaat et al., 2010). To promote the use of TTM, the government passed the Protection and Promotion of Thai Traditional Medicine Wisdom Act B.E. 2542 in 1999, and the Thai Traditional Medicine Profession Act B.E. 2556 in 2013, which established the Thai Traditional Medicine Council in the same year, with the primary objective of regulating and licensing the practice of TTM professions, superseding the Health Service Support Department (Department of Thai Traditional and Alternative Medicine, 2020; Thai Traditional Medical Council, 2013). 173 The COVID-19 outbreak significantly impacted public health, particularly vulnerable patients with NCDs, those in palliative care, and the elderly. This led to an increased focus on academic research and knowledge development on TTM, alternative medicine, and herbs. In particular, there is a push to use Andrographis paniculata for patients with less severe COVID-19 (Tanwettiyanont et al., 2022). The policy drive towards “medical marijuana plants” aims to register herbal medicine formulas mixed with marijuana in the national textbook of TTM (Zinboonyahgoon et al., 2021). These formulas must be safe, easy to produce, and have readily available ingredients. The medicinal properties of medical marijuana will be important in treating diseases that significantly impact the public health system. 5.12.3 Organization of TTM services TTM services are easily accessed in both the private and public sectors. Private facilities are more concentrated in urban areas with patients’ preference of services for health or for complementary treatment such as massage, sauna and compress, which are sometimes offered along with some form of complementary and alternative medicine (CAM). Since standards apply only to facilities that are willing to be certified, private services are diverse in terms of quality and comfort, ranging from service in a small room to a luxurious hotel or health spa. Public facilities are controlled by higher-level authorities with practice guidelines developed by the DTAM. TTM is part of the MoPH’s mandate for health-care provision. According to data from the DTAM in 2023, there are TTM service units in 121 regional and general hospitals, 779 district hospitals and 9750 health centres or subdistrict health-promoting hospitals. Public-sector TTM services are oriented more towards medication: prescribing mixtures of herbal medicines on an individual basis is more common than in the private sector. The first public TTM hospitals that provided TTM services was established in 2012. Other hospitals offer TTM services in a clinic, which generally complements modern medicine. Patients accessing a TTM clinic within a hospital are mostly referred by the nurse or physician who did the initial screening. In 2016, OPDs of TTM were established in parallel with OPDs of modern medicine by 60.24% (532 hospitals) of total regional, general, and district hospitals according to a key performance indicator of the MoPH (Ministry of Public Health, 2016). 174 The majority of patients are beneficiaries of the UCS or CSMBS. This is because treatment given to patients by Thai traditional practitioners or cases referred from physicians in public facilities are included in the benefit packages (Table 5.9). Table 5.9 TTM budget used in two public insurance schemes, 2020–2022 Scheme Budget (THB million) 2020 2021 2022 UCS 714.30 851.23 1 065.10 CSMBS 76.88 94.40 100.66 Sources: (National Health Security Office, 2020b, 2021c, 2022e) 5.12.4 Access to services The utilization report from the Health Data Centre TTM service (Table 5.10) between 2018 and 2022 showed that prescription of herbal medicines was among the most popular services. Nuad Thai (Thai massage), herbal steam bath, and hot herbal compression services at the OPD were the most utilized followed by services outside the facility and inpatient departments. Table 5.10 Mode of TTM utilized by members of all schemes, 2021 and 2022 Type of service No. of visits 2018 2019 2021 2022 OPD Nuad Thai 8 593 187 7 901 099 6 535 069 6 237 794 Herbal steam bath 1 734 925 1 563 029 1 061 251 846 066 Hot herbal compression 7 207 105 6 806 971 5 693 005 5 282 619 IPD Nuad Thai 7 983 6 401 5 560 4 439 Herbal steam bath 958 1 210 714 521 Hot herbal compression 13 576 12 040 8 405 5 996 Outside the facility Nuad Thai 1 152 924 618 949 300 424 252 445 Herbal steam bath 179 058 87 778 20 784 11 731 Hot herbal compression 1 058 306 575 076 273 997 239 986 Postpartum care 269 894 301 898 251 683 187 931 TTM health promotion 13 468 633 10 453 665 7 689 109 6 569 936 Herbal medicine prescription 18 324 544 18 089 274 14 988 583 19 412 556 Source: (Department of Thai Traditional and Alternative Medicine, 2023) 5.12.5 Human resources for TTM services TTM providers can be roughly categorized into three: conventional TTM, applied TTM and TTM assistant. To be eligible to diagnose and provide treatment as in the first two categories, a licence is needed. By law, 175 conventional TTM is divided into four types according to licence: Thai medicine, Thai pharmacy, Thai midwifery, and Thai massage; a practitioner can be licensed for more than one type. Table 5.11 shows the number of different kinds of TTM and other CAM licences. Table 5.11 Number of different kinds of TTM practitioners and other CAM licences Categories 2011 2022 Conventional TTM Medical practice 18 963 27 539 Pharmacy 26 056 34 861 Midwifery 7 273 15 336 Nuad Thai (Thai massage) 1 905 9 541 Applied TTM 1 222 4 556 Folk healer - 2 283 Traditional Chinese Medicine (TCM) 302 1 834 Chiropractor 19 45 Source: data from Department of Thai Traditional and Alternative Medicine Demand for TTM providers is increasing in both the public and private sectors. To cater to this increase, a number of full degree programmes and short courses have been launched. At first, such academic programmes were problematic because of the variation in the length and quality of taught programmes (Noree, 2007). School administrative and TTM professional committees also realized this problem. As of 2023, there are 24 universities or colleges offering a 4-year curriculum for conventional TTM training, and 13 universities offering applied TTM training (Thai Traditional Medical Council, 2021a, 2022). For TTM assistants, there are 109 registered schools offering a 330-hour training course (Thai Traditional Medical Council, 2021b). Moreover, there are 105 accredited schools and health facilities authorized to offer distinct types of conventional TTM education, with varying year-long curricula (Thai Traditional Medical Council, 2023). 5.12.6 Challenges There are questions about whether the role of TTM is merely alternative or complementary; if it should be incorporated into modern medicine as the national policies plan to do; and how TTM could be developed and respected in the mainstream of health care and society as a real and effective treatment. To develop knowledge and innovation in TTM and CAM, it is necessary to adopt an evidence-based approach that can lead to the improvement 176 of health-care services. This requires an increase in data collection, documentation of experiences, and clinical research. Such efforts are essential for expanding the range of herbal medicines, including cannabis preparations, on the NLEM. Thailand aims to improve the competitiveness of entrepreneurs in the herbal product industry, as well as those in the health and tourism businesses. The country also intends to promote innovation to increase product value, particularly in high-growth sectors such as beauty, health care, bio-farming, and integrated medical services (National Herbal Policy Committee, 2023). This is a good opportunity for TTM and CAM to make faster progress and become more attractive than before. 5.13 Health services for specific populations 5.13.1 Migrant profile Over the past decades, Thailand has become a key net-receiving country for migrants, especially from neighbouring countries. The labour migration policy in Thailand has been hugely influenced by bilateral agreements (International Labour Organization, 2022). In 2002 and 2003, MoUs were signed by the Royal Thai government to import low-skilled migrant workers from neighbouring countries. This policy action enabled regular labour migration. In 2016, the Thai government introduced a more comprehensive framework to manage labour migration by implementing border employment or national verification (NV) in parallel with implementation of the MoU. It was estimated that in 2019, there were approximately 4.9 million migrant workers in Thailand (Table 5.12) (Harkins, 2019). About half of these migrants (46.63%) were regular migrant workers from Cambodia, Lao People’s Democratic Republic, Myanmar, and Viet Nam working in the low-skilled sector (International Organization for Migration, 2021; Suphanchaimat et al., 2019b). Of the 4.9 million migrants in Thailand, there were approximately 46.94% irregular migrant workers or undocumented migrants who did not have any legal documents that proved their right to stay in Thailand (International Organization for Migration, 2021). It was predicted that only 2.81% of migrant workers were in professional and skilled work. Myanmar is recorded as the largest source country for low-skilled migrant workers, and Japan is noted for the provision of professional and skilled migrants. Migrants’ contribution to the Thai economy is substantial, accounting for 4.3–6.6% of the total GDP (Harkins, 2019). 177 Table 5.12 Overview of migrant workers in Thailand by characteristics and types of employment in 2019 Status of migrant workers Total (Number of people) % of total Regular migrant workers not from Cambodia, Lao PDR, Myanmar and Viet Nam (professional and skilled workers and ethnic minorities) 197 583 4.30 Regular migrant workers from Cambodia, Lao PDR, Myanmar and Viet Nam 2 284 673 46.63 • MoUs (Cambodia, Lao PDR, Myanmar and Viet Nam) 987 214 20.13 • Border pass holder 30 074 0.61 • Completion of NV process (regularized) 1 267 385 25.87 Irregular migrant workers (estimate) 2 300 000 46.94 Internationally protected 99 806 2.04 Total Estimated 4 900 000 100 Sources: (Harkins, 2019; International Organization for Migration, 2021) 5.13.2 National initiatives on health policies for non-Thai populations: international agreements to protect the rights and promote social security for non-Thai populations in Thailand Thailand has adopted international agreements to protect the social security of non-Thai populations since 1948 (Sinam et al., 2021). The first international document signed by the Thai government is the Universal Declaration of Human Rights (UDHR) (United Nations General Assembly, 1948). This document is a global roadmap, which says that individuals deserve universal protection to live their lives freely and equally. In 1965, the International Convention on the Elimination of All Forms of Racial Discrimination (ICERD) was ratified (United Nations General Assembly, 1965). Thailand agreed to follow ICERD to take action to eliminate all forms of racial discrimination (United Nations General Assembly, 1965). In 1966, the International Covenant on Economic, Social and Cultural Rights (ICESCR) (United Nations General Assembly, 1966b) was adopted to recognize certain standards of living, including a standard of living that is adequate for physical and mental health. In the same year, the Thai government agreed to follow the International Covenant on Civil and Political Rights (ICCPR) (United Nations General Assembly, 1966a). The Thai government condemns all forms of discrimination against women in accordance with the Convention on the Elimination of All Forms of Discrimination against Women adopted in 1979 (United Nations General Assembly, 1979). For children’s rights, the Thai government follows the 178 Convention on the Rights of the Child in 1989 (United Nations Commission on Human Rights, 1990). Additionally, in 2007, the Convention on the Rights of Persons with Disabilities (United Nations General Assembly, 2007) was ratified to promote, protect, and ensure the full enjoyment of human rights by persons with disabilities. In 2012, the ASEAN Human Rights Declaration (Association of Southeast Asian Nations, 2012) was adopted to ensure that every person has an inherent right to life, which shall be protected by law. Individuals have the right to freedom of movement and residence within the borders of each State, and individuals have the right to leave any country, including his or her own, and to return to his or her country. This Declaration also promotes the right to seek and receive asylum in another State in accordance with the laws of such a State and other applicable international agreements. In 2020, Thailand was one of 15 Member States that demonstrated its commitment to the agreement by becoming a Global Compact on Migration (GCM) champion country. Led by the Ministry of Foreign Affairs (MFA), government agencies have been working together to identify working strategies to move towards the realization of GCM objectives. Thailand is also pursuing a whole-of-government approach to implementing the Global Compact on Refugees (Global Compact on Refugees). In 2018, 181 nations, including Thailand, voted in favour of the Compact in the United Nations General Assembly (UNGA). The Compact aims for more predictable and equitable responsibility sharing. It provides a blueprint for governments, international organizations, and other stakeholders to ensure that host communities get the support they need and that refugees can lead productive lives. 5.13.3 Universal health coverage and social protection for migrants in Thailand There are two main schemes to protect the health of migrant workers classified by the types of employment. There is a contributory programme to protect the health of migrant workers in the formal sector, SHI, with contributions made to a collective fund by beneficiaries, employers, and the State (International Organization for Migration, 2021; Suphanchaimat et al., 2019a). It is covered by the Social Security Act B.E. 2533 (1990) with a set of laws concerning workers’ welfare and benefits. Migrant workers who are 18–55 years of age can be eligible for the SHI, which covers seven benefits for work and non-work insurance, including injury or illness, maternity, disability, death, children, old age (retirement pension) and unemployment. 179 Low-skilled migrant workers in the informal sector are eligible for the Health Insurance Card Scheme (HICS) under the management of the MoPH, Thailand. This scheme is operated under the Ministry’s announcement “Health Examination and Health Insurance of Foreign Workers B.E. 2562” (International Organization for Migration, 2021; Suphanchaimat et al., 2019a). It is on a semi-voluntary basis without legal mechanisms for migrant workers enrolling in the HICS. The HICS was initiated in 2002 and is open to all migrants excluded from the SHI, or migrants who are within the three-month period (or waiting period for SHI validation) before obtaining the SHI. According to the NV process, migrant workers need to pass the health examination and then they are encouraged to purchase HICS (Suphanchaimat et al., 2017). Moreover, when migrant workers visit public health facilities for health check-ups, they are also encouraged to buy HICS at those health facilities. The benefit package of HICS includes outpatient, inpatient and emergency care, as well as high-cost treatments. Unlike the SHI, which does not cover PP services, 12% of the HICS premium was earmarked for health promotion and disease prevention activities, including the training of migrant health workers (MHW) and migrant health volunteers (MHV) (Kosiyaporn et al., 2020a). In 2013, the HICS package was expanded to cover HIV/AIDS treatment and enhance eligibility for undocumented migrant dependents aged below seven years (Suphanchaimat et al., 2019a). In 2014, the MoPH in collaboration with NGOs put in place the Expanded Programme on Immunization (EPI) to provide vaccines for migrant children along the Thailand–Myanmar border, especially in Tak province. A study showed an increase in vaccination coverage during 2014–2017. For instance, the vaccination coverage of DTP–HepB3 and OPV3 during the first year of life increased from 34.8% in 2014 to 56.3% in 2017, although the coverage was far below the national goal of 90%. Population mobility and inaccessibility to health services were identified as the main challenges faced by migrant parents. Mobile immunization programmes aided by community health volunteers may help to improve vaccination coverage among migrant children (Pinna et al., 2020). In 2014, there was a coordination mechanism to promote the NV for undocumented migrants in Thailand via the One Stop Service (OSS). The OSS is a mechanism to improve the NV process with collaboration across government departments, including the Ministry of Labour (MoL), Ministry of Interior (MoI), and MoPH of Thailand. As a result, it increased the number of registrations of undocumented migrants to around 1.5 million. The premium of HICS for migrant workers registered via the OSS is THB 1600 with THB 500 for health check-ups. The HICS has a coverage period of one year and is later expanded to two years (with twice the one-year premium). 180 Moreover, migrant children aged less than seven years are eligible for the HICS, which costs THB 365 for one year of coverage regardless of their status. In addition, there is a group of uninsured people with nationality problems or stateless persons. The majority of them are ethnic minorities and have no evidence such as birth certificates or identity documents (Suphanchaimat et al., 2019a). To deal with the risk of exclusion in health-care access, the MoPH has developed a unique health insurance programme for stateless persons called the “Health Insurance for People with Citizenship Problems” (HI- PCP). This special fund aims to subsidize medical costs for stateless patients without copayment, and the benefit package includes outpatient care, inpatient care, emergency treatment, and health promotion (Suphanchaimat et al., 2016). 5.13.4 Enhancing cultural mediation services by promoting migrant health worker (MHW) and migrant health volunteer (MHV) programmes in Thailand One of the major barriers that prevents migrants from accessing the health-care system is a lack of cultural awareness due to language barriers (Legido-Quigley et al., 2019). An effective health policy to support MHWs and MHVs can promote cultural mediators and improve responsiveness to the needs of migrant patients. Evidence suggests that the MHW and MHV programmes had a significant impact on improving the migrant- friendliness of Thai health services. First, the MHV scheme was introduced in Thailand by NGOs to provide interpretation services and assistance to migrant patients with the aim of addressing language barriers. In 1995, the initiative to promote MHWs was launched officially to provide interpreter services in health facilities (Kosiyaporn et al., 2020a). This programme was financially supported by the IOM, the United States Agency for International Development (USAID) and the MoPH (Jittithai, 2009; Kosiyaporn et al., 2020a). This programme was implemented on a pilot scale in two provinces, then further expanded to five provinces. After the withdrawal of international funding in 2008, local NGOs and the MoPH were the key parties responsible for this programme. The programme activities run by the MoPH were mainly the training programmes with materials and guidelines. At the same time, financial support from local NGOs was also available to sustain implementation of the programme with human resource development (Kosiyaporn et al., 2020a). MHWs and MHVs are engaged in migrant-friendly health services and have different roles. MHWs are hired by the health facilities and work in 181 these settings in collaboration with NGOs in migrant communities. For MHVs, employment is voluntary to provide coordination and language interpretation services within migrant communities. The common roles of MHWs and MHVs are to provide support for basic health education, health insurance registration, health promotion and disease prevention, health screening, and being role models for healthy lifestyles (Arayawong W et al., 2016; Kosiyaporn et al., 2020a). Further assignments for MHWs include translation of bilingual materials, participation in training courses and meetings, development of surveys for migrants’ demographic characteristics and following up health care. The budget allocated is mainly for training and MHW employment. Findings suggest that key challenges include budget constraints, non-standardized training methods, unsustainability of MHWs and lack of a legal mechanism to promote the programme’s sustainability (Kosiyaporn et al., 2020a). Effective recruitment of MHWs and MHVs is also a key mechanism for having a proper cultural mediator and for promoting culturally sensitive health-care services responding to the different needs of migrants in various cultural and social settings (Kosiyaporn et al., 2020b; Meuter et al., 2015). 5.14 Disaster risk management for health (DRM-H) 5.14.1 COVID-19 pandemic response in Thailand Containment of the COVID-19 pandemic in Thailand has been recognized at a global level (Global COVID-19 Index, 2021). As Thailand was the first country outside China with a reported COVID-19 case in 2020, the government established the Centre for COVID-19 Situation Administration (Center for COVID-19 Situation Administration secretariat) to manage a whole-of-government response, and the Emergency Operation Centre (EOC) to monitor and manage the situation (Sirilak, 2020). The first wave of COVID-19 in Thailand was in March 2020, to which the response was massive such as a national lockdown and international travel restrictions. Despite the effectiveness of the lockdown policy, the negative economic impact and unemployment rate must be considered (Janssen et al., 2020; Moon, 2020). Therefore, during the second wave in December 2020, which emerged among migrant workers and ongoing labour trafficking (Rajatanavin et al., 2021) in loculated provinces, the government shifted management of the pandemic to localized provincial lockdowns to minimize further economic impact (Rajatanavin et al., 2021). The third wave was triggered by clusters in nightclubs in Bangkok in April 2021, followed by the fourth wave in June 2021, dominated by the Delta variant (Bangkok Post, 2021a). During these third and fourth waves of the 182 pandemic, suppression strategies were adopted by targeted lockdowns in some areas; however, this still could not cope with the large surge of daily cases. On 13 August 2021, a record high of 23 000 daily cases were identified, and on 18 August 2021, there were 300 daily deaths; caused by the high-mortality Delta variant (Worldometer, 2022). The Omicron wave occurred around early 2022 (Bangkok Post, 2021b), when the majority of the population had already received a booster dose of COVID-19 vaccine and service delivery systems could adapt to this pandemic. CCSA mechanisms were effective in multisectoral involvement and direct command from the national to the local level, leading to more coherence in policy direction. Personal protection and prevention such as wearing face masks, washing hands, and social distancing were communicated since the beginning of the pandemic, with full compliance of the people. COVID-19 testing, tracing, quarantine, and treatment were covered by the well-funded UCS. Though there are three main public insurance schemes in the country, COVID-19 testing, tracking, quarantine and treatment were managed by the NHSO to avoid inequity of the system. Initially, provision and reimbursement of RT-PCR was restricted to specific case definitions, resulting in the unexpected spread of undetected cases. However, full-scale RT-PCR testing for all cases strained health-care systems financially and the service delivery capacity. To save costs, a cost- effective approach was implemented using pooled saliva tests, which could analyse at least five samples simultaneously with similar detection sensitivity to single-specimen RT-PCR tests (Wacharapluesadee et al., 2020). Subsequently, the case definition was made more flexible during the third wave to detect, treat, and isolate more cases. Eventually, in July 2021, antigen test kits (ATKs) were introduced for widespread use. Contact tracing was performed only during the first wave and later in large clusters. Another innovation was the “bubble and seal” strategy, which was introduced to contain COVID-19 clusters in factories and allow the continuation of production lines for 30 days until the workers became infection free. Routes to and from workers’ dormitories in the factory were completely sealed to prevent contamination in the community. Symptomatic patients were treated inside the factory; severe cases were transferred to hospital (Department of Disease Control, 2021). At the beginning of the pandemic, all patients with COVID-19 were hospitalized and isolated for the full 14 days. However, as cases surged, health systems needed to adapt. Initially, patients with moderate symptoms 183 were accommodated in hotels converted into hospital rooms through affiliation with medical facilities, utilizing over 100 000 vacant hotel rooms nationwide. This helped to ease the financial burden on hotels following travel restrictions and lockdowns. Home isolation (HI) and community isolation (CI) were introduced to reduce hospital workload by shifting patients to their own homes or dedicated community shelters. Patients received daily necessities, medical equipment, prescribed medications, and telemedicine consultations with doctors. Both public and private clinics and hospitals participated, utilizing a single payment mechanism by the NHSO. Telemedicine was utilized for patients with COVID-19 as well as for treatment of and medicine delivery to patients with NCDs. During the first phase of the pandemic, there was a huge challenge in managing the massive amounts of data. The Government Big Data Institute (GBDI) helped alleviate this problem by pooling all data in a single data warehouse. These public sector support systems, such as the hotline and patient triage centre were fully occupied and could not meet large demands. Private sector information technology companies, banks, tech start- ups, NGOs, the media, and volunteers stepped in to provide support on a voluntary basis. There was insufficiency of COVID-19 vaccines in Thailand in early 2021. As a result, heterologous vaccination schemes were implemented to avoid sole reliance on a single vaccine brand. Domestic clinical trials of heterologous vaccine schedules for efficacy and safety provided inputs for the recommendation of heterologous vaccines. In November 2021, Thailand began phased resumption of economic activity, aiming to contain the pandemic within the capacity of the health-care system. International travellers had to show negative RT-PCR results and full vaccination evidence before departure, with another negative RT-PCR upon arrival. Social measures such as face masks and social distancing were fully enforced. Dealing with the ongoing pandemic, the emergence of the Omicron variant, and reopening the economy and schools required effective multisectoral coordination (Rajatanavin et al., 2021; Sirilak, 2020). 5.14.2 COVID-19 health policy responses for non-Thai populations The spread of COVID-19 among migrant workers at the seafood market in Samut Sakhon province was the trigger for the second wave of the COVID-19 pandemic in Thailand. It resulted in urgent public health responses to contain the pandemic among migrant workers travelling to the country legally and illegally. Public health measures included active 184 case-finding and strict 14-day community quarantine (Tangcharoensathien et al., 2022b). Government organizations and NGOs also provided food, drinking water, and other necessities to migrant communities. Additional budgets were allocated to the MoPH and the Ministry of Defence to support public health measures and State quarantine among migrant workers (Tangcharoensathien et al., 2022b). Additional budgets of THB 99.9 million and THB 959.3 million were allocated to migrant workers who were not insured by any health-care insurance scheme. This policy aimed to ensure that they could access COVID-19 health services regardless of their status (Ministry of Public Health, 2021c). The Thai government introduced COVID-19 vaccines for non-Thais in the fourth quarter of 2021. Migrant workers and their family members were eligible for free vaccines. Importantly, undocumented migrants also had access to free vaccines. Vaccine quotas were assigned to each province based on population size, with additional quotas for provinces with high infection rates and high migrant populations (Ministry of Public Health, 2021c; Tangcharoensathien et al., 2022b). The Department of Disease Control (DDC) of the MoPH developed vaccination strategies to contain the COVID-19 pandemic. The first strategy was to prioritize vaccination in migrant-populated areas. This strategy was proven to be cost effective and resulted in 50% of vaccine effectiveness. It also prevented the province with the highest number of migrants from experiencing the greatest economic losses in comparison to the vaccination policy targeting Thai populations only. A strategy for a combination of vaccination policy and active case-finding (ACF) was also proposed (Suphanchaimat et al., 2021). The results showed that the implementation of vaccination and active case-finding yielded better outcomes in terms of a reduction in the number of cumulative cases and deaths in comparison with a single measure. However, COVID-19 brought out social inequality faced by marginalized and vulnerable groups such as migrants and non-Thai populations (Tangcharoensathien et al., 2022a). Structural reform is required with a long-tern preparedness plan to ensure that global and national resources are in place and access to these is equitable for every individual during an emergency, regardless of their status. 5.14.3 Cross-sectoral engagement and existing laws for DRM-H 5.14.3.1 Natural disasters Over the years, Thailand has been repeatedly hit by several types of disasters, both natural and human induced. Numerous laws and regulations were created to address each of these disasters individually. 185 In terms of disasters caused by nature, there is a national law described as the “Disaster Prevention and Mitigation Act (DPMA) B.E. 2550,” (Royal Thai Government Gazette, 2007a), which was enacted to integrate operations among each agency that is responsible for natural disaster management, including wildfires, floods, earthquakes, disease outbreaks, and other life-threatening hazards. This law is enforced by the Department of Disaster Prevention and Mitigation (DPM), the MoI, and reports directly to the National Disaster Prevention and Mitigation Committee (NDPMC), which is chaired by Thailand’s Prime Minister and consists of senior officers from related ministries; the Permanent Secretary of Health is one of its members. The DPMA allows “province governors” to convene an emergency committee meeting without requesting the Central Government’s permission when it deems that there is a “disaster risk” that cannot be managed by only a few agencies, compared to requiring participation from every pertinent authority (cross- ministerial operation) as stipulated by the Act. National disaster risk management for natural disasters is thus typically enforced by the DPMA, and the MoPH is one of the entities stated to facilitate the implementation of this legislation, particularly for the infectious disease section. However, Thailand has a further law that has been created for use in mitigating pandemics caused by humans. 5.14.3.2 Human-induced disasters and infectious diseases The MoPH has its own laws and regulations that safeguard health care that is impacted by disasters. Thailand has aligned itself with global regulations and health-care laws announced by WHO and intergovernmental organizations, such as the Action Plan of Public Health Emergency (PHE) Programme under WHO CCS 2022–2026 (CCSPHE) (Regional Office for South-East Asia, 2017), International Health Regulations (IHR) (World Health Organization, 2016b), and Universal Health Preparedness Review (UHPR) (World Health Organization, 2022c). Thailand established the “National Communicable Disease Act (NCDA) B.E. 2558” (Royal Thai Government Gazette, 2015) that intends to mitigate hazards to health caused by infectious diseases. The Act granted authority to the Director-General of the DDC, MoPH, to implement any action necessary to mitigate an outbreak and protect people’s lives. This action, however, is overseen by the National Communicable Disease Committee (NCDC), which is headed by the Minister of Public Health and is made up of high-ranking officials from multisectoral agencies as members, with the DDC serving as its secretariat. One of the most “effective regulations” that went into effect with the pandemic is that the Director-General of the DDC can delegate authority to the province governor and the MoPH 186 representative to form a “Provincial Communicable Disease Committee (PCDC)” (Royal Thai Government Gazette, 2005b) and initiate disease control procedures issued by the NCDC without seeking consent from the Minister. 5.14.3.3 Climate change-induced disasters Hazards affecting Thailand are likely to be exacerbated due to the impacts of climate change. Given that Thailand is a major exporter of rice and cassava, and because agriculture still employs large numbers of the population, the impacts of climate change on the sector are projected to have significant economic consequences at all levels. The economic costs due to loss of farmland value and output alone have been projected to exceed US$ 94 billion under a high-emissions scenario by 2050 due to changes in precipitation and temperature. Sea level rise is also likely to worsen the impacts of flooding and storms, and lead to permanent inundation in some areas. Additionally, chronic environmental stress from pollution contributes to a deteriorating quality of life. Cities in the north suffer from degraded air quality seasonally due to particulate matter arising from the burning of farm residues and forest fires, while in Bangkok, factory emissions, vehicles, construction sites and stagnant airflows of the dry season are major contributors to toxic haze. In Thailand, contemporary development policies and planning instruments are largely in alignment with the global agendas: the SDGs, Sendai Framework for Disaster Risk Reduction (SFDRR) and Paris Climate Agreement, 2015. The 12th National Economic and Social Development Plan (2017–2021), under the auspices of Thailand’s 20-year National Strategy (2018–2037), sets a goal to strengthen the energy and agriculture sectors, alongside water management. As a member of the United Nations Framework Convention on Climate Change (UNFCCC) since 1995, Thailand is also active in integrating climate change action into its policy frameworks. The main responsibility for this work is assigned to the Office of Natural Resources and Environmental Policy and Planning (ONEP), under the Ministry of Natural Resources and Environment (MoNRE). Building upon the preceding climate strategy, the Climate Change Master Plan (CCMP) 2015–2050, aligned with the Paris Agreement 2015, is a roadmap for Thailand to achieve sustainable low carbon growth and climate change resilience by 2050. However, challenges to implementation remain due to limited institutional capacity and resources. 5.14.4 Policies, planning, and coordination of DRM-H across the preventive, preparedness, response, and recovery phases 187 5.14.4.1 EmergencyDecree Thailand has a special law known as the “Emergency Decree on Public Administration in Emergency Situation, B.E. 2548 (2005)” or “Emergency Decree” (Royal Thai Government Gazette, 2005a), which enables the Prime Minister to enact all administrative laws, regulations, and protocols and integrate administrative functions across sectors. During the COVID-19 pandemic, the Prime Minister used the Decree as the DRM-H and set up a single command centre for health management called the “Center for COVID-19 Situation Administration (Center for COVID-19 Situation Administration secretariat)” (Royal Thai Government Gazette, 2020c), where the Prime Minister maintained the highest executive authority and demanded that senior officers (ministers, permanent secretaries, directors- general, and directors) in charge of disaster management from every ministry be members of it. The CCSA regularly meets on a weekly basis and releases the regulations that are needed (1) to prevent disease outbreaks, (2) mitigate the crisis’s impact, (3) respond to the negative effects of the infection, and (4) enhance access to vaccines, medicines, and personal protective equipment (PPE) in Thailand as well as other essential issues as appropriate (Royal Thai Government Gazette, 2020d). Furthermore, the CCSA has “serious penalty” enforcement that usually prevents individuals from breaching its orders; this law does not require Parliament’s approval. In comparison to the NCDC’s authority, the CCSA has more policy power as it can make an “official announcement” immediately after the meeting without having to pass it through the Cabinet for consent for public enforcement, unlike the NCDC. Consequently, Thailand relied on the “Emergency Decree” rather than the NCDC at the time. Indeed, these powers, including the DPMA, NCDA, and Emergency Decree, have major responsibility for prevention of and response to disaster risk management for health, together with allowing cross-sectoral operations to take place at the same time when the country experiences a dire situation. 5.14.4.2 National Vaccine Security Act The National Vaccine Security Act (NVSA), B.E. 2561 (Royal Thai Government Gazette, 2018 ) is the highest vaccine policy that gives the National Vaccine Committee (NVC) the authority to develop national vaccine regulations and make recommendations to the Cabinet, thereby achieving the country’s vaccine security and self-reliance in the long term. The NVSA became important during the COVID-19 pandemic for a vaccine response to the crisis. The NVC is chaired by the Prime Minister and consists of ministers, senior officers, and experts involved 188 with vaccine and immunization. The NVC has the power to plan and monitor the implementation of the national vaccine policy. In 2020, the NVC made blueprint access to COVID-19 vaccines for Thailand the priority among other health regulations (National Vaccine Institute, 2020). The blueprint was developed and endorsed by the NVC on 22 April 2020, using the power given by the NVSA, then declared to be the supreme authority framework for COVID-19 vaccine access ever since. Accordingly, the National Vaccine Institute (NVI) has accelerated Thai people’s access to the COVID-19 vaccine by facilitating implementation of the blueprint to reach concrete outcomes and objectives. The above- mentioned approach has received such financial support that it can move forward. The blueprint encompassed three potential strategies: (1) promote the development of proof-of-concept vaccines in Thailand, with a total budget of THB 7277 million (2020–2022); (2) promote local COVID-19 vaccine production through technology transfer with a capital budget of THB 896 million; and (3) promote an advance market commitment for those commercialized vaccines, with a total budget of THB 56 265 million. Thailand has met nearly 150 million doses of vaccines through these effective blueprint strategies and possesses viral vector technology and is developing infrastructure for several vaccines for use in the future. According to the vision of the NVC, stipulated by the NVSA, the creation of a blueprint for the purpose of allocating funding and rules for the national vaccination campaign are indispensable. When the pandemic struck, this plan of action became the “response” and “preparedness” components for Thai disaster risk management for health in the shape of a “prevention measure”. 5.14.5 Risk communication and knowledge management during national disasters Throughout the disaster scenario, risk communication and knowledge management are essential. In dealing with emergencies in Thailand, the CCSA has the authority to form task forces that handle numerous facets of risk reduction; among these is the Effective Communication and Infodemics Management (ECIM) Task Force, which is supervised by the Deputy Permanent Secretary of the MoPH. This Task Force includes public relations officers from the various departments involved as well as representatives from the CCSA, NVC, and NCDC. The Task Force has been tasked with the CCSA declaration and appointed the permanent secretary of the MoPH or his/her deputy (1) to develop an efficient communication plan that bolsters the CCSA work and promotes the public’s awareness regarding the pandemic scenario; (2) to incorporate and consolidate the 189 entire public relations from interested parties and disclose these from a single information centre, rather than releasing information by each agency; and (3) to gather the information necessary for the CCSA’s work. The CCSA also has a communication committee and a spokesperson who releases the situation and meeting reports, and an associated declaration on the CCSA’s behalf (Center for COVID-19 Situation Administration secretariat, 2020). Knowledge management (KM) is also done by the CCSA’s communication committee and medical team drawn from multiple institutions. The CCSA draws public attention by collecting technical data from the ECIM Task Force, DDC, NVI, and consults regularly with those medical committees. Dashboards, infographics, and social media publications were presented daily throughout the broadcast on social media and on official websites during the pandemic. Furthermore, a series of webinars was conducted by MoPH entities, either face to face or online. This platform aimed to lessen miscommunication, eliminate fake news, and infodemics that were used as “political tools” for discrediting an opposition party, or the government in charge at that time. 5.14.6 Contingency funding for disaster and dedicated budget allocation for DRM-H Thailand has a national “emergency fund” for catastrophes and hazardous risk prevention (Royal Thai Government Gazette, 2018). The Prime Minister controls this portion of the finances by releasing an “Emergency Decree” proclamation to reach out to this money. The emergency budget is part of the “central budget” (Royal Thai Government Gazette, 2019c), which is authorized by the Prime Minister. This budget is meant to ensure that funds are available for use in a crisis scenario in a timely way. In comparison to fiscal financing, an emergency fund is more flexible, free from inspection, and does not require legislative approval, which might lead to transparency concerns. Another financing source is a “loan”, which became the greatest financial expenditure option employed throughout the pandemic, total THB 1 trillion. Thailand had a “Royal Decree authorizing the Ministry of Finance to loan money to solve the problem and rehabilitate the economy and society affected by the outbreak of coronavirus disease 2019, B.E. 2563” or “Emergency loan for COVID-19” (Royal Thai Government Gazette, 2020b). The loan was used to fund DRM-H and financial assistance for persons who had been affected by the pandemic or disaster, regardless of economic status, religion, or age. Most of the funds were used to secure PPE, medications, therapies, national infrastructure development, and human resource development. National vaccine research and development consumed around THB 7.3 190 billion from this corpus, in addition to the central budget. Moreover, Thailand has used the central budget for the purpose of advance market commitment (AMC) and purchase arrangement (PA) for the vaccine procurement strategy (Committee for Facilitating the Procurement of COVID-19 Vaccine for the Thai Population, 2020; Royal Thai Government Gazette, 2020a). The central fund invested around THB 56 billion to assist the government in acquiring COVID-19 vaccines for all Thai people throughout 2021–2022. This is permissible and within the Prime Minister’s authority (emergency decree), with the support of the Cabinet, and Thailand eventually secured about 150 million doses of the vaccines. 5.14.7 Summary In conclusion, Thailand has several regulations in place to deal with health emergencies and disasters. However, in some instances, novel legislation must be enacted to encompass all facets of issues, such as good government administration, in an organized and uniform manner, which assists Thailand in protecting, recovering, and maintaining people’s lives together with economic rehabilitation. Another significant regulation is a law on budget management during emergencies, including establishing a central budget and a special emergency budget. Throughout the nation’s recent crises, information management and fake news regulation have been equally important. In the case of a disaster, having one central information centre and a unified knowledge administration system could significantly decrease the public’s anxiety. Consequently, without emergency administration laws and existing disaster management acts, the government would be unable to manage DRM-H as efficiently and smoothly as it has. Therefore, a comprehensive set of disaster, health, and administrative laws remains the key to preparation for forthcoming dangers. 191 6. Principal health reforms Chapter summary There were no major health reforms after the first publication of Thailand HiT report in 2015, except the devolution of subdistrict health centres from the MoPH to the locally elected government at the provincial level; namely the Provincial Administration Office (PAO). A major launch took place in 2022. As it is in a phase of transition, there is no published evidence on its impacts, either positive or negative, on access to services by the population. A constitutional challenge that argued certain provisions in the Criminal Code criminalizing abortion was partially upheld by the Constitution Court and subsequently demanded legislative amendment of the Criminal Code. By amendment of the Criminal Code (28th revision) in 2021 (National Assembly of Thailand, 2021), abortion became legal for <12 weeks’ gestation; while abortion of 12–20 weeks’ gestation shall be under examination and counselling by a physician according to rules and regulations promulgated by the Medical Council. A few outstanding incremental reforms were analysed. First, the NHSO’s expansion of the benefit package guided by evidence of cost–effectiveness, long-term budget affordability, and health system capacity to deliver services resulted in better financial risk protection to the people. All new benefit packages were fully funded either through a new budget or some small reserves from the previous years, ensuring that there were no unfunded mandates. Second, the COVID-19 pandemic responses between 2020 and 2022 unprecedently consumed a significantly large proportion of resources, particularly through domestic loans, especially during the third quarter of 2021 at the peak of the Delta strain, which had a high mortality rate and almost overwhelmed health systems. The pandemic accelerated innovative adaptations, though not a major health reform, to reduce overcrowding of hospital-based outpatient services and improve access, such as application of telemedicine, teleconsultation and dispatching medications via post. Third, legislating the Primary Health Care System Act B.E. 2562 in 2019, which advocates a family doctor care team, can have positive impacts on access to quality primary care. Since it is at the early phase of roll-out, future impact assessment is required. Finally, introduction of a progressive tax rate on 192 sugar-sweetened beverages (SSBs) in 2017, as an additional strategy to address obesity and NCDs, has shown a positive impact on reduction of consumption. The current SSB tax rate can be further increased to achieve the public health goals of reduced body mass index (BMI) and obesity. 6.1 Analysis of recent reforms 6.1.1 Amendment of abortion sections 301–305 the Criminal Code There was a constitutional challenge that the legal provisions on abortion (Sections 301–305) of the Criminal Code are unconstitutional. These provisions criminalize Thai women seeking abortion or conducting self- abortion, with up to three-year imprisonment, or a fine of up to THB 6000 (US$ 180), or both; and up to five-year imprisonment or fine of THB 10 000 (US$ 300), or both for abortion providers (Chaturachinda et al., 2020). In 2018, a lawsuit was filed in the Constitutional Court by a doctor. The Constitutional Court ruled on 19 February 2020 that the existing provisions on abortion in the Criminal Code are partially unconstitutional as it breaches the principles of equality and liberty. In its ruling, the Court decided that section 301 of the Code violated section 28, paragraph 1 of the Thai Constitution, which states that “[a] person shall enjoy the right and liberty in his or her life and person,” and obligated the legislature to amend the provision within 360 days from the court’s decision (Umeda, 2021). Section 305 stipulates that a medical practitioner who committed the offense described in section 301 or section 302 was not guilty of committing an offense when (1) the act was necessary for the sake of the health of the woman or (2) the woman was pregnant as the result of a sexual crime. Although the Constitutional Court did not rule that section 305 was unconstitutional, the legislature also amended section 305 to clarify and facilitate access to safe abortion. The new section 305 provides additional justifications for medical practitioners when the acts described in sections 301 and 302 adhere to the criteria set by the Thai Medical Council. Under the new section, abortions are justified for pregnancies when they • are terminated during the first 12 weeks, • pose a threat to either the physical or mental health of the mother, • carry a high risk of health problems that may lead to infant deformities or disabilities, • result from sexual offense. 193 In addition, the new section allows abortions after 12 weeks but no later than 20 weeks of gestation in cases where a woman, after consulting with experts, insists that she must have an abortion. There are no evaluation studies yet that assess the impact of amendment of abortion provisions in the Criminal Code on reduction of the prevalence of unsafe abortion and its related mortality. Future impact assessment and implementation experiences are required. 6.1.2 Extension of the UCS benefit package Though this is not a major reform as it is a regular activity conducted by the NHSO, extension of the UCS benefit package increases coverage through new, cost-effective interventions. Assessment of new interventions is conducted using an incremental cost–effectiveness ratio (ICER) of THB 160 000 Thai per quality-adjusted life year (QALY) gained, long-term affordability, health systems capacity to deliver services equitably across geographical areas, and other considerations. Once these new interventions are adopted by the National Health Security Board, the Board will also approve a budget to secure additional funding to finance these services; this is to prevent unfunded mandates (Tangcharoensathien et al., 2020a). Further, the National Essential Medicines Sub-committee constantly reviews and decides on the inclusion of new medicines into the National List of Essential Medicines (NLEM), based on the aforementioned health technology assessment criteria. The inclusion of new benefits was adopted not only by the UCS, but also by the two other schemes (CSMBS and SHI), which applied these benefits to their schemes as appropriate, except for the NLEM, which is a pharmaceutical benefit package for all three schemes. These additional benefit packages result in a high level of financial risk protection, low level of OOP payment for health, low prevalence of catastrophic health expenditure and medical impoverishment. It is noteworthy that Thailand has the institutional capacity to conduct cost–effectiveness analysis, with rigorous peer-review processes. Tables 6.1–6.3 provide lists of new interventions in the UCS package, new facility options, and medicines included in the NLEM. 194 Table 6.1 Inclusion of new interventions into the UCS benefit package, 2017–2023 2017 Universal human papillomavirus (HPV) vaccine for girls 11–12 years old through the school-based vaccination programme. As vaccination is a prevention and health promotion intervention, the HPV vaccination covers all Thai girls, not only UCS members. Note that the gross primary school enrolment rate (total enrolment regardless of age, relative to the population of the officially defined age group) in Thailand was 100% in 2021 (UNESCO Institute for Statistics, 2022). 2019 Screening for HLA allele-B* 1502 prior to the initiation of carbamazepine to prevent the risk of carbamazepine-induced Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) in corroboration with a study of cost– effectiveness (Choi et al., 2019) 2021 Liver transplantation in patients with intermediate and late-stage cirrhosis 2021 Extracorporeal membrane oxygenator (ECMO) for acute heart and/or lung failure 2021 Hearing screening for high-risk newborns (0–6 months old) and cochlear implantation for children younger than 5 years with hearing level 90+ dB (profound hearing loss) who have never practised sign language. Pre- authorization for cochlear implantation surgery was developed to ensure the benefit to patients, including reviewing pre-surgical condition, ensuring fitness to undergo implant surgery (Piromchai et al., 2022). 2022 Abolishment of self-payment for haemodialysis as a previous criterion, increases choices available to patients for selecting renal replacement therapy in consultation with a physician or nephrologist 2022 Diapers for frail elderly having (a) Barthel activities of daily living (ADL) index equal to or lower than 11, (b) care plan for long-term care management. This is for the whole population, a lump sum budget of THB 5000 per annum per person 2022 Eyeglasses for children with visual impairment through proactive screening in the community 2022 BRCA1/BRCA2 genetic screening for hereditary breast cancer in high-risk breast cancer patients with a family history or relatives showing the presence of the mutated gene 2022 Expanded newborn screening by tandem mass spectrometry to detect metabolic genetic diseases 2022 Oral cancer screening by dentists 2022 Dental implant service for edentulous UCS members 2022 Thalassaemia screening for all pregnant women and their spouses 2023 Screening for hepatitis B and hepatitis C in the general population born before 1992 2023 Screening for congenital heart disease by pulse oximeter. A study shows that newborn screening for critical congenital heart disease using pulse oximetry has led to significant improvements in child health outcomes (Martin et al., 2020). 2023 HIV self-testing Source: compiled by the NHSO 195 Table 6.2 Expansion of options in health facilities to improve access to UCS members 2021 Permission to seek cancer treatment, radiation therapy or chemotherapy at any hospital after being diagnosed; aims to reduce waiting time for treatment and disease progression 2021 Seeking outpatient care from any primary health-care provider with reasonable causes defined by the patient. This departs from the previous regulation, which requires referral from the member’s registered contractor provider network. 2022 Nursing services at private clinics 2022 Physical therapy at private clinics 2022 Access to private laboratory services near patients’ homes; aims to reduce waiting time and congestion in hospitals and ensures lab results are ready to be seen by the doctor 2023 Laboratory examinations such as blood testing at home by private laboratory medical technologist Source: compiled by the NHSO Table 6.3 Inclusion of new medicines in the NLEM 2019 Donepezil for mild-to-moderate Alzheimer disease; it is cost effective with an incremental cost–effectiveness ratio of THB 138 524/QALY (Kongpakwattana et al., 2020). 2019 Thyrotropin alfa for differentiated papillary and/or follicular thyroid carcinoma 2019 Intravenous immunoglobulin (IVIG) as second-line therapy for chronic inflammatory demyelinating polyradiculoneuropathy 2019 Dolutegravir (HIV integrase inhibitor) for third-line therapy (antiretroviral drug) 2020 Rituximab for non-Hodgkin lymphoma diffuse large B-cell (DLBCL) in children 2020 Erlotinib for non-small cell lung carcinoma (NSCLC) 2021 Imatinib, dasatinib for acute lymphoblastic leukaemia (ALL) 2021 Tocilizumab for systemic juvenile idiopathic arthritis (SJIA) 2021 Ceftazidime/avibactam for patients with infection due to carbapenem-resistant Enterobacteriaceae Source: compiled by the NHSO 6.1.3 COVID-19 pandemic: health system adaptations During the pandemic, the comprehensive benefit package, which includes laboratory tests, contact tracing, active case-finding, quarantine measures, ambulance services for referral, clinical services at hospitals, field hospitals, home and community isolation, vaccines and vaccination cost, were provided without copayment by users. No-fault compensation for adverse events or deaths following vaccination was also provided. Services were purchased from qualified public and private providers using the same rate, terms and conditions. The benefit package was applicable to everyone living in Thailand, 196 including both Thai citizens and migrant workers. It was a standardized and comprehensive COVID-19 benefit package for the Thai and non-Thai populations without copayment facilitates universal and equitable access to care, irrespective of the capacity to pay, social status and nationality, all while aiming to contain the pandemic (Tangcharoensathien et al., 2022b). The NHSO and DDC, as budget executing agencies for COVID-related services to all Thai and non-Thai individuals, respectively, sought additional funding from the National Economic and Social Development Council (NESDC), which manages a significant amount of loans (mostly from national sources). The Cabinet approved the loans after examining NESDC reviews and recommendations (Sachdev et al., 2022). The overall loans for COVID responses were THB 1 trillion (approximately US$ 29 700 million). Of the total THB 1 trillion, impact mitigation took the major share of 70.9%, followed by economic and social recovery (22.7%) and health sector responses (6.4%), see Table 6.4. The overall disbursement rate was 97%, though there was a slight variation across three programmes. Table 6.4 Loan for COVID-19 responses: allocation to three programmes, Cabinet approval and disbursement as of May 2023 Programmes for COVID responses Al lo ca tio n, m ill io n TH B % Pr og ra m m e al lo ca tio n Ca bi ne t ap pr ov al , m ill io n TH B % a pp ro va l t o al lo ca tio n Di sb ur se d, m ill io n TH B % d is bu rs ed to a pp ro va l 1. Health sector response 63 897.99 6.4% 63 402.41 99% 58 885.49 93% 2. I mpact mitigation people, agriculture, business 709 059.02 70.9% 709 059.02 100% 704 749.77 99% 3. Economic and social recovery 227 042.99 22.7% 209 881.76 92% 185 611.91 88% Total 1 000 000.00 100.0% 982 343.19 98% 949 247.17 97% Source: (Office of the National Economics and Social Development Council, 2023) In addition to UHC financing systems, reviews showed that funding support to respond to the pandemic was adequate using three major sources: (a) the central budget for emergencies; (b) reprogramming from the routine programme budget in 2020, 2021; and (c) the majority from loans. National Health Accounts is tracking the sources of budget, size and spending profile. While management of public financing provides rapid fund mobilization, there are a few bottlenecks, such as delays in execution due to bureaucratic 197 spending rules. Public hospital revenue is the intermediary that facilitates rapid budget execution. Flexible public financial rules and regulations are recommended during a pandemic, while maintaining accountability, reporting and auditing (Sachdev et al., 2022). The key to effective public health responses was the nationwide distribution of over 1000 well-trained surveillance and rapid response teams, comprising public health nurses and officers, even including epidemiologists in some areas (Rajatanavin et al., 2021). Community trust in the government and social capital within the community (Samutachak et al., 2023), and over a million health volunteers (Kaweenuttayanon et al., 2021) in rural villages and urban communities were enabling factors for successful responses. The Department of Medical Sciences of the MoPH had scaled up certified public and private laboratories across the country. By 2022, there were a total of 571 certified laboratories for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), of which 209 were in Bangkok (66 public and 143 private), and 362 in 76 provinces outside Bangkok (235 public and 127 private) (Department of Medical Sciences, 2022), and they had secured local production of laboratory supplies. These enhanced diagnostic capacity for future pandemics. Thailand had strengthened its capacity to identify whole- genome sequences, processing up to 500 samples per week at the peak of the Omicron variant, and regularly shared this information with the WHO Biohub. The second joint external evaluation (JEE) assessment in 2022 of the 19 International Health Regulations, 2005 (IHR) core capacity technical areas had shown improved results. The average score increased from 3.75 out of 5 (75%) in 2017 to 4.25 out of 5 (85%) in 2022. Positive findings from the second JEE assessment, laboratory capacity, and Surveillance and Rapid Response Team (SRRT) are the foundations for effective preparedness and response. However, Thailand has yet to establish sentinel sites for One Health Integrated Surveillance and maximize the use of artificial intelligence (Department of Medical Sciences, 2022). The pandemic provided an opportunity for significant public investment on R&D of vaccines, granted by the NVI to various research agencies. Between 2020 and 2023, the total public investment on R&D of the COVID vaccine reached THB 7300 million (US$ 243 million at THB 30 exchange rate) through various strands of investment, such as R&D of vaccines on different platforms (live attenuated, viral vector, mRNA and subprotein unit), standard animal facilities and pilot plant and fill and finish facilities. These investments are essential for a timely vaccine response to a future pandemic, though challenges remain, especially to diversify production of 198 routine vaccines during interpandemic periods. This also requires securing a demand for these routine vaccines, such as for seasonal influenza. Adaptation of practices during the pandemic focuses on health service arrangements aimed at reducing exposure to infection in crowded hospital outpatient settings and improving access. Acute respiratory infection clinics were relocated from the main hospital building to open spaces, which included cabins for collection of nasal swab specimens to protect health workers. Further, the application of telemedicine, mobile clinics, and home wards for older persons were adopted. Adaptation of service modalities used during the pandemic was further applied after the pandemic. Recently, the NHSO approved the treatment of 16 common illnesses by a certified community pharmacy for UCS beneficiaries (National Health Security Office, 2023a). Pharmacies are usually the first point of contact by people and patients, and they play a vital role in improving people’s access to medicines and preliminary consultations. The pharmacies joining the partnership can claim consultation fees and medication costs from the NHSO, with full subsidies of THB 380 per visit. This will reduce irrational self-medication by the population as well as hospital-based outpatient density. Future reform includes outsourcing hospital-based outpatient dispensing services to private pharmacies. Note that by 2022, all community pharmacies were required by law to achieve Good Pharmaceutical Practice. Further, the ongoing reforms in health information systems, which facilitate linkages of different health data platforms through interoperability, will eventually be accessible by individual citizens through personal health records, with full privacy protection of their health conditions, awareness of their right to health, strengthened health literacy and empowerment for healthy living. 6.1.4 Primary health-care reform in 2019 In April 2019, the Primary Health Care System Act B.E. 2562 was legislated by the Parliament (Royal Thai Government Gazette, 2019e). The Act is mandated by the 2017 Constitution, Article 258, Section 7(4), which stipulates that individuals are entitled to receive public health services from the State (Constitution Drafting Commission, 2017). These public health services must cover health promotion, disease control and prevention, medical treatment, and rehabilitation (Pinyopornpanich et al., 2022). Furthermore, the State must continuously improve the quality and standards of public health services. Further, Article 258, Section 7(5) of the Constitution also mandates establishment of primary care systems provided by family physicians with an appropriate family physician-to-population ratio (one family doctor 199 care team consisting of one family physician, two professional nurses, two public health officers, and other interdisciplinary teams for a population of 8000–10 000 people (Royal Thai Government Gazette, 2019b). Primary care units are required to have an adequate number of family physicians to fulfil the constitutional mandates and the mandate by the Primary Health Care System Act. The MoPH is the agency responsible for implementing the Act. As of 2023, more than 4000 primary care units have been registered all over the country (Ministry of Public Health, 2023). Since implementation of the Act is still in the initial stage, future evidence and research on its impacts are required. 6.1.5 Introduction of tax on sugar-sweetened beverages in 2017 Since 1984, Thailand has imposed an excise tax on several products, including non-alcoholic beverages, utilizing a combination of ad valorem (based on the price of tobacco) and specific volume-based rates (based on weight or numbers of cigarettes). Notably, certain beverages with sugar content were taxed less as a result of tax exemption on fruit and vegetable juices as well as on tea and coffee, with the objective of motivating local industries to use more domestic fruits and vegetables in the beverages and boost local agriculture. Thus, it allowed these beverages to be sold at a lower price than other types of beverages (Osornprasop et al., 2018). In 2017, the Thai Cabinet passed the Ministry of Commerce Regulation, in line with the Excise Tax Act B.E. 2560 (2017) for a tax on sugar-sweetened beverages (SSBs), which aims to reduce SSB consumption, with the goal of preventing overweight and obesity and NCDs among the Thai people. The revised approach adopted a tiered tax structure, incorporating both ad valorem and specific taxes based on sugar content (g per 100 mL). The ad valorem rate varied from a range of 0% to 14% for different beverage types as shown in Table 6.5 (Markchang et al., 2019). 200 Table 6.5 Ad valorem tax structure according to Excise Tax Act B.E. 2560 (2017) Group Ad valorem tax (%) Mineral water and soft drinks containing sugar or sweetening agents or additives and other beverages but not including fruit or vegetable juice under this category, such as carbonated drink, energy drink, mineral drinks 14 Non-fermented and non-alcoholic fruit juice (including grape must) and vegetable juice, regardless of whether sugar or other sweetening agent is added or not, such as tea, coffee 10 Non-fermented and non-alcoholic fruit juice (including grape must) and vegetable juice, regardless of whether sugar or other sweetening agent is added or not, in accordance with the rules, procedures and conditions prescribed by the Director-General, such as fruit juice, vegetable juice 0 Instant powder drinks or concentrated drinks that contain sugar and can be soluble 0 Furthermore, specific tax rates were adjusted based on sugar content, ranging from less than 6 g to over 18 g as shown in Table 6.6. The specific tax rates would increase after 2019 and every two years afterward and settle in 2023 with a maximum rate of THB 5 per litre for fruit and vegetable juice, soda, and carbonated drinks and THB 44 per litre for beverage concentrates (Osornprasop et al., 2018). Table 6.6 Specific tax structure according to the Excise Tax Act B.E. 2560 (2017) Sugar content Sep 2017 to Sep 2019 Oct 2019 to Sep 2021 Oct 2021 to Sep 2023 Oct 2023 onwards g/100 mL THB/L THB/L THB/L THB/L ≤6 0.00 0.00 0.00 0.00 6–8 0.10 0.10 0.30 1.00 8–10 0.30 0.30 1.00 3.00 10–14 0.50 1.00 3.00 5.00 14–18 1.00 3.00 5.00 5.00 Over 18 1.00 5.00 5.00 5.00 A study showed that since the tax was imposed, SSB prices were increased by 11%. However, this is still lower than the WHO-recommended increase in retail price of SSBs by 20% to prevent overweight and obesity (Markchang et al., 2019). Another study conducted in 2020 showed that there was a significantly greater reduction in taxed SSB consumption compared to non-taxed SSB, suggesting that the surcharge was affecting consumer behaviour. However, the decline in SSB consumption was not found across all socioeconomic groups (Phulkerd et al., 2020). 201 A modelling study showed that a 20% and 25% price increase in SSBs tended to reduce higher energy intake, weight status and BMI, when compared with an 11% increase in the existing price. The percentage reduction in obesity prevalence using hypothetical tax rates of 11%, 20% and 25% on SSBs was 1.73%, 3.83%, and 4.91%, respectively. The study suggests a 20–25% tax rate (Phonsuk et al., 2021). 6.2 Future developments 6.2.1 Rapid epidemiological and demographic transition These two transitions result in an older society with a high and increased prevalence of NCDs. A study shows that effective coverage for diabetes and hypertension was unsatisfactorily low (Rajatanavin et al., 2022). Major reforms may include primary prevention of priority NCDs through the application of WHO-recommended best buy interventions through a whole- of-government and whole-of-society approach. Though the tobacco industry interference index in Thailand is favourable, ranking 11th on the overall score, Thailand ranks third for tobacco industry interference in policy development; and cigarettes have not become less affordable (Assunta, 2021). 6.2.2 Use of digital health modalities and technology Due to the high coverage of digital technology in the population, Internet usage in Thailand reached 85% of the population in 2021 compared with the 76% average for upper-middle-income countries (International Telecommunication Union, 2021a). Additionally, mobile cellular subscription was 169 per 100 Thai population; compared with a 123 average for upper- middle-income countries (International Telecommunication Union, 2021b); there is a high potential to maximize this platform to build the health of the population. Nudging people to move has a high potential for increasing physical activity and reducing sedentary behaviour in the population (Forberger et al., 2019). Experiences from Singapore (Yao et al., 2022) and Thailand on step count initiatives can be scaled up, along with strengthening social environments that facilitate physical activity. 6.2.3 Preparedness for future pandemics Thailand should aim for higher scores across the 19 IHR core capacity technical areas in the next JEE assessment using recommendations from the second assessment on various gaps to be filled as well as establishing sentinel sites for One Health Surveillance in wildlife, domesticated animals and humans. A national action plan and implementation of the plan on pandemic preparedness and response can gradually improve the capability and capacity to contain the next pandemic effectively. 202 7 Assessment of health systems Chapter summary This chapter discusses the objectives of health systems, including health improvement, responsiveness to the population, fairness of financial contribution, and efficiency. The chapter assesses the health systems in Thailand against the three ultimate goals – health improvement, responsiveness to the legitimate expectations of the population, and fairness of financial contribution. In addition, system efficiency and transparency dimensions are also discussed, mostly based on time-series data from around the turn of the century, when Thailand achieved universal health coverage (UHC) in 2002. Thailand’s health-care financing system is mainly based on general tax revenue, which has increased progressively over time. Thailand’s current health expenditure as a proportion of gross domestic product (GDP) slightly increased from 3.0 in 1995 to 3.9 in 2019. Domestic general government health expenditure (GGHE-D) as a percentage of CHE significantly increased from 43.1% in 1995 to 72.2% in 2019, while domestic private health expenditure (PVT-D) as a percentage of CHE decreased from 56.9% to 27.7% between 1995 and 2019. Out-of-pocket (OOP) expenditure as a percentage of CHE substantially declined since 1995 and, in 2019, household payment was only 8.5% of current health spending. The achievement of UHC significantly reduced the incidence of catastrophic health expenditure and the number of health-impoverished households. The rich in Thailand contribute to health financing disproportionately more than the poor, but financing health care has been progressive since 2000, with direct tax payment being the most progressive source. UHC implementation led to increased usage of outpatient and inpatient services, with higher net public budget subsidy in favour of the poorest members. Pro-poor subsidy was driven by higher service utilization among the economically worse off, equitable access to health services at the district health system level; while satisfaction with the UHC system has increased among users, providers, and stakeholders. 203 Maternal mortality ratio in Thailand have decreased significantly from 48 per 100 000 live births in 2000 to 29 in 2020 (United Nations Children’s Fund, 2023) and Thailand has a lower maternal mortality ratio compared to other regions of the world. The country also experienced a steady decline in under- five mortality rate even before achieving UHC. Thailand had a successful immunization programme for children, with high coverage rates for BCG, DTP3, OPV3, and TT2. However, the country has been facing challenges related to hospitalization for chronic conditions such as chronic obstructive pulmonary disease (COPD), diabetes, and coronary heart disease. Effective coverage for diabetes and hypertension has been low, but improving, particularly among men and younger populations. Analysis of the UCS’s claim dataset found that hospital networks with hospital-accredited provincial hospitals had lower standardized mortality ratios for acute stroke and sepsis. The close-ended provider payment implemented by the SHI and UCS in Thailand led to significant technical efficiency gains by promoting the use of low-cost generic medicines and rational prescribing. Under capitation, unit costs and rates of use are monitored, and members can change contractors if they are not satisfied. The Thai health-care system emphasizes people’s participation in policy processes and promotes citizen representation and involvement in UHC governance, implementation, and management (Marshall et al., 2021). The UHC legislation in Thailand supports citizens’ ability to voice concerns, protects access to information, and ensures access to and provision of quality care (Kantamaturapoj et al., 2020b). However, not all schemes equally bolster citizen participation and government responsiveness (Kantamaturapoj et al., 2020a). 7.1 Objectives of the health systems A well-performing health system should achieve at least three goals: (1) health improvement; (2) responsiveness to the legitimate expectations of the population; and (3) fairness of financial contribution (World Health Organization, 2000). The 2000 World health report (WHR) entitled Health systems: improving performance identified equity as one of the key goals of health systems and emphasized the need to ensure that people with different socioeconomic status have equal access to health services and achieve comparable health outcomes. The first objective was framed to measure and monitor health inequity within countries, and to assess whether people with different socioeconomic status were making a fair contribution to overall health financing. The second objective addressed responsiveness to people’s non-medical expectations. The third objective was framed to assess 204 population health. Both responsiveness and health are measured in terms of an overall level and distribution. Even though the WHR has been criticized on its possible misranking of some WHO Member States against the goals and controversy in measuring equality versus equity or fairness (Almeida et al., 2001), it was a landmark paper proposing new concepts and measurements of health systems. Additionally, the WHR addressed stewardship as one of the main functions of a health system. In 2007, WHO laid out a comprehensive health systems framework linking inputs and outcomes (World Health Organization, 2007). This framework identified six key building blocks of health systems, which are essential for delivering high-quality health services to populations. The report included improved efficiency as an additional fourth goal as a key component of its approach to health systems strengthening. It laid out the six system building blocks, including health service delivery, health workforce, medicines and technologies, and health financing, of which governance and information technology are classified as cross-cutting issues. In 2022, WHO proposed a framework for the assessment of health systems performance. The framework is an elaborated version of the six health systems building blocks. In the framework, various health systems functions are proposed, namely: governance, resource generation, health financing and service delivery, with proposed areas of performance to be measured for each function. The governance function also contributes to other functions while various functions contribute to service delivery, which finally contribute to the intermediate objectives of access, quality, safety, efficiency, equity. These intermediate objectives finally feed into the attainment of the final health systems goals of health improvement, financial risk protection, people-centredness, equity and efficiency (Papanicolas et al., 2022). This chapter gives an assessment of the health systems in Thailand against the three ultimate goals (health improvement, responsiveness to the legitimate expectations of the population, and fairness of financial contribution) plus equity of access and equity of outcome, quality of care, health system efficiency and transparency dimensions. The analysis is mostly based on time-series data, covering periods around the turn of the century, when Thailand achieved UHC in 2002, which health insurance covered comprehensive health services to all Thai citizens and legal residents, regardless of their ability to pay (Fig. 7.1). 205 The universal coverage reform is considered the second-largest health reform following the 1970s geographical expansion of district-level health infrastructure and mandatory government service in rural areas by all new medical, dental, pharmacy and nursing graduates. Fig. 7.1 Population coverage by different health insurance schemes and the remaining uninsured, 2001–2021 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2001 2005 2009 2013 2017 2021 Uninsured LIC VHC UC CSMBS SHI Other LIC: Low-income Card (medical welfare) scheme; VHC: Voluntary Health Card scheme; UCS: Universal Coverage Scheme; CSMBS: Civil Servant Medical Benefit Scheme; SHI: Social Health Insurance scheme Source: (National Statistical Office, 2022b) Over the four decades 1970–2010, the stated objectives of the health system were in favour of health equity. Rhetorical statements are not as important as what has been implemented with good outcomes. Thailand has invested in rural PHC infrastructure, making PHC functional by increasing the health-care workforce and ensuring that it serves rural communities, and by consistent expansion of financial risk protection to facilitate financial access to care by all citizens – starting with the poor, expanding to public- and private-sector employees, and finally to those engaged in the informal sector – until Thailand reached UHC in 2002 (Patcharanarumol et al., 2011). Well before ratification of the Framework Convention on Tobacco Control in June 2003, two major legislations were adopted in Thailand: the Tobacco Control Act, 1992 and the Health Protection of Non-smokers Act, 1992. These two Acts were replaced by a comprehensive Tobacco Products Control Act BE 2017, with stronger regulation in line with provisions in the Framework Convention on Tobacco Control, 2003. Adequate law enforcement and intersectoral actions are concrete examples of commitment to the health of the population. Thailand’s establishment of the sin tax-financed Thai Health 206 Promotion Foundation to support active health promotion activities puts it among the few countries in the world to have such a health innovation (Pongutta et al., 2019). 7.2 Financial protection and equity in financing 7.2.1 Financial protection A macro-view of health financing Between 2000 and 2019, the current health expenditure (CHE) of Thailand was around 3.44% of the country’s GDP. The majority of this expenditure, around 2.43% of GDP, was mainly financed through public sources (World Health Organization, 2022a). Domestic general government health expenditure (GGHE-D) gradually increased over time and reached 2.71% of GDP in 2019 (Fig. 7.2). Public financing of health as a ratio of GDP in Thailand was higher than in the South Asia region, though lower than in Europe and Central Asia, and East Asia and Pacific. Fig. 7.2 Public financing of health as a ratio of GDP, Thailand and selected regions, 2000–2019 Thailand World East Asia & Pacific South Asia Europe & Central Asia 0 1 2 3 4 5 6 7 8 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17 20 18 20 19D om es tic g en er al g ov er nm en t h ea lth ex pe nd itu re (% o f G DP ) Source: (World Bank, 2021h) During the past two decades, the CHE increased from US$ 5079.5 million in 1995 to US$ 20 997.3 million in 2019 (Chapter 3, Table 3.1). CHE as proportion of GDP slightly increased from 3.0 in 1995 to 3.9 in 2019. GGHE-D as a percentage of CHE significantly increased from 43.1% in 1995 to 72.2% in 2019, while domestic private health expenditure (PVT-D) as a percentage of CHE decreased from 56.9% to 27.7% between 1995 and 2019. In addition, OOP expenditure as a percentage of CHE substantially declined from 44.9% in 1995 to 8.5% in 2019 (Fig. 7.3). 207 Fig. 7.3 Share of current health expenditure by private and public financing, 1995–2019 0% 20% 40% 60% 80% 100% 19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17 20 18 20 19% o f t ot al h ea lth e xp en di tu re Government Private Insurance Social insurance Household other sources Source: (National Health Accounts Working Group, 2021) Household direct payment on health Based on microdata of nationally representative household surveys – the Socioeconomic Survey (SES) – the overall household spending on health care before UHC achievement was above 2% of total household consumption expenditure in which household spending in the richest (decile 10) (orange line) was higher than the poorest (decile 1) (blue line) (Fig. 7.4). In 2012, direct health payment was lower than 2% in both subgroups, in which the poorest (expenditure decile 1) was about 1%. In 2020, direct payment for health as a percentage of total household expenditure slightly increased in both subgroups. Fig. 7.4 Direct payment for health as a percentage of total household expenditure, overall and by richest and poorest expenditure deciles, 1996–2020 Decile1 Decile10 Overall 0 1 2 3 4 5 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 H ea lth a s % o f t ot al he al th e xp en di tu re Notes: Decile 1 = poorest; Decile 10 = richest Source: (National Statistical Office, 2021c) 208 Impact of reforms/initiatives to strengthen financial protection The incidence of catastrophic health spending, which was at 3–4% of total household spending during the first decade of UHC achievement, is a result of using hospitalization services in private hospitals outside the entitlement as well as in large public hospitals without proper referral (Tangcharoensathien et al., 2007). In addition, provinces with a large proportion of informal sector workers or household members who are economically inactive tended to have a greater degree of health impoverishment (Kongsri et al., 2011). Further, a recent publication showed that the incidence of catastrophic spending dropped from 6.0% in 1996 to 2% in 2015 using the 10% threshold (Tangcharoensathien et al., 2020b). A study confirms that the rich–poor and urban–rural gaps in catastrophic health spending were negligible (Tangcharoensathien et al., 2020b). There was a significant decrease in both the incidence of catastrophic health expenditure and health-impoverished households following the achievement of UHC in 2002 (Fig. 7.5). The impact of UHC in reducing poverty was mainly attributed to the coverage provided to the informal sector and economically inactive households, who were uninsured before 2002. With the establishment of UCS in 2002, these households became eligible for UCS coverage and consequently experienced a reduction in the incidence of poverty. In addition, the comprehensive benefit package and literally no copayment at the point of service facilitated reduction in catastrophic health spending (Tangcharoensathien et al., 2020a). Fig. 7.5 Reduction in the incidence of catastrophic health expenditure and health-impoverished households in 1988–2020 0 100 000 200 000 300 000 400 000 500 000 600 000 700 000 800 000 900 000 1 000 000 19 88 19 90 19 92 19 94 19 96 19 98 20 00 20 02 20 04 20 06 20 08 20 10 20 12 20 14 20 16 20 18 20 20 N um be r o f h ou se ho ld s incidence of catastrophic health expenditure incidence of impoverishment Source: (National Statistical Office, 2014, 2021c) 209 Among 11 Member States in the South-East Asia Region, Thailand achieved a relatively high level of UHC service coverage index (SDG 3.8.1), from 68 in 2010 it increased to 82 in 2020 (Fig. 7.6). Fig. 7.7 demonstrates the performance of SDG 3.8 UHC indicators across countries when matching the UHC service coverage index with the incidence of catastrophic health spending. Thailand’s achievement of a high level of the service coverage index and a low level of catastrophic health spending (SDG3.8.2) using a threshold of >10% of total household expenditure in 2021 was better than the global median. Fig. 7.6 Changes in coverage of essential health services in Member States of the WHO SE Asia Region, 2010–2020 0 20 40 60 82 73 67 65 61 62 60 56 52 50 50 80 2010 2020 100 10 30 50 70 90 Th ai la nd DP RK K or ea Sr i L an ka Co ve ra ge (% ) Bh ut an In di a In do ne si a M al di ve s M ya nm ar Ti m or -L es te Ba ng la de sh N ep al Source: (World Health Organization. Regional Office for South-East Asia, 2021) 210 Fig. 7.7 Comparison of health service coverage and financial protection in Member States of the WHO SE Asia Region by income level, 2021 Bangladesh (2016) Bhutan(2017) India(2011) Indonesia(2018) Maldives(2016) Myanmar(2015) Nepal(2014) Sri Lanka(2016) Thailand(2017) Timor-Leste(2014) 0 20 40 60 80 100 051015202530 M or e is b et te r UH C es se nt ia l s er vi ce c ov er ag e in de x 20 21 (% ) Population with household expenditure on health >10% of total household expenditure/income (%) Less is better Lower middle-income Upper middle-income Gl ob al m ed ia n= 12 .7 Global median=66 Source: (World Health Organization. Regional Office for South-East Asia, 2021) 7.2.2 Equity in financing Progressivity of health financing The rich in Thailand contribute to health financing disproportionately more than the poor (Prakongsai et al., 2009). During 2002–2006, the concentration index (CI)1 for direct and indirect taxes was 0.769–0.822 and 0.551–0.596, respectively – indirect tax is less progressive than direct tax. Contribution to SHI and the voluntary private insurance premium was less concentrated among the rich (CI = 0.449–0.497 and 0.378–0.422, respectively), thus less progressive. The CI for direct health payment by households over the same period was 0.463–0.488, the least progressive among all sources. Since 2000, financing of health care has been progressive, meaning that the rich pay a higher proportion of their income to health financing. Of the four 1 The CI value ranges from –1 to +1, the closer to +1, the more progressive, and the closer to –1, the less progressive. 211 major sources of health financing, direct tax payment is the most progressive with respect to income. This is evident in the Kakwani Index (KI) (Wagstaff et al., 2014), which shows a positive value of approximately 0.4 between 2000 and 2019. Conversely, indirect tax and direct payment methods were relatively regressive, with a negative value of KI of less than zero (even though the KI of SHI and private insurance increased to about 0.05 in 2019) (Fig. 7.8). Because of the major share of direct tax and the dominant role of general government revenue (GGR) in health-care financing sources, overall health financing was progressive relative to the income of household members. In conclusion, the progressivity of health financing has improved since 2000, with direct tax payment being the most progressive source. The data show that health financing has helped offset income inequality as measured by the Gini coefficient, although there is still room for improvement in other financing sources, including the indirect tax and direct payment methods. In the future, if value added tax increases from 7% to 10%, indirect tax would have a higher influence, which may reduce the progressivity of health-care financing in Thailand. Fig. 7.8 Progressivity of major sources of health financing as measured by Kakwani Index, 2000–2019, reflecting the relative contributions by four sources of health financing Ka kw an i I nd ex (p ro gr es iv e, K I> 0; re gr es si ve K I< 0) -0.300 -0.200 -0.100 0.000 0.100 0.200 0.300 0.400 0.500 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17 20 18 20 19 Household SHI and private insurance Direct tax Indirect tax Overall financing sources Source: (National Statistical Office, 2022b) 212 7.3 User experience and equity of access 7.3.1 Increased access to health services Following the implementation of UHC, there was a significant increase in the use of curative services, as reported by the National Health Security Office (NHSO), which managed the UCS. The annual outpatient visits per capita among UCS members increased from 2.45 visits in 2003 to 3.45 visits in 2020 (Fig. 7.9). The trend seemed to have become saturated and tapered down in recent years. Additionally, the annual inpatient admissions per capita also increased from 0.09 admission per person per year in 2003 to 0.12 admission per person per year in 2020 with a similar trend of saturation and slight tapering down. Notably, the growth rate in outpatient usage was considerably faster than that of inpatient admissions. Fig. 7.9 Annual outpatient visits and inpatient admissions per capita among UCS members, 2003–2020 Outpatient care of UCS members Inpatient care of UCS members 0 0.05 0.1 0.15 0.2 0 0.5 1 1.5 2 2.5 3 3.5 4 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17 20 18 20 19 20 20 IP u tii za tio n ra te (a dm is si on /p er so n/ ye ar ) OP u til iz at io n ra te (v is it/ pe rs on /y ea r) Source: (National Health Security Office, 2020a) 7.3.2 User experience Satisfaction with the UCS Fig. 7.10 illustrates an average score (with a narrow 95% confidence interval) of the overall satisfaction with UCS on the 1–10 Likert scale, as rated by UCS members, providers, and stakeholders, over the period 2003–2020, conducted annually by competent survey agencies using standardized survey tools. The surveys were funded by the NHSO. The result showed a stable and high level of satisfaction among UCS users, health-care providers, and stakeholders. 213 Fig. 7.10 Overall average rating of satisfaction with UCS (on 1–10 Likert scale, 2003–2022) 8.2 8.3 8.2 8.3 8.0 8.5 8.6 8.8 8.8 8.6 8.6 8.9 9.1 9.0 9.2 8.7 9.0 9.2 8.7 6.2 6.2 6.1 6.3 6.5 6.6 6.5 7.6 7.0 7.1 7.0 6.9 7.0 7.0 7.0 7.1 7.3 7.9 7.4 8.0 8.0 8.0 8.0 8.4 8.6 7.5 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17 20 18 20 19 20 20 20 21 20 22 sc or e UCS member Provider Stakehodlers Source: (National Health Security Office (NHSO), 2022a) 7.3.3 Equity of access to health care Utilization and benefit incidence across socioeconomic groups Fig. 7.11 describes the rich–poor distribution of members covered by the three insurance schemes by wealth quintile. The majority of the Thai population, approximately 70%, belongs to the UCS group, which comprises individuals with a relatively lower socioeconomic status when compared to members of the other two public health insurance schemes. More UCS members were in the first to third quintiles, and fewer in the richest quintiles. In contrast, most of the CSMBS and SHI groups were in the richest quintiles (Q5). 214 Fig. 7.11 Distribution of UCS, SHI, and CSMBS members according to national quintiles of household wealth, 2005–2021 0% 10% 20% 30% 40% 50% 60% UC S SH I CS M BS UC S SH I CS M BS UC S SH I CS M BS UC S SH I CS M BS UC S SH I CS M BS 20% Poorest (Q1) Q2 Q3 Q4 20% Richest (Q5) 2005 2011 2015 2021 CSMBS: Civil Servant Medical Benefit Scheme; SHI: Social Health Insurance Scheme; UCS: Universal Coverage Scheme Source: (National Statistical Office, 2022b) From 2004 to 2021, there was a notable pro-poor utilization of outpatient services across wealth quintiles. The poorest quintile (Q1) used outpatient services disproportionately more often than the richest quintile (Q5), accounting for around 25.9–30.2% of total national outpatient visits, while the latter only accounted for 7.5–12.2% of total national outpatient services. To a similar degree, inpatient admissions were also concentrated more among the poor (21.5–28.5%) than the rich (8.5–16.5%) over the same period (Fig. 7.12). 215 Fig. 7.12 Proportions of outpatient visits and inpatient admissions, compared with the number of beneficiaries of UCS by the poorest and richest household wealth quintiles, 2004–2021 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 Q1 Q5 Q1 Q5 Q1 Q5 Q1 Q5 Q1 Q5 Q1 Q5 Q1 Q5 Q1 Q5 Q1 Q5 Q1 Q5 Q1 Q5 2004 2005 2006 2007 2009 2011 2013 2015 2017 2019 2021 Pe rc en ta ge UCS beneficiaries Total OP visits Total IP admissions Source: (National Statistical Office, 2022b) Benefit incidence analysis in Fig. 7.13 shows consistent pro-poor subsidies. The outpatient service used by the poorest quintile of UCS members (Q1) accounted for 25.5–29.3% of the net government subsidy, whereas that for the richest quintile of UCS members (Q5) accounted for just 7.6–12.0% during 2004–2021. Similarly, the inpatient service subsidy was disproportionately more concentrated among poor (21.3–31.4%) than rich UCS members (5.3– 14.9%) (Fig. 7.13). In 2021, 23.5% of total UCS members belonged to the poorest quintile (Q1), but benefited disproportionally from out- and inpatient services, 28.4% and 21.6% of total public subsidies. Meanwhile, the richest quintile (Q5), consisting of 14.4% of total UCS members, benefited from 11.2% and 14.7% of total out- and inpatient subsidies. This indicates that the UHC reform is able to maintain a pro-poor government health subsidy, partly driven by improved access to health services among the poor subgroup of those under the UCS. Pro-poor utilization was the result of the NHSO contracting the district health systems’ PHC services, which people in the lower wealth quintiles can easily access due to proximity to their domiciles. At the same time, the richest quintiles did not use their entitlement, and likely preferred to bypass and pay OOP or seek services from private-sector providers. 216 Fig. 7.13 Proportions of government subsidy for out- and inpatient services, compared with the number of beneficiaries of the UCS by the poorest and richest quintiles of household asset index, 2004–2021 0.00 5.00 10.00 15.00 20.00 25.00 30.00 35.00 Q1 Q5 Q1 Q5 Q1 Q5 Q1 Q5 Q1 Q5 Q1 Q5 Q1 Q5 Q1 Q5 Q1 Q5 Q1 Q5 Q1 Q5 2004 2005 2006 2007 2009 2011 2013 2015 2017 2019 2021 Pe rc en ta ge UCS beneficiaries Total OP subsidy Total IP subsidy UCS: Universal Coverage Scheme; OP: outpatient; IP: inpatient Note: benefit incidence in 2009 is pro-poor; for example, 23.2% of total UCS members belonged to the poorest quintile (Q1) but benefited disproportionally from out- and inpatient services – 27.1% and 27.2% of total public subsidies, respectively. Meanwhile, the richest quintile (Q5), consisting of 12.3% of total UCS members, benefited from 10.2% and 9.6% of total out- and inpatient subsidies, respectively. Source: (National Statistical Office, 2022b) The International Health Policy Program (IHPP) worked closely with the NSO to introduce an unmet health-care needs module, which was adapted from the European Union Statistics on Income and Living Conditions (EU SILC) (OECD, 2020), into the biennial Health and Welfare Survey since 2011 (Thammatacharee et al., 2012). The overall prevalence of unmet health-care needs in Thailand has decreased over time. The results show that the annual prevalence of unmet need is less than 3%, with specific percentages for different types of services. In 2019, the prevalence of unmet need was 1.4% for outpatient services, 1.1% for dental services, and about 0.1% for inpatient care. However, it remains a significant issue, particularly among certain subgroups such as the elderly and those with lower income and education levels. The main reasons for unmet health-care needs were financial 217 constraints, difficulty in accessing health-care services, and long waiting times (Vongmongkol et al., 2021) (Fig. 7.14). The study, aimed at tackling the unmet need in diabetes care for Thailand’s population under UHC, revealed substantial deficiencies in screening and diagnosis, reporting an overall unmet need of 74.0%. Factors such as age, gender, and health-care infrastructure were found to exert an influence on diagnosis and control rates (Yan et al., 2020). Fig. 7.14 Annual prevalence of unmet need by three types of services, 2011–2019 1.30 1.56 1.50 1.44 1.35 1.38 0.18 0.15 0.14 0.07 0.87 1.05 0.99 0.85 0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 1.80 2011 2013 2015 2017 2019 2021 Pe rc en ta ge Unmet need (OP) Unmet need (IP) Unmet need (Dental service) Note: IP and dental service data in 2017 and 2019 were not available. Source: (National Statistical Office, 2021c) 7.4 Health outcomes, health service outcomes and quality of care 7.4.1 Population health Trends in population mortality The maternal mortality ratio in Thailand has decreased significantly, from 48 per 100 000 live births in 2000 to 29 in 2020 (United Nations Children’s Fund, 2023). Using data from the World Development Indicators on the maternal mortality ratio in Thailand to compare with other regions, Thailand has a lower maternal mortality ratio than South Asia, and East Asia and Pacific and the global average (Fig. 7.15). An internal situational analysis of the Department of Health in 2023 suggested that non-obstetric complications was a leading cause. This was partly due to an increase in NCDs among the Thai population, including pregnant women. Furthermore, delay in seeking 218 and receiving adequate health care, especially those related to the referral system, were strongly related to the cause of maternal mortality and should be closely monitored. Other remaining challenges for Thailand were getting marginalized pregnant women to attend antenatal care (ANC) at 12 weeks of gestation as well as to receive complete quality ANC of 8–10 visits to health facilities throughout the pregnancy period (United Nations Population Fund, 2021). Fig. 7.15 Maternal mortality ratio (modeled estimate, per 100 000 live births) in Thailand, world and selected world regions, 2000–2017 0 100 200 300 400 500 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17M at er na l m or ta lit y ra tio (m od el le d es tim at e, p er 1 00 0 00 li ve b irt hs ) Thailand World South Asia East Asia & Pacific (excluding high income) Europe & Central Asia (excluding high income) Source: (World Bank, 2021h) Since 2000, Thailand has experienced a steady decline in the under-five mortality rate (U5MR) even before achieving UHC (Fig. 7.16). The U5MR was much lower than the global average and that in other regions. 219 Fig. 7.16 Mortality rate of under-5 children (per 1000 live births) in Thailand, world and selected world regions, 2000–2021 Thailand World South Asia East Asia & Pacific (excluding high income) Europe & Central Asia (excluding high income) 0 20 40 60 80 100 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17 20 18 20 19 20 20 20 21 M or ta lit y ra te o f u nd er -5 (p er 1 00 0 liv e bi rt hs ) Source: (World Bank, 2021h) Adult male and female (15–59 years) mortality rates were lower than the global average and other regions (Fig. 7.17 A and 7.17B). The Thai Burden of Disease study 2019 suggested that road injuries and stroke were the two leading causes of DALY loss among men, while women were more likely to be affected by diabetes and stroke (see Chapter 1). This could be an area for further study and implementation of interventions to improve the mortality rate among males in Thailand, which was higher than that in women, in relation to both the global rate and in the East Asia and Pacific region. Fig. 7.17A Adult female mortality in Thailand and selected world regions, 2000–2020 0 50 100 150 200 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17 20 18 20 19 20 20 Thailand World South Asia East Asia & Pacific (excluding high income) East Asia & Pacific Fe m al e ad ul t m or ta lit y ra te (p er 1 00 0 fe m al e ad ul ts ) Source: (World Bank, 2021h) 220 Fig. 7.17B Adult male mortality in Thailand and selected world regions, 2000–2020 Thailand World South Asia East Asia & Pacific (excluding high income) East Asia & Pacific 0 50 100 150 200 250 300 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17 20 18 20 19 20 20M al e ad ul t m or ta lit y ra te (p er 1 00 0 m al e ad ul ts ) Source: (World Bank, 2021h) Mortality amenable to medical interventions In this chapter, breast cancer, cervical cancer, and colorectal cancer were selected to illustrate the mortality amendable to medical intervention. This is because of the availability of data and services ranging from prevention to treatment of the three cancers under the Thai UHC. Cancer incidence and survival Breast cancer incidence increased following the country’s economic growth, just as in high-income regions (Fig. 7.18A). Fig. 7.18A Incidence of breast cancer in Thailand, globally and selected world regions, 2000–2019 0 20 40 60 80 100 120 2000 2005 2010 2015 2019 Br ea st c an ce r i nc id en ce (p er 1 00 0 00 w om en ) Europe & Central Asia - WB South Asia - WB Thailand Global East Asia & Pacific - WB Source: (Institute for Health Metrics and Evaluation, 2022a) 221 The incidence of cervical cancer in Thailand showed a decrease during 2000– 2015 and started to increase in 2019. The overall incidence is still above the global incidence (Fig. 7.18B). The coverage of screening has been increased in the past decade in Thailand. Fig. 7.18B Incidence of cervical cancer in Thailand, global, and selected world regions, 2000–2019 Europe & Central Asia - WB South Asia - WB Thailand Global East Asia & Pacific - WB 0 5 10 15 20 25 30 35 2000 2005 2010 2015 2019 Ce rv ic al c an ce r i nc id en ce (p er 1 00 0 00 w om en ) WB: World Bank Source: (Institute for Health Metrics and Evaluation, 2022b) The overall survival of cervical cancer decreased in the latter period (year 2020) as compared with that in the earlier years (2005, 2010), whereas the survival of breast and colorectal cancers improved in the latter period. These findings are consistent with the comparison of one-year mortalities between 2021 versus 2019–2020 from selected cancers (Fig. 7.19A, B, C). Fig. 7.19A Overall survival of UCS patients admitted with breast cancer, 2005–2020 Su rv iv al ra te Years since first hospitalization with cancers 0 0 20% 40% 60% 80% 100% 1 2 3 4 5 6 7 8 9 10 2005 2010 2015 2020 Source: UCS data (2005–2020) analysed by author 222 Fig. 7.19B Overall survival of UCS patients admitted with cervical cancer, 2005–2020 Su rv iv al ra te Years since first hospitalization with cancers 0 0 20% 40% 60% 80% 100% 1 2 3 4 5 6 7 8 9 10 2005 2010 2015 2020 Source: UCS data (2005–2020) analysed by the author Fig. 7.19C Overall survival of UCS patients admitted with colorectal cancer, 2005–2020 Su rv iv al ra te Years since first hospitalization with cancers 0 0 20% 40% 60% 80% 100% 1 2 3 4 5 6 7 8 9 10 2005 2010 2015 2020 Source: UCS data (2005–2020) analysed by the author A national programme on cervical cancer screening using Pap smear and visual inspection and acetic acid application has been fully financed by the NHSO for the entire female population aged 30–60 years nationwide. The MoPH has set an ambitious goal to achieve 80% screening coverage; however, the actual coverage from fiscal years 2017 to 2019 was 38%, 49% and 57%, respectively. The coverage rates had dropped during COVID-19 to around 30% (Ministry of Public Health, 2019 ). In addition, in 2020, the NHSO approved the use of the HPV DNA test for cervical cancer screening 223 in accordance with the guidelines produced by the Royal Thai College of Obstetricians and Gynaecologists, 2018. This policy aimed to increase the effectiveness of the cervical cancer screening programme in Thailand by enhancing case detection. Moreover, the HPV vaccine was included in the benefit package for the entire population (as the prevention and health promotion package is for the whole population) and is available since 2017 to all girls aged 10 years. This school-based implementation targets grades five and six students with high coverage, as the net attendance rate of children in the primary school age group was 95.5% in 2020 (United Nations Children’s Fund, 2020). Further efforts are needed to catch young girls outside the primary school system. The worsening survival of patients with cervical cancer in recent years could be explained by a low coverage of cervical cancer screening, which in turn resulted in late diagnosis and treatment. An analysis of national databases in Thailand found that only 5–8% of the female population at the target ages of 30–59 years were screened for cervical cancer in 2020–2022 (Limwattananon et al., 2023). The same analysis also reported that those treated and screened for cervical cancer had a lower one-year, all-cause mortality than those treated without prior screening (odds ratio 0.66). In addition, screening facilitated early detection of cervical cancer as the ratio between invasive cervical cancer and carcinoma in situ among those without screening (14.7–19.0) was higher than that among those who were screened (1.8–1.9). Clinical breast examination and breast self-examination are current screening practices in Thailand. Mammogram has not yet been included in the UCS benefit package. Coverage of both clinical breast examination and breast self-examination in females aged 30–70 years ranged from 50% to 70% in the past five fiscal years (Ministry of Public Health, 2019 ). In 2022, the NHSO included the BRCA1/BRCA2 gene test for the high-risk group (with a familial history of breast cancer) in the benefit package for all citizens (as the prevention and health promotion package is for the whole population). Additionally, in 2018, the NHSO included colorectal cancer screening using the fecal immunochemical test (FIT), which applies antibodies to detect blood in the stool. The FIT test is offered to the whole Thai population aged 50–70 years once every two years. The implementation of these prevention measures for three selected cancers were expected to yield long-term outcomes of rapid detection and treatment, which can improve the survival rate in the future. 224 7.4.2 Health service outcomes and quality of care Preventive care: child vaccination rates Thailand experienced a rapid scale up of child immunization during the 1980s. After launching the national EPI in 1982, the coverage of child vaccination reached the 80% threshold within 3 years for Bacillus Calmette– Guérin (BCG for tuberculosis, due to high coverage of institutional births), followed by diphtheria–tetanus–pertussis (DTP3), oral polio vaccine (OPV3) and tetanus-toxoid vaccine (TT2). With PHC capacities, scaling up the measles and hepatitis B vaccines have been faster. From 2000 (Fig. 7.20), DTP3 and measles-containing vaccine (MCV)1 have been well covered at more than 95%, though gaps between MCV1 and MCV2 need improvement. Fig. 7.20 Achievement of universal access to child immunization in Thailand, 2000–2021 75 80 85 90 95 100 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17 20 18 20 19 20 20 20 21 Pe rc en ta ge (% ) Immunization coverage of MCV1, MCV2 qnd DTP3 MCV1 MCV2 DTP3 Source: (World Health Organization, 2021a) Chronic conditions: avoidable hospital admission rates Like other countries under economic development, Thailand is faced with the burden from hospitalization of NCD cases, which could be better controlled in ambulatory care settings. The most prevalent condition was COPD, followed by diabetes and heart failure. Rajatanavin et al. (Rajatanavin et al., 2022) assessed the effective coverage of diabetes and hypertension in Thailand during 2016–2019. Effective coverage (EC), defined as the “fraction of real health gain from an intervention”, can be used as an indicator to measure health system performance. This study found that effective coverage (using HbA1C lower than 7% for diabetes mellitus and blood pressure under control) was low for both conditions, though it improved in 2016–2019, especially among men and younger populations. The increasing rate of 225 effective coverage was significantly smaller than the crude coverage. The limitation of health information systems is a major barrier to comprehensive measurement. To maximize effective coverage, long-term actions should address primary prevention of the risk factors for NCDs, while short-term actions focus on improving the chronic care model. Acute exacerbations of chronic conditions: in-hospital mortality, 30-day mortality for admission following acute myocardial infarction and stroke For the UCS, as a result of fast-track interventions for STEMI, there was a decrease in mortality following hospitalization with acute myocardial infarction (AMI) and stroke over the period 2005–2011. Reduction in the death rate within 30 days after hospital admission with AMI parallels the rapid decline in the in-hospital death rate. A study shows that patients with STEMI had increasing access to percutaneous cardiac intervention (PCI) and that the use of PCI was associated with lower mortality compared with thrombolysis only (Limwattananon et al., 2020). In addition, the 2022 annual report of the NHSO reported that STEMI treatment had achieved 75% of the target (3406 persons). Reduction in deaths from ischaemic and haemorrhagic strokes demonstrated slower progress than those from AMI over the same period. Note that both figures were analysed from all types of hospitals, which reflected better progress in survival outcomes from AMI than ischaemic and haemorrhagic strokes. As UCS patients preferred to die at home, the 30-day mortality is probably a better indicator for assessing the treatment outcome than the in-hospital death rate; however, in-hospital mortality reflects either case- mix severity due to late arrival, or long duration of referral processes, or quality of care. Appropriateness of care and the impact of reforms and initiatives to improve quality in health service delivery A 5-year retrospective analysis of the UCS’s claim dataset was conducted, using 1 297 869 inpatient discharges from 76 provincial hospitals under the MoPH. Mortality outcomes of three major acute care conditions – acute myocardial infarction, acute stroke, and sepsis – were selected. Using generalized estimating equations to adjust for area-based control variables, hospital networks with accredited status of provincial hospitals showed significant association with lower standardized mortality ratios of acute stroke and sepsis (Sriratanaban et al., 2020). Note that in 2023, 949 out of 1491 total hospitals (public and private) were accredited (Healthcare Accreditation Institute, 2023). 226 7.4.3 Equity of outcomes With near-universal access to preventive interventions, immunization coverage with essential vaccines in Thai children is equitable between the high–low education, rich–poor and urban–rural groups according to the national survey jointly conducted by the NSO and UNICEF, the Multiple Indicator Cluster Survey (MICS) in 2005–2006, 2015–2016, 2019 (Table 7.21). Inequity in child health outcomes, however, is still a major policy concern. Given an increased prevalence of low birth weight (<2.5 kg at birth) and malnutrition in the whole country, all health problems are concentrated among children whose mothers have a low level of education, live in poorer households and in rural areas (Table 7.22). A study shows that equity in coverage of key maternal and child health (MCH) services is high throughout Thailand; the inequitable health outcomes are largely due to socioeconomic factors, especially differences in the educational level of mothers or caregivers (Limwattananon et al., 2010). 227 Ta bl e 7. 21 O ve ra ll co ve ra ge a nd e xt re m al q uo tie nt s of ch ild im m un iz at io n be tw ee n th e hi gh es t a nd lo w es t so ci oe co no m ic g ro up s, 2 00 6– 20 19 BC G OP V DP T M CV HB V 20 06 20 16 20 19 20 06 20 16 20 19 20 06 20 16 20 19 20 06 20 16 20 19 20 06 20 16 20 19 O ve ra ll co ve ra ge 87 .5 % 96 .4 % 98 .8 % 84 .9 % 86 .9 % 87 .8 % 84 .9 % 89 .0 % 89 .9 % 75 .2 % 92 .9 % 93 .7 % 80 .4 % 86 .6 % 89 .0 % Ex tr em al q uo tie nt s: P os ts ec on da ry s ch oo l:n o ed uc at io n 1. 01 1. 21 1. 01 1. 05 1. 14 1. 05 0. 96 1. 16 1. 08 1. 12 1. 21 1. 20 0. 93 1. 08 1. 13 Q ui nt ile s of a ss et in de x 5: 1 1. 02 0. 94 1. 02 1. 02 0. 84 0. 89 0. 97 0. 97 0. 94 1. 02 0. 97 1. 06 0. 89 0. 74 0. 94 U rb an :r ur al 0. 99 0. 96 1. 00 0. 99 1. 02 0. 94 0. 97 1. 02 0. 93 0. 98 0. 97 0. 97 0. 95 0. 97 0. 94 B C G : B ac ill us C al m et te –G ué ri n (t ub er cu lo si s va cc in e) ; O P V: o ra l p ol io v ac ci ne ; D TP : d ip ht he ri a, te ta nu s an d pe rt us si s; M C V: m ea sl es -c on ta in in g va cc in e; H B V: he pa tit is B v ac ci ne So ur ce s: M ul tip le In di ca to r C lu st er S ur ve y in 2 00 5– 20 06 , 2 01 5– 20 16 , a nd 2 01 9 (N at io na l S ta tis tic al O ff ic e et a l., 2 00 6, 2 01 6, 2 02 0) . Ta bl e 7. 22 O ve ra ll co ve ra ge a nd e xt re m al q uo tie nt s of ch ild h ea lth b et w ee n th e hi gh es t a nd lo w es t s oc io ec on om ic gr ou ps , 2 00 6– 20 19   Lo w b ir th w ei gh t Re po rt ed il ln es se s M al nu tr iti on Di ar rh oe a Su sp ec te d pn eu m on ia (s ym pt om s of A RI ) Un de rw ei gh t St un tin g W as tin g 20 06 20 16 20 19 20 06 20 16 20 19 20 06 20 16 20 19 20 06 20 16 20 19 20 06 20 16 20 19 20 06 20 16 20 19 O ve ra ll pr ev al en ce 8. 3% 9. 4% 9. 5% 8. 7% 4. 9% N /A 4. 6% 1. 4% N /A 9. 3% 6. 7% 7. 7% 11 .9 % 10 .5 % 13 .3 % 4. 1% 5. 4% 7. 7% Ex tr em al q uo tie nt s:   P os ts ec on da ry s ch oo l:n o ed uc at io n 0. 80 0. 91 1. 52 0. 61 1. 25 N /A 0. 93 5. 00 N /A 0. 29 1. 31 0. 80 0. 39 0. 66 0. 69 0. 53 0. 62 0. 56 Q un til es o f a ss et in de x 5: 1 0. 84 1. 04 0. 76 0. 58 0. 63 N /A 0. 46 0. 73 N /A 0. 27 0. 54 0. 41 0. 43 0. 90 0. 86 0. 85 0. 67 0. 58 U rb an :r ur al 1. 14 0. 84 0. 97 0. 90 0. 73 N /A 0. 62 0. 87 N /A 0. 52 0. 63 0. 80 0. 66 0. 89 1. 07 0. 93 0. 73 0. 83 So ur ce s: M ul tip le In di ca to r C lu st er S ur ve y in 2 00 5– 20 06 , 2 01 5– 20 16 , a nd 2 01 9 (N at io na l S ta tis tic al O ff ic e et a l., 2 00 6, 2 01 6, 2 02 0) . 228 7.4.4 Disaster risk management for health (DRM-H) The UNDP Disaster risk management report 2020 assessed that the Thai government approved a fiscal package of THB 1.5 trillion (around 9.6% of GDP) for the response to the COVID-19 pandemic for both health- and non- health-related activities (United Nations Office for Disaster Risk Reduction, 2020). Health systems resilience is the result of 40 years of investment in, and political commitment to, primary health services, UHC and public health functions, notably surveillance of notifiable diseases, which is the foundation for pandemic preparedness. The key interventions for the COVID-19 response and recovery involved functions under multiple laws, namely, the Communicable Diseases Act, 2015, the State Administration Act (rev5), 2005, and the Disaster Prevention and Mitigation Act, 2007. The MoPH led the national health response efforts in collaboration with a number of ministries and departments, including the Ministry of Interior’s Department of Provincial Administration, and Department of Disaster Prevention and Mitigation (United Nations Office for Disaster Risk Reduction, 2020). Meanwhile the Health Sector Disaster Risk Management Framework in Thailand is the responsibility of the National Institute for Emergency Medical Service (NIEMS). 7.5 Health system efficiency 7.5.1 Allocative efficiency In 2019, Thailand demonstrated a high level of health achievement in terms of low under-five mortality at a lower GGHE-D per capita compared with international peers (Fig. 7.21). Achieving better child health outcomes with lower health expenditure reflects a relatively efficient health system. 229 Fig. 7.21 Under-five mortality and domestic general government health expenditure per capita (current US$) in Thailand and selected world regions, 2019 Thailand WorldSouth Asia East Asia & Pacific (excluding high income) Europe & Central Asia (excluding high income) 0 5 10 15 20 25 30 35 40 45 0 100 200 300 400 500 600 700 800 Un de r- 5 m or ta lit y (p er 1 00 0 liv e bi rt hs ) Domestic general government health expenditure per capita (current US$) Source: (World Bank, 2019c) In Thailand, health technology assessment (HTA) has been fully applied to prioritize the UCS benefit package and inclusion of new medicines into the NLEM and support evidence-informed decisions. Contributing factors include political will and leadership, capacity-building on HTA-related disciplines, adequate resources, technical expertise, and data. Conversely, challenges faced include the absence of a governing body and strategic plan for HTA systems development, lack of a formal mechanism for mobilizing financial support, an inadequate number of HTA researchers in non-profit research institutes, and the rapid advancement of medical and biotechnologies (Leelahavarong et al., 2019). Since 2008, inclusion of new medicines and interventions into the benefit package of the UCS has required full-blown studies of cost–effectiveness, where the Health Intervention and Technology Assessment Program (HITAP), established in 2007 as a non-profit-making organization, is mandated to appraise a wide range of health technologies and programmes, including pharmaceuticals, medical devices, interventions, individual and community health promotion and disease prevention (Tantivess et al., 2009). HITAP is an associate organization under the auspices of the International Health Policy Program (IHPP). HITAP contributed to a number of studies that had a major 230 policy impact, including the study on cervical cancer screening. In light of the high-cost HPV vaccine campaign by the industry, HITAP recommended that it not be adopted into the benefit package, while at the same time recommended the scaling up of cervical cancer screening through Pap smear and visual inspection and acetic acid application (Yothasamut et al., 2010). Price negotiation process of HPV vaccine had been going on for a long period of time, until the vaccine was included in the benefit package in 2017(National Health Security Office, 2018). 7.5.2 Technical efficiency The close-ended provider payment applied by the SHI in 1991 and UCS in 2002 contributed significantly to gains in technical efficiency, as it aligns proper incentives towards efficiency through the use of cheaper cost-effective generic medicines and rational prescribing. The risk under capitation is inadequate services, so unit costs and rates of use are monitored and members can change contractors yearly if they are not satisfied. Studies have suggested that service use of this model in Thailand is adequate in terms of rate of use (more than 3.5 visits per person per year and around 11% admission rate) and good quality of care provided to both UCS and SHI members (Mills et al., 2000; Prakongsai et al., 2009; Tangcharoensathien V et al., 1999). The medical service utilization rate among SHI members was 2.28 outpatient visits per capita per year and 0.06 inpatient visit per capita per year in 2020 (Social Security Office, 2020). For UCS members, the utilization rate in 2021 was 3.44 outpatient visits per capita per year and 0.12 inpatient visit per capita per year (National Health Security Office, 2021c). The contracting model under capitation designating PHC as the gatekeeper further strengthens technical efficiency. To cope with high spending, the CSMBS imposes strong vigilance by auditing the indications for prescribing certain expensive drugs and revoking reimbursement. Some hospitals help to control overprescribing of less technically efficient expensive drugs by asking patients to pay cash and later process for reimbursement. Utilization reviews of CSMBS and UCS patients with diabetes reveal that as the morbidity burdens of both patient cohorts increased, they had better access to cost-effective expensive drugs according to clinical practice guidelines, with cost reduction over time for CSMBS patients, but with cost increase over time for UCS patients. Moreover, other factors also highly contributed to the lower cost and higher technical efficiency. They are the heavy reliance on nurses and VHVs, collective price negotiation of drugs and medical equipment, lower health worker salary 231 in the public sector, which is the dominant sector for the Thai health-care system, among others. Sakulbumrungsil et al. assessed the impact of the drug financing system under the Thailand UHC on the performance of the drug system (Sakulbumrungsil et al., 2020). The review found a continuously increasing trend in drug spending, driven by the use of highly expensive health technology. There was good access to essential medicines that are on the national list, used by all three public health insurance schemes. Higher efficiency was found in the close-ended payment basis scheme (as applied by the UCS and SHI) than the fee-for-service basis payment scheme (as applied by the CSMBS). However, there were inequities in access to higher-cost drugs across the three health insurance schemes. Medications covered by close- ended payment schemes tend to be more cost-effective, but with a narrower selection, in contrast to the fee-for-service scheme. This discrepancy may suggest an overuse of medication in the fee-for-service model and an underutilization in the close-ended reimbursement system. The closed- end payment methods promote operational efficiency by discouraging unnecessary healthcare service utilization, aligning providers with the goal of prescribing essential medicines. The current financing system encourages intensive cost-driven competition in drug markets, which can be harmful to local drug manufacturing in Thailand. The continuously increasing trend of importing drugs of value was also reported. This signifies the country’s dependence on imported finished medicines, which negatively affect national drug security. 7.6 Transparency and accountability People’s participation in policy process has been a key principle of the Thai health-care system. This is well reflected by the key legislative provision of the National Health Act, 2002 and throughout the journey of health- care reform in Thailand. In terms of legislations, a recent analysis on UHC legislative provisions conducted by Marshall et al. (Marshall et al., 2021) showed that the UCS legislations promote citizen representation and involvement in UCS governance, implementation and management, support citizens’ ability to voice concerns and improve UCS performance, facilitate citizens’ access to information as well as ensure access to quality care. Accountability is reflected by voluntary hospital accreditation, which improves quality, safety and standard of care. Evidence suggests that while several legislative provisions for both participatory and responsive governance exist in the Thai UCS, the two other schemes (CSMBS and SHI) do not have a similar level of legislative provisions, which bolster citizen participation and the scheme’s responsiveness to its members. 232 The above study also draws key lessons on participatory and responsive governance for UCS in Thailand. This includes citizen participation in the proposal of a draft act for parliamentary consideration, participatory and responsive governance; public participation through annual public hearings and management of suggestions from the hearing; CSO representatives in the UCS governing board and other subcommittees appointed by the governing boards; public disclosure of the annual performance report; ensuring provision of quality care and initial financial support for adverse events. 233 8 Conclusions 8.1 Key findings UHC, achieved since 2002 and financed by progressive general tax, continues to produce favourable outcomes. Notably, it has increased service coverage and financial protection, pro-poor access and pro-poor benefit, and health gains in the population, which nullifies the provincial disparities of infant mortality (Gruber et al., 2014). Compared with international peers, Thailand (THA highlighted in red font in Fig. 8.1) outperforms other upper-middle-income countries as measured by child mortality (Fig. 8.1) and life expectancy at birth (Fig. 8.2) in relation to the current health expenditure per capita. This finding may be explained by close-ended provider payment, particularly capitation and diagnosis-related groups (DRGs). Fig. 8.1 Scatter plot between per capita current health expenditure, US$ and U5MR among upper-middle-income countries, latest year 2020 ARG ARM AZE BLR BLZ BIH BWA BRA BGR CHN COL CRI CUB DMA DOM ECU SLV GNQ FJI GAB GEO GRD GTM IDN IRQ JAM KAZ MYS MDV MHL MUSMEX MDA MNE NAM MKD PRYPER RUS SRB ZAF LCA VCT SUR THA TON TUR TKM TUV 0 200 400 600 800 1000 1200 1400 0 10 20 30 40 50 60 70 80 90 Cu rr en t h ea lth e xp en di tu re p er c ap ita ( US $) Mortality rate, under-5 (per 1 000 live births) Average U5MR among UMIC Average CHE per capita among UMIC Source: Analysis from World Development Indicators (World Bank, 2022a) 234 Fig. 8.2 Scatter plot between per capita current health expenditure, US$ and life expectancy among upper-middle-income countries, latest year 2020 ARG ARM AZE BLR BLZ BIH BWA BRA BGR CHN COL CRI CUB DMA DOM ECU SLV GNQ FJI GAB GEO GRD GTM IDN IRQ JAMKAZ MYS MDV MHL MUSMEX MDA MNE NAM MKD PRY PER RUS SRB ZAF LCA VCT SUR THA TON TUR TKM TUV 0 200 400 600 800 1000 1200 1400 0 10 20 30 40 50 60 70 80 90 Cu rr en t h ea lth e xp en di tu re p er c ap ita ( US $) Life expectancy at birth, total (years) Average life expectancy among UMIC Average CHE per capita among UMIC Source: Analysis from World Development Indicators (World Bank, 2022a) Thailand has improved its IHR core capacities during the second round of JEE; the overall score increased from 3.5 out of 5 (75%) in 2017 to 4.25 (85%) in 2022. The merits of the robust and agile health system in Thailand significantly contributed to the COVID-19 pandemic response (Tangcharoensathien et al., 2023). The large surge of cases and deaths from the Delta strain during the third quarter of 2021 almost disrupted health systems. Strategies were adopted to mobilize home- and community isolation with full support for mild cases, scaling up the capacities of field hospitals for moderate cases, and admissions to hospital for severe cases. These agile and adaptive strategies saved health systems, ensuring continued provision of emergency and other essential services. The key attributes include well-established health systems and PHC with UHC anchored in a strong legal basis. Comprehensive health services related to COVID-19, including vaccination, were provided free of charge to all people in Thailand, both Thai and non-Thai. Public and private health facilities were mobilized to provide services to the people, with the government ensuring adequate payment and services provided free at the point of service. 235 This facilitated full and timely access to the whole range of interventions (Tangcharoensathien et al., 2022b). Public and private laboratories capable of conducting RT-PCR were scaled up, certified and distributed in all 77 provinces within a few months of the pandemic. To date, the national reference laboratory in the MoPH Department of Medical Sciences is able to identify and report genome sequencing of coronavirus of up to 500 samples a week, while ensuring self-sufficiency of local production of essential laboratory supplies. Robust capacities for public health response were demonstrated at all levels nationwide by competent, multidisciplinary rapid response teams. This was backed up by four decades of the Field Epidemiology Training Programme for physicians, pharmacists, public health officials and veterinarians, though further strengthening is needed, such as career progression and sufficient incentives for working in epidemic risk-prone areas and points of entry of all borders between Thailand and neighbouring countries. The routine case- based reporting of notifiable diseases by all public and private health-care facilities, as well as event-based reporting by VHVs in communities, such as abnormal deaths in poultry, are the key backbone for preparedness and early detection of outbreaks and preventing their wider spread. The current pilot of avian influenza surveillance systems has great potential to scale up to “One Health integrated surveillance” in wildlife, domesticated animals and humans for pathogens with pandemic potential (Innes et al., 2022). Significantly large and sustainable investments are required for One Health integrated surveillance systems. The government had invested considerably in R&D before COVID-19 broke and provided substantial additional support during the pandemic. This included R&D for vaccines (such as local R&D of COVID-19 vaccines and technology transfer), innovative research for diagnostic tests, virus genome sequencing and its application, mathematical modelling and the use of information technology (IT), artificial intelligence and robotics. To facilitate R&D for an emergency situation, Thailand needs to enhance a supportive national regulatory mechanism for timely licensing of pandemic response products. Effective collaboration across all government sectors, academia and the private sector will strengthen self-reliance and preparedness for future public health emergencies. Key responses such as application of telehealth, teleconsultation and telemedicine were sustained, as reported in Chapter 6. 236 8.2 Remaining challenges Despite achievements in the health system, challenges persist in effectively addressing and reversing the trend of NCDs in Thailand. The Institute of Heath Metrics and Evaluation (IHME) provides invaluable information for policy. A few salient challenges are given below (Institute for Health Metrics and Evaluation, 2019). • NCDs were responsible for 8 out of 10 major causes of death in 2019. • NCDs contributed to 7 out of the top 10 causes of DALY loss in 2019. • Compared with countries in the middle sociodemographic index (SDI) group, Thailand performed poorer on road injuries, stroke and ischaemic heart disease. However, it fared better in term of headache disorders, lower respiratory infection, chronic kidney diseases and neonatal disorders. Addressing the commercial determinants (Gilmore et al., 2023) of NCDs needs effective implementation of “best buy” interventions recommended by WHO (World Health Organization, 2017). These include increasing the taxes on and prices of tobacco and alcohol, introducing plain packaging, banning advertising, and regulating the availability of alcohol. These can be done only by government actors such as the MoPH – the definitive stakeholder (Mitchell et al., 1997), which is the custodian of the Alcoholic Beverage Control Act, 2008 and Tobacco Products Control Act, 2017. Additionally, the Excise Department can increase SSB tax rates. Although ThaiHealth does not have the regulatory authority to do so, this limitation can be overcome by effective multisectoral collaboration (Bennett et al., 2018), and working with CSOs to ensure adequate response by government actors. Implementation of the SSB tax reduced the consumption of beverages with a high sugar content (Phulkerd et al., 2020). If the government increases the current SSB tax rate to at least 20%, it could reduce both consumption and obesity prevalence (Phonsuk et al., 2021). Multiple interventions such as increased tobacco tax reduced the prevalence of adult smoking from 23% in 2004 to 17.4% in 2021 (National Statistical Office, 2021b). Despite the decreasing prevalence, the reduction is projected to be insufficient to achieve a 30% reduction in the prevalence of tobacco smoking by 2025 (Aungkulanon et al., 2019). While addressing primary exposure to NCD risk factors, health-care delivery systems need to improve the very low level of effective coverage of diabetes (11.7%) and hypertension (15.7%) (Rajatanavin et al., 2022). 237 Progress in the exclusive breastfeeding rate during the first 6 months of life was erratic: it increased from 12.3% in 2012 to 23.1% in 2015, but then decreased to 14% in 2019, influenced by aggressive market promotion of breast milk substitutes by industry. Furthermore, a decline in early initiation from 49.6% in 2006 to 34% in 2019 was noted; these low performances hamper the achievement of global targets set for 2030 (Topothai et al., 2021). The Thailand Multiple Indicator Cluster Survey (MICS) in 2019 reported 13% stunting, too short for age (SDG2.2.1), 8% wasting, too thin for height (SDG2.2.2) and 8% overweight, too heavy for height (SDG2.2.2) among Thai children under the age of 5 years. There was a large disparity across geographical regions and maternal education (National Statistical Office et al., 2020). MICS 2019 also reported that 92.3% of children under 5 years had achieved an appropriate level of early childhood development index (children who were developmentally on track in at least three out of these four domains: cognitive, physical, social, and learning). Children who had appropriate parental interactions of more than four out of six interactions had a significantly higher chance of having an appropriate index compared to those with less than four interactions. This requires multisectoral policies to support child development in low socioeconomic households (Topothai et al., 2022). Challenges remain among children living in poverty, with poor health, high levels of family and environmental stress and exposure to violence, abuse, neglect and exploitation, as well as those with inadequate care and learning opportunities. Such children may fail to reach their developmental potential through early childhood development interventions. Effective interventions require multisectoral actions for health beyond health-care delivery and UHC systems. 8.3 Future prospects Thailand’s health system demonstrates strong performance in terms of access, quality and equity. It is also able to respond to unforeseen challenges, especially those such as the COVID-19 pandemic. Despite these achievements, a key deficiency is the government’s capacity to address the social and commercial determinants of health through effective multisectoral collaboration and policy coherence. The political manifesto by various political parties during the 2023 general elections focused on improved access to health services, despite an already high level of access. However, there was a lack of emphasis on addressing primary prevention, especially in the context of the NCD epidemic. Some 238 parties advocated for lifting the ban on electronic nicotine delivery systems (ENDS) in alignment with the tobacco industry. Pro-ENDS advocacy groups pressured the government to lift the ban, using five tactics: creating front groups, lobbying decision-makers, running public relations campaigns, seeking to discredit tobacco control advocates and funding pro-tobacco harm reduction research (Patanavanich et al., 2021). End Cigarette Smoke Thailand, the industry front group, urged Thailand to legalize vaping, citing the United Kingdom’s progressive approach to e-cigarettes as an example (Tobacco Reporter, 2023). In conclusion, a significant gap persists in strengthening multisectoral actions to address the decreasing trend of exclusive breastfeeding, increased stunting and obesity in children, road traffic injuries and alcohol consumption. The total alcohol consumption per capita in individuals aged 15 years and above was consistently high at 7.6 L of pure alcohol in 2010 and 7.8 in 2019 (World Bank, 2019b). Addressing these issues requires the government’s transparency and accountability to the health of the population. 239 Chapter 9: Appendices 9.1 References Adulyanon S (2012). Funding health promotion and disease prevention programmes: an innovative financing experience from Thailand. WHO South-East Asia Journal of Public Health. 1(2):201-7. https://journals. lww.com/wsep/fulltext/2012/01020/funding_health_promotion_and_ disease_prevention.9.aspx Aekplakorn W, Porapakkham Y, Taneephanitsakul S, Puckcharern H, Satheannoppakao W, Thaikla K (2009). National health examination survey, (NHES) IV B.E. 2551-2552 (2008–2009). (https://kb.hsri. or.th/dspace/handle/11228/2976?locale-attribute=en, accessed 30 May 2023). Aekplakorn W, Puckcharern H, Satheannoppakao W (2021). National health examination survey, (NHES) VI B.E. 2562-2563 (2019-2020). (https:// www.hiso.or.th/thaihealthstat/report/sreport.php?y=2019&l=sreport6, accessed 3 April 2023). Aekplakorn W, Puckcharern H, Thaikla K, Satheannoppakao W (2014). National health examination survey, (NHES) V B.E. 2557 (2014) (https:// www.hiso.or.th/thaihealthstat/report/sreport.php?y=2014&l=sreport5, accessed 3 April 2023). Ajanapanya N (2023). Big data healthcare system will deliver better medicine to all Thais. (https://www.nationthailand.com/thailand/ policies/40030514, accessed 26 January 2024). Akaleephan C, Wibulpolprasert S, Sakulbumrungsil R, Luangruangrong P, Jitraknathee A, Aeksaengsri A, et al. (2009). Extension of market exclusivity and its impact on the accessibility to essential medicines, and drug expense in Thailand: analysis of the effect of TRIPs-Plus proposal. Health Policy. 91(2):174-82. https://doi.org/10.1016/j. healthpol.2008.12.009 Almeida C, Braveman P, Gold MR, Szwarcwald CL, Ribeiro JM, Miglionico A, et al. (2001). Methodological concerns and recommendations on policy consequences of the world health report 2000. Lancet. 357(9269):1692- 7. https://doi.org/10.1016/S0140-6736(00)04825-X 240 Arayawong W, Saengkhong C, Thanaisawanyangkoon S, Punjangampattana A (2016). Introduction In: Suteerawut T, Haruthai C, Thanaisawanyangkoon S, Punjangampattana A editors. Training curriculum of migrant health volunteers. Theppenvanich Printing; 1-11. https://dol.thaihealth.or.th/resourcecenter/sites/default/files/ documents/23_hlaksuutrbrmaasaasmakhrsaathaarnsukhtaangda.pdf Association of Southeast Asian Nations (2012). ASEAN human rights declaration. (https://www.refworld.org/docid/50c9fea82.html). Assunta M (2020). Global tobacco industry interference index 2020. Global Center for Good Governance in Tobacco Control. (https:// globaltobaccoindex.org/report-summary, accessed 3 April 2023). Assunta M (2021). Global tobacco industry interference index 2021. Global Center for Good Governance in Tobacco Control. (https:// exposetobacco.org/wp-content/uploads/GlobalTIIIndex2021.pdf, accessed 26 January 2024). Aungkulanon S, Pitayarangsarit S, Bundhamcharoen K, Akaleephan C, Chongsuvivatwong V, Phoncharoen R, et al. (2019). Smoking prevalence and attributable deaths in Thailand: predicting outcomes of different tobacco control interventions. BMC Public Health. 19(1):984. https:// doi.org/10.1186/s12889-019-7332-x Baker C, Phongpaichit P (2009). A history of Thailand, second edition. Cambridge: Cambridge University Press (https://www.cambridge.org/ core/books/history-of-thailand/883A68FBB58CDC471CDACCF3D7A49 0C3, accessed 21 February 2024). Balabanova D, Mills A, Conteh L, Akkazieva B, Banteyerga H, Dash U, et al. (2013). Good health at low cost 25 years on: lessons for the future of health systems strengthening. Lancet. 381(9883):2118-33. Bangkok Post (2021a). 70% of city COVID cases are Delta strain. (https://www. bangkokpost.com/thailand/general/2142915/70-of-city-covid-cases- are-delta-strain, accessed 30 May 2023). Bangkok Post (2021b). Thais test positive for Omicron. (https://www. bangkokpost.com/thailand/general/2234491/thais-test-positive-for- omicron, accessed 30 May 2023). Bangprapa M (2022, 10 March 2022). Amendment to ensure women paid for all 98 days of maternity leave. Bangkok Post. https://www.bangkokpost. com/thailand/general/2277139/amendment-to-ensure-women-paid- for-all-98-days-of-maternity-leave 241 Bennett S, Glandon D, Rasanathan K (2018). Governing multisectoral action for health in low-income and middle-income countries: unpacking the problem and rising to the challenge. BMJ Glob Health. 3(Suppl 4):e000880. https://doi.org/10.1136/bmjgh-2018-000880 Booddawong B, Uppatham J (2022). From RDU communities to RDU province: lessen learned in “Sisaket”. Yaa Wipaak. 12(50):20-4. https://www. thaidrugwatch.org/download/series/series50.pdf Boonsang A, Penpim S (2023). Development strategy for the local health security fund in National Health Security Office region 10. J Popul Ther Clin Pharmacol. 30(3):e545–e58. https://doi.org/10.47750/ jptcp.2023.30.03.058 Burden of Disease Research Program Thailand (2021). Report on the study of causes of death among the Thai population, 2017-2019. Burden of Disease Research Program Thailand (http://bodthai.net/download/ รายงานการศึกษาสาเหตุกา/, accessed 24 Januray 2023). Bureau of AIDS TB and STIs (2023). HIV info hub. Division of AIDS and STIs, Department of Disease Control, Ministry of Public Health. (https:// hivhub.ddc.moph.go.th/index.php, accessed 15 May 2023). Center for COVID-19 Situation Administration secretariat (2020). Order of the CCSA secretariat No. 3/2563, establish a working committee to integrate information sources for pandemic situation management. (https://ict.moph.go.th/upload_file/files/ e4068dc95efbcfd7ac1bf948a154d9db.pdf, accessed 12 May 2023). Central office for Healthcare Information (2023). The revised list of medical service fees under the Social Health Insurance Scheme including cases of loss of function of an organ or part of an organ, and cases of surgery to implant an artificial organ or device for the treatment of diseases. (https://www.chi.or.th/ss/News/News47.html, accessed 26 January 2024). Chaikledkaew U, Jittikoon J, Talungchit P, Wongkrajang P, Malasai K, Sangroongruangsri S, et al. (2022). Economic evaluation of genetic testings for Thalassemia carrier diagnosis among married couple in Thailand. (https://kb.hsri.or.th/dspace/handle/11228/5752?src=%2 Fdspace%2Fhandle%2F11228%2F1%2Fdiscover%3Fquery%3Dthal assemia%26submit%3D&offset=2&firstItem=&lastItem=, accessed 23 May 2023). Chaturachinda K, Boonthai N (2020). A commentary on the recent ruling by the Thai constitutional court in relation to abortion law in Thailand. Sex Reprod Health Matters. 28(1):1776542. https://doi.org/10.1080/2641039 7.2020.1776542 242 Chen H, Chunharas S (2009). Introduction to special issue on “population aging in Thailand”. Ageing Int. 33:1-2. https://doi.org/10.1007/ s12126-009-9029-4 Chinnacom D, Kittiratchakool N, Luankongsomchit V, Ekakkararungroj C, Kittibovorndit N, Tantivess S, et al. (2022). Scaling up newborn hearing screening program in Thailand: a study on the feasibility, costs, and cost-effectiveness. (https://kb.hsri.or.th/dspace/bitstream/ handle/11228/5693/hs2841.pdf, accessed 23 May 2023). Choi H, Mohit B (2019). Cost-effectiveness of screening for HLA-B*1502 prior to initiation of carbamazepine in epilepsy patients of Asian ancestry in the United States. Epilepsia. 60(7):1472-81. https://doi. org/10.1111/epi.16053 Chokevivat V (2020). Political economy of Thailand drug system: what lessons learned? Journal of Health Science. 29(Special):S167-87. https://thaidj. org/index.php/JHS/article/download/8421/7734/11805 Clark D, Baur N, Clelland D, Garralda E, López-Fidalgo J, Connor S, et al. (2019). Mapping levels of palliative care development in 198 countries: the situation in 2017. Journal of Pain and Symptom Management. 59. https://doi.org/10.1016/j.jpainsymman.2019.11.009 Committee for Facilitating the Procurement of COVID-19 Vaccine for the Thai Population (2020). Order number 3/2563 on an appointment of a working group to draft an agrement and negotiate for the procurement of COVID-19 vaccines through collaboration with AstraZeneca (Thailand) Limited. Committee for National Reform on Public Health (2020). National reform plan for public health (revised version). (http://nscr.nesdc.go.th/wp-content/ uploads/2021/05/07-ด้านสาธารณสุข.pdf, accessed 22 May 2023). Comptroller General Department (2015). List of private hospitals participating in the project (for scheduled surgeries). Comptroller General Department (https://www.cgd.go.th, accessed 30 May 2023). Comptroller General Department (2016). List of rates for healthcare services to be used for reimbursement of medical expenses in government hospitals; category 13 dental service fees. (https://www.nhso.go.th/lgo/ download/9, accessed 2 June 2023). Comptroller General Department (2021). List of private hospitals participating in the direct billing project (for schedule surgeries) under the Civil Servant Medical Benefit Scheme. Comptroller General Department (https://www.cgd.go.th, accessed 30 May 2023). 243 Constitution Drafting Commission (2017). Constitution of the Kingdom of Thailand B.E. 2560. (https://www.parliament.go.th/ewtcommittee/ ewt/draftconstitution2/ewt_dl_link.php?nid=1038&filename=index, accessed Nov 27, 2023). Decentralization to the Local Government Organization Committees (2021). Guideline of procedure for transferring the duties of the Chaloem Phra Kiat 60 years Nawamin Maharachini health center and Tambon health promoting hospital to the provincial administrative organization B.E. 2564 (https://odloc.go.th/transfer/คู่มือแนวทางการดำาเนินก%2F, accessed 31 March 2023). (Thai) Dental Council of Thailand (2022). Domestic and international university accredited by the Dental Council of Thailand. (https://dentalcouncil. or.th/Pages/Dentistry, accessed 31 March 2023). Department of Disease Control (2021). Bubble and seal approach: from disease prevention and control policy to lessons for the health security of Thailand. (https://ddc.moph.go.th/uploads/ publish/1378220230130084325.pdf, accessed 26 January 2024). Department of Empowerment of Person with Disabilities (2023). Situation of disability 31 March B.E. 2023 (https://dep.go.th, accessed 30 April 2023). Department of Health (2016a, 22 March 2023). Annual report of dental personal in public health 2015. Department of health, MOPH. (https:// dental.anamai.moph.go.th/th/dental-personnel-information/190862, accessed 8 April 2023). Department of Health (2016b). Review of climate change and health activities in Thailand. (https://hia.anamai.moph.go.th/web-upload/12xb1c83353 535e43f224a05e184d8fd75a/m_magazine/35644/2892/file_download/ a0dc88900525f498d1d953ac9788fcd6.pdf, accessed 26 January 2024). Department of Health Service Support (2020). Handbook for prototype: guideline for redesign aging service delivery (https://anyflip.com/ycglt/ wrpi/basic, accessed 30 May 2023). Department of Health Service Support (2022). Number of healthcare facilities that do not admit patients for overnight stays nationwide, categorized by facility type: 34,032 facilities as of August 30, B.E. 2565. (https://mrd. hss.moph.go.th, accessed 2 June 2023). Department of Health Service Support (2023). List of licensed private facilities for the elderly. (https://esta.hss.moph.go.th, accessed 30 May 2023 ). 244 Department of Helath Service Support (2019). Guildline for village health volanteer, village doctor. (http://phc.moph.go.th/www_hss/data_ center/dyn_mod/OSM_Doctor.pdf, accessed 12 May 2023 ). Department of Land Transport (2020). Number of vehicle registered in Thailand 2020. (https://web.dlt.go.th/statistics/index.php, accessed 24 January 2023). Department of Livestock Development (2015). Notification of the Ministry of Agriculture and cooperatives re: characteristics and conditions for prohibiting the use of antibiotics as growth promoters B.E. 2558. (http://afvc.dld.go.th/webnew/index.php/en/lawdld-menu/2018-10-31- 08-11-45/2-uncategorised/663-2558-2/ accessed 5 April 2023). Department of Local Aministration (2022). Provincial administration organization that has been transferred the mission of caring for the elderly and social service centers. (http://www.dla. go.th/upload/document/type2/2022/4/27268_1_1651118683543. pdf?time=1651198209282, accessed 30 May 2023). Department of Medical Sciences (2022). List of network laboratories that has been accredited for medical testing laboratories Ministry of Public Health,. (https://service.dmsc.moph.go.th/labscovid19/thai, accessed 24 April ). Department of Medical Services (2014). Model development of integrated service delivery system for elderly (http://agingthai.dms.go.th/ agingthai/wp-content/uploads/2021/01/book-2557-09_1.pdf, accessed 3 April 2023). Department of Medical Services (2020). Guideline for palliative and end- of-life care (for healthcare professionals). (https://www.dms.go.th, accessed 7 May 2023). Department of Mental Health (2016). Guideline for quality development of mental healthcare delivery: for regional hospital, general hospital, district hospital, and sub-district health promotion hospital. (https:// mhso.dmh.go.th/fileupload/20200226493046092.pdf, accessed 30 April 2023). Department of Mental Health (2021a). Annual report B.E. 2564. (https://dmh- elibrary.org/items/show/1298, accessed 3 April 2023). Department of Mental Health (2021b). Report of mental health patient B.E. 2564. (https://dmh.go.th/report/datacenter/dmh/, accessed 5 May 2023). 245 Department of Mental Health (2022a). Annual report B.E. 2565 (https://dmh. go.th/report/dmh/rpt_year/, accessed 30 April 2023). Department of Mental Health (2022b). Annual reports (B.E. 2561-2565) (2018-2022). Ministry of public health (https://dmh.go.th/report/dmh/ rpt_year/, accessed 30 May 2023). Department of Mental Health (2022c). Report on access to services for depression patients in fiscal year 2023, September (Health Data Center) (https://thaidepression.com/www/report/main_report/pdf/ahb- 09-22-mix_HDC.pdf, accessed 26 January 2024). Department of Mental Health (2023a). Mental health hotline 1323; a consultation service via telephone for 24 hours (https://ict.dmh.go.th, accessed 5 May 2023). Department of Mental Health (2023b). Organization structure of the Department of Mental Health. (https://dmh.go.th/intranet/structure/, accessed 5 May 2023). Department of Older Person (2023). Organizational structure. (https://www. dop.go.th/th/aboutus/3, accessed 30 May 2023). Department of Thai Traditional and Alternative Medicine (2020). The Protection and Promotion of Thai Traditional Medicine Wisdom Act B.E. 2542 (https://www.dtam.moph.go.th/index.php/th/services/laws/ enactment/6151-enactment-17.html, accessed 5 May 2023). Department of Thai Traditional and Alternative Medicine (2023). Health data center for Thai traditinal medicine services. MOPH. (http://hs.dtam. moph.go.th, accessed 5 May 2023). Department of Trade Negotiations (2020). Medicines and pharmaceutical goods. Ministry of Commerse. (https://api.dtn.go.th/files/ v3/606ffdb7ef414015ce2cbf99/download, accessed 30 May 2023). Detwattanayotin A (2022). The conditions led to the coup d’etat of Thailand. Interdisciplinary Academic and Research Journal. 2(3):335-56. https:// so03.tci-thaijo.org/index.php/IARJ/article/view/261386/173895 Division of Epidemiology (2019). HIV infection situation in Thailand B.E. 2562. (http://aidsboe.moph.go.th/app/bookup/ uploads/2023-01-121413068088.pdf, accessed 23 May 2023). Division of Epidemiology (2021). The results of HIV surveillance in specific areas of Thailand, the 39th round (June 2021), categorised by province. (http://aidsboe.moph.go.th/app/homeup/ uploads/2020-07-30354372811.pdf, accessed 23 May 2023). 246 Division of Epidemiology (2023). AIDS surveillance system. (http://aidsboe. moph.go.th/aids_system/index.php?link=anc#, accessed 23 May 2023). Eng PJ, Kertesz D, Brown R, Bunluesin S (2020). Thailand’s 1 million village health volunteers - “unsung heroes” - are helping guard communities nationwide from COVID-19. (https://www.who.int/thailand/news/ feature-stories/detail/thailands-1-million-village-health-volunteers- unsung-heroes-are-helping-guard-communities-nationwide-from- covid-19, accessed 8 April 2023). Faculty of Medicine Ramathibodi Hospital (2015). Declaration of patient’s rights and duty. (https://www.rama.mahidol.ac.th/medicalrecord/en/ siti_EN, accessed 25 December 2023). Food and Drug Administration (2022). Medical device and the role of medical device entrepreneurs. (https://medical.fda.moph.go.th/media.php?id=4 79638654629847040&name=คู่มือกฎหมายเครื่องมือแพทย์%2520และหน้าที่ผู้ประกอบ การเครื่องมือแพทย์%2520(พิมพ์ครั้งที่%25202).pdf, accessed 26 January 2024). Forberger S, Reisch L, Kampfmann T, Zeeb H (2019). Nudging to move: a scoping review of the use of choice architecture interventions to promote physical activity in the general population. Int J Behav Nutr Phys Act. 16(1):77. https://doi.org/10.1186/s12966-019-0844-z Foundation of Thai Gerontology Research and Development (2021). Situation of the Thai older persons 2021. (https://thaitgri.org/?p=40108, accessed 1 May 2023). Foundation of Thai Gerontology Research and Development (2023). Home care volunteers (https://thaitgri.org/?s=%E0%B8%AD%E0%B8%B2%E 0%B8%AA%E0%B8%B2%E0%B8%AA%E0%B8%A1%E0%B8%B1%E0% B8%84%E0%B8%A3, accessed 1 May 2023). Gilmore AB, Fabbri A, Baum F, Bertscher A, Bondy K, Chang HJ, et al. (2023). Defining and conceptualising the commercial determinants of health. Lancet. 401(10383):1194-213. https://doi.org/10.1016/s0140- 6736(23)00013-2 Glassman A, Chalkidou K, Giedion U, Teerawattananon Y, Tunis S, Bump JB, et al. (2012). Priority-setting institutions in health: recommendations from a center for global development working group. Glob Heart. 7(1):13-34. https://doi.org/10.1016/j.gheart.2012.01.007 Global Center for Good Governance in Tobacco Control (2021). Country ranking: Thailand. (https://globaltobaccoindex.org/country-ranking, accessed 30 April 2023). 247 Global Compact on Refugees (2023). Thailand: an overview of how the global compact on refugees is being turned into action in Thailand. (https:// globalcompactrefugees.org/gcr-action/countries/thailand, accessed 30 May 2023). Global COVID-19 Index (2021). Coronavirus disease (COVID-19) dashboard. (https://covid19.pemandu.org/, accessed 30 May 2023). Gruber J, Hendren N, Townsend RM (2014). The great equalizer: health care access and infant mortality in Thailand. Am Econ J Appl Econ. 6(1):91- 107. https://doi.org/10.1257/app.6.1.91 Hanvoravongchai P, Letiendumrong J, Teerawattananon Y, Tangcharoensathien V (2000). Implications of private practice in public hospitals on the cesarean section rate in Thailand. Hum Resour Develop. 4(1). https://kb.hsri.or.th/dspace/bitstream/ handle/11228/163/2000_DMJ6_Implications%20of%20Private. pdf?sequence=1&isAllowed=y Harkins B (2019). Thailand migration report 2019. United Nations Thermatic Working Group on Migration in Thailand. (https://www.aidsdatahub. org/sites/default/files/resource/un-thailand-migration-report-2019. pdf#page=33, accessed 30 May 2023). Hawkins L, Srisasalux J, Osornprasop S (2009). Devolution of health centers and hospital autonomy in Thailand: a rapid assessment. Health Systems Research Institute and The World Bank. (http://www-wds. WorldBank.org/external/default/WDSContentServer/WDSP/IB/2011/10 /19/000386194_20111019000954/Rendered/PDF/650190ESW0whit0Aut onomy0in0Thailand.pdf, accessed 4 February 2015). Health Administration Division (2016). Service plan B.E. 2561-2565 (2017- 2022). (http://phdb.moph.go.th/main/index/detail/29296, accessed 23 May 2023). Health Administration Division (2019). Guideline for intermediate care for healthcare provider according to the service plan. (https://phdb.moph. go.th/main/index/detail/30103, accessed 30 April 2023). Health Administration Division (2020). Providing new normal medical service. (https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd =&ved=2ahUKEwjQy_ido_D-AhV_QPUHHcllBYIQFnoECAcQAQ&url=http s%3A%2F%2Fphdb.moph.go.th%2Fmain%2Findex%2Fdownload%2F67 4&usg=AOvVaw1_3D16zZ5RA5G1_Neqe8oh, accessed 12 May 2023). Health Administration Division (2023). Service plan B.E. 2566-2570 (2023- 2027). (https://phdb.moph.go.th/main/index/detail/31007, accessed 26 January 2024). 248 Health Insurance Information Service Centre (2012). Administration of capitation budget. (http://eis.nhso.go.th/FrontEnd/SingleContent.aspx? menu=530000001&pid=540000024, accessed 20 June 2012). Health Intervention and Technology Assessment Program (2022). HITAP emphasises Thailand’s leadership in health system as the host of the health technology assessment (HTA) conference at the regional level gathering around 300 academics from 20 countries. (https://www.hitap. net/en/news/185348, accessed 23 May 2023). Health Product Vigilance Center (2021). About the agency. (https://hpvcth.fda. moph.go.th/about-us/, accessed 26 January 2024). Health Systems Research Institute (2002). Health insurance system in Thailand. (https://kb.hsri.or.th/dspace/bitstream/handle/11228/946/ he0098.pdf?sequence=4&isAllowed=y, accessed 26 January 2024). Healthcare Accreditation Institute (2010). HA standards: practice & assessment (HA SPA) B.E. 2553. (https://www.si.mahidol.ac.th/th/ division/soqd/admin/standard_files/HA-SPA.pdf, accessed 1 May 2023). Healthcare Accreditation Institute (2018). Hospital and health care standard, 4th edition. (https://www.ha.or.th, accessed 30 May 2023). Healthcare Accreditation Institute (2022). Hospital and health care standard, 5th edition. (https://www.ha.or.th, accessed 30 May 2023). Healthcare Accreditation Institute (2023, March 2023). Hospital authority data The Healthcare Accreditation Institute,. (https://data.ha.or.th/, accessed 2 May 2023). Hfocus (2012). MOPH develops a 5-year plan to reduce illness and mortality rates and improve access to standardized healthcare services. (https:// www.hfocus.org/content/2012/11/1797, accessed 23 May 2023). Hfocus (2016). Comptroller General Department updated 124 private hospital participating the direct billing for schedule surgeries. (https://www. hfocus.org/content/2016/08/12538, accessed 6 May 2023). Hfocus (2017). MoPH expands the service plan from 13 branches to 19. (https://www.hfocus.org/content/2017/08/14466, accessed 30 April 2023). Hfocus (2023a). The mental health hotline became a contracting unit with the NHSO expanding services accessibility, increasing a number of psycologists for taking care people. (https://www.hfocus.org/ content/2023/03/27200, accessed 5 May 2023). 249 Hfocus (2023b). NHSO proposed a draft royal decree to take care of all Thai people solve the problem of sustainable health promotion budget. (https://www.hfocus.org/content/2023/03/27208, accessed 26 January 2024). Innes GK, Lambrou AS, Thumrin P, Thukngamdee Y, Tangwangvivat R, Doungngern P, et al. (2022). Enhancing global health security in Thailand: strengths and challenges of initiating a one Health approach to avian influenza surveillance. One Health. 14:100397. https://doi. org/10.1016/j.onehlt.2022.100397 Institute for Health Metrics and Evaluation (2019). Thailand Institute for Health Metrics and Evaluation. (https://www.healthdata.org/thailand, accessed 6 May 2023). Institute for Health Metrics and Evaluation (2022a). Incidence of breast cancer in Thailand, global and selected world regions (2000-2019). (https://vizhub.healthdata.org/gbd-results?params=gbd-api-2019- permalink/c863b7d8bfd36f9c07cb3220d20d3cf8, accessed 2 May 2023). Institute for Health Metrics and Evaluation (2022b). Incidence of cervical cancer in Thailand, global, and selected world regions, (2000-2019). (https://vizhub.healthdata.org/gbd-results?params=gbd-api-2019-per malink/6ec27398cc8a9a0142714a02a6d8c90f, accessed 2 May 2023). Institute for Population and Social Research, Mahidol University (2021). Thai health – 2021: COVID-19 disaster shakes the world. (https:// dol.thaihealth.or.th/Media/Pdfview/80bed3e5-5105-ec11-80f5- 00155d90fb07, accessed 12 March 2024). International Labour Organization (2006). Integrating occupational health services into public health systems: a model devloped wtih Thailand’s primary care units. (https://www.ilo.org/wcmsp5/groups/public/--- asia/---ro-bangkok/documents/publication/wcms_bk_pb_309_en.pdf, accessed 5 February 2024 ). International Labour Organization (2022). Triangle in ASEAN quarterly briefing note. (https://www.ilo.org/asia/publications/WCMS_614378/ lang--en/index.htm, accessed 30 May 2023). International Monetary Fund (2021). Five things to know about Thailand’s economy and COVID-19. (https://www.imf.org/en/News/ Articles/2021/06/21/na062121-5-things-to-know-about-thailands- economy-and-covid-19, accessed 26 January 2024). 250 International Organization for Migration (2021). Thailand social protection diagnostic review: social protection for migrant workers and their families in Thailand. (https://publications.iom.int/books/thailand- social-protection-diagnostic-review-social-protection-migrant- workers-and-their accessed 30 May 2023). International Telecommunication Union (2021a). Individuals using the internet (% of population) - Thailand, upper middle income. (https:// data.worldbank.org/indicator/IT.NET.USER.ZS?locations=TH-XT, accessed 24 April 2023). International Telecommunication Union (2021b). Mobile cellular subscriptions (per 100 people) - Thailand, upper middle income. (https://data. worldbank.org/indicator/IT.CEL.SETS.P2?locations=TH-XT, accessed 24 April 2023). Janssen M, van der Voort H (2020). Agile and adaptive governance in crisis response: lessons from the COVID-19 pandemic. International journal of information management. 55:102180. https://www.sciencedirect. com/science/article/pii/S0268401220309944 Jaroonwattana M (2020). Situation and problems of opioids accessibility: case study of Thai Food and Drug Administration. Thai Food and Drug Journal. 27(2):13-27. https://he01.tci-thaijo.org/index.php/fdajournal/ article/view/244659 Jindawatana A, Jindawatana W, Sirikanokwilai N (1996). Planning for human resources for health. Health Systems Research Journal. 4(3):226–34. https://kb.hsri.or.th/dspace/bitstream/handle/11228/1051/jv4n3-10. pdf?sequence=1&isAllowed=y Jirawattanapisal T, Kingkaew P, Lee T-J, Yang M-C (2009). Evidence-based decision-making in Asia-Pacific with rapidly changing health-care systems: Thailand, South Korea, and Taiwan. Value Health. 12 Suppl 3:S4-11. https://doi.org/10.1111/j.1524-4733.2009.00620.x Jittithai N (2009). Healthy migrants, healthy Thailand: a migrant health program model. International Organization for Migration and Ministry of Public Health. (https://publications.iom.int/books/healthy-migrants- healthy-thailand-migrant-health-program-model, accessed 24 January 2024). Jongudomsuk P, Limwattananon S, Prakongsai P, Srithamrongsawat S, Pachanee K, Mohara A, et al. (2012). Evidence-based health financing reform in Thailand. International Monetary Fund. (https://www. elibrary.imf.org/display/book/9781616352448/ch016.xml, accessed 26 January 2024). 251 Ju C, Wei L, Man KKC, Wang Z, Ma TT, Chan AYL, et al. (2022). Global, regional, and national trends in opioid analgesic consumption from 2015 to 2019: a longitudinal study. Lancet Public Health. 7(4):e335-e46. https://doi.org/10.1016/S2468-2667(22)00013-5 Kanchanabhishek Institue of Medical and Public Health (2023). Medical record program in bachelor degree and diploma. (http://www.kmpht. ac.th/homekmp/?page_id=1579, accessed 8 April 2023). Kantamaturapoj K, Kulthanmanusorn A, Witthayapipopsakul W, Viriyathorn S, Patcharanarumol W, Kanchanachitra C, et al. (2020a). Legislating for public accountability in universal health coverage, Thailand. Bulletin of the World Health Organization. 98(2):117. https://doi.org/10.2471/ BLT.19.239335 Kantamaturapoj K, Marshall AI, Chotchoungchatchai S, Kiewnin K, Patcharanarumol W, Tangcharoensathien V (2020b). Performance of Thailand’s universal health coverage scheme: evaluating the effectiveness of annual public hearings. Health Expectations. 23(6):1594-602. https://doi.org/https://doi.org/10.1111/hex.13142 Kaweenuttayanon N, Pattanarattanamolee R, Sorncha N, Nakahara S (2021). Community surveillance of COVID-19 by village health volunteers, Thailand. Bull World Health Organ. 99(5):393-7. https://doi.org/10.2471/ blt.20.274308 Kespichayawattana J, Jitapunkul S (2008). Health and health care system for older persons. Ageing Int. 33:28-49. https://doi.org/10.1007/ s12126-009-9028-5 Kheawcharoen O, Pannarunothai S, Reawphiboon W (2007). Classification and alternative payment for sub-acute and non-acute inpatient care in Thailand. Journal of Health Science(16):213-5. Kiewnin K, Chotchoungchatchai S, Kantamaturapoj K, Marshall AI, Patcharanarumol W, Tangcharoensathien V (2020). Citizen participation in governing Thailand’s universal health coverage scheme. Journal of Health Systems Research. 14(3):274-88. https://kb.hsri.or.th/dspace/ handle/11228/5246 Kijsanayotin B (2011). Using health care service administration data to improve national vital statistics: Thailand experiences. In Paper prepared for United Nations Expert Group Meeting on “International standards for civil registration and vital statistics systems”. New York, 27–30 June. 252 Kijsanayotin B (2016). EHealth in Thailand: interoperability and health information standards. (https://kb.hsri.or.th/dspace/bitstream/ handle/11228/4452/he0140.pdf?sequence=4&isAllowed=y, accessed 23 May 2023). Kingkaew P, Maleewong U, Ngarmukos C, Teerawattananon Y (2012). Evidence to inform decision makers in Thailand: a cost-effectiveness analysis of screening and treatment strategies for postmenopausal osteoporosis. Value Health. 15 Suppl S20-8. https://doi.org/10.1016/j. jval.2011.11.015. Kitreerawutiwong K, Kitreerawutiwong N (2018). The development direction for long-term care giver in community. Journal of Nursing and Health Care. 36(4):15-24. https://he01.tci-thaijo.org/index.php/jnat-ned/ article/view/164854 Kongpakwattana K, Chaiyakunapruk N (2020). Application of discrete-event simulation in health technology assessment: a cost-effectiveness analysis of Alzheimer’s disease treatment using real-world evidence in Thailand. Value Health. 23(6):710-8. https://doi.org/10.1016/j. jval.2020.01.010 Kongsakon R, Pattanateepapon A (2020). Situation report of tobacco use in Thailand B.E. 2562 (2019). Tobacco Control Research and Knolwedge Mangagement Center, Mahidol University,. (https://www.trc.or.th/th/ attachments/article/527/รายงานสถานการณ์%20การบริโภคยาสูบของประเทศไทย%20 พ.ศ.2562.pdf, accessed 3 April 2023). Kongsri S, Limwattananon S, Sirilak S, Prakongsai P, Tangcharoensathien V (2011). Equity of access to and utilization of reproductive health services in Thailand: national reproductive health survey data, 2006 and 2009. Reprod Health Matters. 19(37):86-97. https://doi.org/10.1016/ s0968-8080(11)37569-6 Koonnathamdee P (2013). A turning point for the service sector in Thailand. SSRN Electronic Journal. 353. https://doi.org/10.2139/ssrn.2292285 Kosiyaporn H, Julchoo S, Phaiyarom M, Sinam P, Kunpeuk W, Pudpong N, et al. (2020a). Strengthening the migrant-friendliness of Thai health services through interpretation and cultural mediation: a system analysis. Glob Health Res Policy. 5(1):53. https://doi.org/10.1186/ s41256-020-00181-0 Kosiyaporn H, Julchoo S, Sinam P, Phaiyarom M, Kunpeuk W, Pudpong N, et al. (2020b). Health literacy and Its related determinants in migrant health workers and migrant health volunteers: a case study of Thailand, 2019. Int J Environ Res Public Health. 17(6). https://doi. org/10.3390/ijerph17062105 253 Layton M, Chadbunchachai S, Thinkhamrop B, Tangcharoensathien V (2005). Impact of pharmaceutical policies on promotional targeted drugs. Journal of Pharmaceutical Finance, Economics & Policy. 14(4):53–68. https://kb.hsri.or.th/dspace/bitstream/handle/11228/794/ ITJ39_2005%282548%29_Abstract.pdf?sequence=1&isAllowed=y Leelahavarong P, Doungthipsirikul S, Kumluang S, Poonchai A, Kittiratchakool N, Chinnacom D, et al. (2019). Health technology assessment in Thailand: institutionalization and contribution to healthcare decision making: review of literature. Int J Technol Assess Health Care. 35(6):467-73. https://doi.org/10.1017/s0266462319000321 Leerapan P, Atthasit R (2005). The situation of local health decentralization: the case study from the Committee of Health at Phuket provice. Health Systems Research Institute. (https://kb.hsri.or.th/dspace/ handle/11228/1332, accessed 24 January 2024). Leeyaphan J, Leeyaphan C, Suttha P, Kulthanachairojana N (2021). Healthcare resource utilization and healthcare costs of COVID-19 patients in a tertiary care public hospital: a retrospective cohort study in Thailand. J Med Assoc Thai. 104(12):1953-8. Legido-Quigley H, Pocock N, Tan ST, Pajin L, Suphanchaimat R, Wickramage K, et al. (2019). Healthcare is not universal if undocumented migrants are excluded. BMJ. 366:l4160. https://doi.org/10.1136/bmj.l4160 Limwattananon C, Jaratpatthararoj J, Thungthong J, Limwattananon P, Kitkhuandee A (2020). Access to reperfusion therapy and mortality outcomes in patients with ST-segment elevation myocardial infarction under universal health coverage in Thailand. BMC Cardiovascular Disorders. 20. https://doi.org/10.1186/s12872-020-01379-3 Limwattananon C, Limwattananon S, Waleekhachonlert O, Rattanachotpanich T (2023). Research report on in-depth analysis for evidence-based management evaluation, fiscal year B.E. 2566. International Health Policy Program, Nonthaburi. Limwattananon S, Tangcharoensathien V, Prakongsai P (2010). Equity in maternal and child health in Thailand. Bull World Health Organ. 88(6):420-7. https://doi.org/10.2471/blt.09.068791 Lohsiriwat V, Chaisomboon N, Pattana-Arun J (2020). Current colorectal cancer in Thailand. Annals of Coloproctology. 36(2):78–82. https://doi. org/10.3393/ac.2020.01.07 254 Luankongsomchit V, Boonma C, Soboon B, Ranron P, Isaranuwatchai W, Pimsarn N, et al. (2023). How many people experience unsafe medical care in Thailand, and how much does It cost under universal coverage scheme? Healthcare (Basel). 11(8). https://doi.org/10.3390/ healthcare11081121 Markchang K, Pongutta S (2019). Monitoring prices of and sugar content in sugar-sweetened beverages from pre to post excise tax adjustment in Thailand. Journal of Health Systems Research. Marshall AI, Kantamaturapoj K, Kiewnin K, Chotchoungchatchai S, Patcharanarumol W, Tangcharoensathien V (2021). Participatory and responsive governance in universal health coverage: an analysis of legislative provisions in Thailand. BMJ Global Health. 6(2):e004117. https://doi.org/10.1136/bmjgh-2020-004117 Marshall AI, Witthayapipopsakul W, Chotchoungchatchai S, Wangbanjongkun W, Tangcharoensathien V (2023). Contracting the private health sector in Thailand’s universal health coverage. PLOS Glob Public Health. 3(4):e0000799. https://doi.org/10.1371/journal.pgph.0000799 Martin GR, Ewer AK, Gaviglio A, Hom LA, Saarinen A, Sontag M, et al. (2020). Updated strategies for pulse oximetry screening for critical congenital heart disease. Pediatrics. 146(1). https://doi.org/10.1542/ peds.2019-1650 Medical Council of Thailand (2021). Domestic medical schools accredited by the Medical Council of Thailand. (https://www.tmc.or.th/medical_ school_th.php, accessed 31 March 2023). Medical Council of Thailand (2023a, 21 March 2023). Foreign medical School. (https://www.tmc.or.th/foreign_med.php, accessed 8 April 2023). Medical Council of Thailand (2023b, 21 March 2023). Medical statistical data in Thailand. (https://www.tmc.or.th/statistics.php, accessed 8 April 2023). Medicine Regulation Division (2022). Numbers of pharmacies in different types. Food and Drug Administration. (https://www.fda.moph.go.th/ sites/drug/Shared%20Documents/Statistic/Licensee-20221223.pdf, accessed 30 May 2023). Meuter RFI, Gallois C, Segalowitz NS, Ryder AG, Hocking J (2015). Overcoming language barriers in healthcare: a protocol for investigating safe and effective communication when patients or clinicians use a second language. BMC Health Services Research. 15(1):371. https://doi.org/10.1186/s12913-015-1024-8 255 Miankerd W (2020). Ageing in protection home for the destitute. (http://www. wpq.dsdw.go.th/attach/f1-t1625624199.pdf, accessed 30 May 2023). Mills A, Bennett S, Siriwanarangsun P, Tangcharoensathien V (2000). The response of providers to capitation payment: a case-study from Thailand. Health Policy. 51:163–80. Ministry of Public Health (2009). The national strategic plan for human resources for health B.E. 2550-2559 (2007–2016). Bureau of Policy and Strategy, Ministry of Public Health. (https://kb.hsri.or.th/dspace/ handle/11228/2798, accessed 26 January 2024). Ministry of Public Health (2016). Strategies, indicators, and guideline for data collection, MoPH, fiscal year B.E. 2559. (http://data.ptho.moph.go.th/ inspec/inspec2559/mophplan_2559_final.pdf, accessed 5 May 2023). Ministry of Public Health (2018). Health KPI: percentage of hospitals that offered palliative care in fiscal year B.E. 2561. (http://healthkpi.moph. go.th/kpi2/kpi/index/?id=778&kpi_year=2561, accessed 30 April 2023). Ministry of Public Health (2019 ). Health data centre: ratio of cervical cancer screening in Thai female population aged 30-60 years. (https:// hdcservice.moph.go.th/hdc/reports/page.php?cat_id=59acae7a68f02c8 e2c0cb88dfc6df3b3, accessed 2 May 2023). Ministry of Public Health (2020). Ministerial regulation establishing elderly care or persons with disabilities care business as separate entities within healthcare facilities, B.E. 2563. (https://download.asa. or.th/03media/04law/swfa/mr63.pdf, accessed 30 May 2023). Ministry of Public Health (2021a). Health Data Center: percentage of home- based palliative care patient, fiscal year B.E. 2564. (https://hdcservice. moph.go.th/hdc/reports/report.php?source=pformated/format1. php&cat_id=b08560518ca0ebcaf2016dab69fb38b5&id=8eb4ec8a40c080 aadfdbb895be74e771, accessed 26 January 2024). Ministry of Public Health (2021b). Health KPI: percentage of pain release and other symtomp management with opioids in palliative care patients. (http://healthkpi.moph.go.th/kpi2/kpi/index2/?kpi_year=2564, accessed 30 April 2023). Ministry of Public Health (2021c). Ministry of Public Health announcement regarding health examination and health insurance for migrant workers during the Covid-19 pandemic, new wave, in the year B.E. 2564. (https://dhes.moph.go.th/?p=12477, accessed 30 May 2023). 256 Ministry of Public Health (2022a). Action plan of Ministry of Public Health, for 5 years (B.E. 2566-2570). (https://spd.moph.go.th/wp-content/ uploads/2023/05/MOPH_plan-66-70-for-web.pdf, accessed 22 May 2023). Ministry of Public Health (2022b). Health KPI: percentage of intermediate care patients who were followed up for 6 months or until Barthel index reached 20 before 6 months, fiscal year B.E. 2565. (http://healthkpi. moph.go.th/kpi2/kpi/index/?id=1864&kpi_year=2565, accessed 26 January 2024). Ministry of Public Health (2023). PCU/NPCU. (http://pcc.moph.go.th/pcc/, accessed 27 November 2023). Ministry of Transport (2022). Total road length of Thailand. (https://datagov. mot.go.th/dataset/thailand-road-length/resource/0bb805a6-dd03- 4118-890d-17623c01a10f, accessed 26 January 2023). Mitchell RK, Agle BR, Wood DJ (1997). Toward a theory of stakeholder identification and salience: defining the principle of who and what really counts. Academy of management review. 22(4):853-86. Mohara A, Youngkong S, Velasco RP, Werayingyong P, Pachanee K, Prakongsai P, et al. (2012). Using health technology assessment for informing coverage decisions in Thailand. J Comp Eff Res. 1(2):137-46. https://doi.org/10.2217/cer.12.10 Moon MJ (2020). Fighting COVID–19 with agility, transparency, and participation: wicked policy problems and new governance challenges. Public Admin Rev. 80:651-6. https://onlinelibrary.wiley.com/doi/ abs/10.1111/puar.13214 NaRanong A, NaRanong V (2011). The effects of medical tourism: Thailand’s experience. Bull. World Health Organ. 89:336-44. NaRanong V, NaRanong A (2005). Capital investment for universal health coverage. In: Thailand Development Research Institute. NaRanong V, NaRanong A, Srianant N (2004). Grievance systems in public health insurance schemes. (https://tdri.or.th/wp-content/ uploads/2012/11/A134.pdf, accessed 26 January 2024). National Assembly of Thailand (2021). Act Amending the Penal Code (No. 28) B.E. 2664. (https://en.wikisource.org/wiki/Translation:Act_Amending_ the_Penal_Code_(No._28),_2564_BE, accessed 26 January 2024). National Comittee on Ageing (2020). The action plan on the eldery phase 2 (B.E. 2545-2565). (https://www.dop.go.th/download/laws/ th1614675775-828_0.pdf, accessed 30 April 2023). 257 National Drug Information (2021). National drug policy and national drug development strategy B.E. 2563-2565 (https://ndi.fda.moph.go.th/ uploads/policy_file//20210330101713.pdf, accessed 26 January 2024). National Drug System Development Committee (2016). Ethical criteria for medicinal drug promotion of Thailand. (https://ndi.fda.moph.go.th/ uploads/file_news/20200612939904171.pdf, accessed 26 January 2024). National Economic and Social Development Office (2009). Health care infrastructure investment plan under economic stimulus package phase 2: 2010–2013. In. Nonthaburi: Minstry of Public Health. National Health Accounts Working Group (2013). Thai national health accounts 2011. International Health Policy Program Foundation. (https://www.ihppthaigov.net/publication/ nationalhealthaccountsofthailand2011, accessed 26 January 2024). National Health Accounts Working Group (2019). Thai national health accounts: studies of tracking health expenditure by diseases, 2014- 2016. International Health Policy Program Foundation. (https://www. ihppthaigov.net/publication/thailandnationalhealthaccounts, accessed 26 January 2024). National Health Accounts Working Group (2021). Thai national health accounts 2017-2019. International Health Policy Program Foundation. (https://www.ihppthaigov.net/publication/ thainationalhealthaccounts2017-2019, accessed 26 January 2024). National Health Commission Office (2007). National Health Act, B.E. 2550. (https://infocenter.nationalhealth.or.th/Ebook/NationalhealthAct2007/ book.html#p=3, accessed 7 May 2023). National Health Commission Office (2010). Ministerial regulation: criteria and procedures for implementation according to the living will which expresses the intention not to receive medical services solely for the purpose of prolonging life in the final stage of life or for ending suffering from illness, B.E. 2553. (https://infocenter.nationalhealth. or.th/node/19129, accessed 7 May 2023). National Health Commission Office (2020 ). Notification of the National Helath Commission on the operational definitions of terms pertaining to palliative care for Thailand, B.E. 2563 (https://en.nationalhealth.or.th/ wp-content/uploads/2021/09/Final_Eng_Final_17092021_Operational- Definition-on-Palliative-Care.pdf, accessed 7 May 2023). National Health Commission Office (2022a). National Health Assembly (NHA). (https://en.nationalhealth.or.th/nha/, accessed 12 May 2023). 258 National Health Commission Office (2022b). NHA resolutions. National Health Commission Office. (https://en.nationalhealth.or.th/nha-resolutions/, accessed 26 January 2024). National Health Commission Office (2022c). Thai standards for advance care planning B.E. 2565. (https://www.nationalhealth.or.th/sites/default/ files/upload_files/ประกาศ-ACP.pdf, accessed 7 May 2023). National Health Security Office (2008). NHSO annual report B.E. 2551. (https://www.nhso.go.th/operating_results/34, accessed 3 April 2023). National Health Security Office (2009). NHSO annual report B.E. 2552. (https://www.nhso.go.th/operating_results/35, accessed 30 April 2023). National Health Security Office (2010). NHSO annual report B.E. 2553. (https://www.nhso.go.th/operating_results/36, accessed 30 April 2023). National Health Security Office (2011a). NHSO annual report B.E. 2554. (https://www.nhso.go.th/storage/downloads/operatingresult/37/ Annual_Report_2554.pdf, accessed 12 March 2024). National Health Security Office (2011b). OP/IP individual program of MoPH and NHSO. In. Nonthaburi: National Health Security Office. National Health Security Office (2012a). Guidebook for managing the essential rehabilitation fund for provincial health level. (https://www. nhso.go.th/storage/files/shares/PDF2/fund_medi36.pdf, accessed 30 May 2023). National Health Security Office (2012b). Manual for management of National Health Security Fund, fiscal year B.E. 2555. (https://www.nhso.go.th/ storage/files/shares/PDF/fund_man25.pdf, accessed 7 May 2023). National Health Security Office (2012c). NHSO annual report B.E. 2555. (https://www.nhso.go.th/storage/downloads/operatingresult/38/ Annual_Report_2555.pdf, accessed 12 March 2024). National Health Security Office (2014). NHSO annual report B.E. 2557. (https://www.nhso.go.th/operating_results/41, accessed 30 April 2023). National Health Security Office (2015). NHSO annual report B.E. 2558. (https://eng.nhso.go.th/view/1/Annual_Reports/EN-US, accessed 30 May 2023). National Health Security Office (2016a). The manual of long term care for the dependent elderly in community (long term care) under unversal health coverage scheme in fiscal year 2016. (https://www.nhso.go.th/storage/ downloads/main/37/%E0%B8%84%E0%B8%B9%E0%B9%88%E0%B8 %A1%E0%B8%B7%E0%B8%AD_LTC_.pdf, accessed 30 April 2023). 259 National Health Security Office (2016b). NHSO annual report B.E. 2559 (https://eng.nhso.go.th/view/1/Annual_Reports/EN-US, accessed 30 May 2023). National Health Security Office (2018). NHSO annual report B.E. 2561. (https://eng.nhso.go.th/view/1/Annual_Reports/EN-US, accessed 30 May 2023). National Health Security Office (2019). People’s paticipation in the universal coverage scheme (UCS) in Thailand (https://eng.nhso.go.th/assets/ portals/1/files/05%20UCS%20PublicParticipation.pdf, accessed 24 January 2024). National Health Security Office (2020a). NHSO administrative reports (https:// eng.nhso.go.th/view/1/Reports/EN-US, accessed 26 January 2024). National Health Security Office (2020b). NHSO annual report B.E. 2563. (https://eng.nhso.go.th/view/1/Annual_Reports/EN-US, accessed 30 May 2023). National Health Security Office (2020c). Postal medicine delivery plays key role in telemedicine. (https://eng.nhso.go.th/view/1/home/Postal- medicine-delivery-plays-key-role-in-telemedicine/230/EN-US, accessed 26 January 2024). National Health Security Office (2020d). Telehealth, telemed, telepharmacy seen as new normal in universal health coverage (UHC): NHSO. (http:// eng.nhso.go.th/view/1/home/Telehealth-telemed-telepharmacy-seen- as-new-normal-in-Universal-health-Coverage-UHC-NHSO/231/EN- US, accessed 12 May 2023). National Health Security Office (2020e). Ten outstanding achievement of the UCS in 2020 to support COVID-19 response. (https://www.nhso.go.th/ news/2977, accessed 26 January 2024). National Health Security Office (2020f). UCS medicine delivery initiative. (https://eng.nhso.go.th/view/1/DescriptionNews/UCS-medicine- delivery-initiative-/139/EN-US, accessed 26 January 2024). National Health Security Office (2020g). Universal coverage for emergency patients (UCEP). (https://eng.nhso.go.th/assets/portals/1/files/ Thailand_UHC/64-4_UCEP_Book(Eng).pdf, accessed 23 May 2023). National Health Security Office (2021a). Manual for management of the National Health Security Fund B.E. 2564. (https://www.nhso.go.th/ storage/files/shares/PDF/fund_man01.pdf, accessed 3 April 2023). 260 National Health Security Office (2021b). National health security budget 2022 “the right to health of all Thai people”. (https://www.nhso.go.th/ news/3320, accessed 26 January 2024). National Health Security Office (2021c). NHSO annual report B.E. 2564. (https://eng.nhso.go.th/view/1/Annual_Reports/EN-US, accessed 30 May 2023). National Health Security Office (2021d). NHSO board announced six new benefits. (https://bit.ly/3bc4Qsx, accessed 25 January 2024). National Health Security Office (2022a). Benefit package for dental care. (https://www.nhso.go.th/page/coverage_rights_dental, accessed 2 June 2023). National Health Security Office (2022b). Guideline for reimbursment of health care expenditure, fiscal year B.E. 2565. (https://ubon.nhso.go.th/ upload/downloads/คู่มือแนวทางปฏิบัติในการขอรับค่าใช้จ่าย%20.pdf, accessed 18 March 2024). National Health Security Office (2022c). It has started. Pharmacy Council announces pharmacies ready to provide care for common illnesses with 16 symptoms, medications available at pharmacies. (https://www. nhso.go.th/news/3809, accessed 30 May 2023). National Health Security Office (2022d). New treatment option for COVID-19 patients presenting with mild symptoms. (https://eng.nhso.go.th/ view/1/DescriptionNews/New-treatment-option-for-COVID-19- patients-presenting-with-mild-symptoms/440/EN-US, accessed 26 January 2024). National Health Security Office (2022e). NHSO annual report B.E. 2565. (https://www.nhso.go.th/operating_results/54, accessed 30 April 2023). National Health Security Office (2022f). Population by health insurance schemes and provinces. (https://ucinfo.nhso.go.th/ucinfo/ RptRegisPop-3, accessed 25 July). National Health Security Office (2023a). Announcement of the National Health Security Office on paying for additional healthcare services for pharmacy referral units. (https://www.nhso.go.th/storage/downloads/ main/233/10_ประกาศการจ่ายร้านยา_2566_.pdf, accessed 18 March 2024). National Health Security Office (2023b). Cancer anywhere. (https://www.nhso. go.th/news/3950 accessed 26 January 2024). National Health Security Office (2023c). UCBP relevant research. (https:// ucbp.nhso.go.th/research/projects.html, accessed 26 January 2024). 261 National Health Security Office (NHSO) (2022a). NHSO annual reports. (https://eng.nhso.go.th/view/1/Annual_Reports/EN-US). National Health Security Office (NHSO) (2022b). Webbord. (https://www.nhso. go.th/webboard/post/206, accessed 22 July). National Herbal Policy Committee (2023). National working plan for herb. (https://nph.dtam.moph.go.th/publications/4224/, accessed 26 January 2024). National Institute for Emergency Medicine (2021). Announcement of the Emergency Medical Committee on criteria and conditions for the performance and supervision of the medical operation units. (https://www.niems.go.th/1/UploadAttachFile/2022/ EBook/415212_20220412172414.pdf, accessed 23 May 2023). National Institute for Emergency Medicine (2022a). Guidelines for disbursing funds from the emergency medical fund to support and provide compensation for emergency medical operations. (https://www.niems. go.th/1/UploadAttachFile/2022/EBook/414526_20220111095104.pdf, accessed 30 May 2023). National Institute for Emergency Medicine (2022b). Information technology for emergency medical system (ITEMS). (https://ws.niems.go.th/items_ front/index.aspx, accessed 8 November 2023). National Statistical Office (2007). Survey of population change B.E. 2548-2549 (2005-2006). (https://www.nso.go.th/nsoweb/nso/survey_detail/AA, accessed 26 January 2024). National Statistical Office (2009). Health and welfare survey (1986-2007). (http://www.hiso.or.th/Health_survey/Search/F/F2.php, accessed 22 May 2012). National Statistical Office (2010a). The 2010 population and housing census. (https://ebook.nso.go.th/nso/book_cover_PDF/COVER_ NOO06600000182.pdf, accessed 3 April 2023). National Statistical Office (2010b). Population and housing census (2000- 2010). (http://service.nso.go.th/nso/nsopublish/census/pophouse53-01. html#:~:text=ประโยชน์ที่จะได้รับ,การทำาการสำารวจต่าง%20ๆ, accessed 22 May 2023). National Statistical Office (2014). Socioeconomic survey (1986-2014). (https:// www.hiso.or.th/health_survey/DOC/H172.php, accessed 2 May 2023). National Statistical Office (2017). The 2017 disablity survey. (https://www.nso. go.th/nsoweb/nso/survey_detail/LI, accessed 30 April 2023). 262 National Statistical Office (2021a). The 2021 health and welfare survey (https://www.nso.go.th/sites/2014/DocLib13/ด้านสังคม/สาขาสวัสดิการสังคม/ อนามัยและสวัสดิการ/2564/report_120165.pdf, accessed 3 April 2023). National Statistical Office (2021b). The 2021 health behaviour of population survey https://www.nso.go.th/sites/2014/DocLib13/ด้านสังคม/สาขาสุขภาพ/ พฤติกรรมการดูแลสุขภาพของประชากร/2564/report_2501_64.pdf National Statistical Office (2021c). Socioeconomic survey (2001- 2021). (https://www.nso.go.th/nsoweb/nso/survey_detail/qC, accessed 2 May 2023). National Statistical Office (2022a). The 2022 disablity survey. (https://www. nso.go.th/nsoweb/nso/survey_detail/LI, accessed 30 April 2023). National Statistical Office (2022b). Health and welfare survey (2001-2021). (https://www.nso.go.th/nsoweb/nso/survey_detail/96, accessed 26 January 2024). National Statistical Office (2022c). Household survey on the use of information and communication technology (quarter2). (https://www.nso.go.th/nsoweb/download/ eyJwYXRoIjoic3RvcmFnZVwvc3VydmV5X2RldGFpbFwvMjAyM1wvMjAy MzA0MzAxMzA5NDZfODQ5NzgucGRmIiwiZmlsZW5hbWUiOiJmdWxs X3JlcG9ydF9xMl82NS5wZGYifQ==, accessed 12 March 2024). National Statistical Office, United Nations Children’s Fund (2006). Thailand multiple indicator cluster survey (MICS) (2005-2006). (https:// hp.anamai.moph.go.th/web-upload/4xceb3b571ddb70741ad132d75876 bc41d/tinymce/OPDC/OPDC2564-F/IDC1_7/opdc_2564_IDC1-7_15.pdf, accessed 26 January 2024). National Statistical Office, United Nations Children’s Fund (2016). Thailand multiple indicator cluster survey (MICS) (2015-2016). (https://www. unicef.org/thailand/sites/unicef.org.thailand/files/2018-06/Thailand_ MICS_Full_Report_EN_0.pdf, accessed 3 April 2023). National Statistical Office, United Nations Children’s Fund (2020). Thailand multiple indicator cluster survey (MICS) (2019). (https://uni. cf/3m6aXUR, accessed 3 April 2023). National Vaccine Institute (2019). Annual report B.E. 2562. (http://nvi.go.th/ Information/DataGov/AnnualReport/2562_AnnualReport.pdf, accessed 25 May 2023). National Vaccine Institute (2020). Blueprint: access to COVID-19 vaccines for Thailand (endorsed by national vaccine committee on 22 April 2020). 263 National Vaccine Institute (2021). Annual report B.E. 2564. (http://nvi.go.th/ Information/DataGov/AnnualReport/2564_AnnualReport.pdf, accessed 25 May 2023). National Vaccine Institute (2022). Annual report B.E. 2565. (http://nvi.go.th/ Information/DataGov/AnnualReport/2565_AnnualReport.pdf, accessed 25 May 2023). National Vaccine Institute (2023). History: establishment of the National Vaccine Institute. (http://nvi.go.th/en/history/, accessed 20 May 2023). Nimkulrat S, Wangmethekul S, Powthong P (2020). Current situation of the modern pharmaceutical manufacturing industry in Thailand. Journal of Health Science. 29(Special Issue):S129-S40. https://thaidj.org/index. php/JHS/article/view/8418 Nittayaramphong S, Tangcharoensathien V (1994). Thailand: private health care out of control? Health Policy and Planning. 9(1):31-40. https:// www.jstor.org/stable/45089111 Nittayasoot N, Suphanchaimat R, Namwat C, Dejburum P, Tangcharoensathien V (2021). Public health policies and health-care workers’ response to the COVID-19 pandemic, Thailand. Bull World Health Organ. 99(4):312-8. https://doi.org/10.2471/blt.20.275818 Noree T (2007). A 10-year plan for demand and supply of health workforce providing Thai traditional medicine (TTM) service in public health facilities. International Health Policy Program. International Health Policy Program, Nonthaburi,. Noree T, Pagaiya N (2020). Long-term care: quality long-term care for dependent in Thai Society. (https://dol.thaihealth.or.th/Media/ Pdfview/26937061-2c56-eb11-80ec-00155d09b41f, accessed 18 March 2024). Nursing Division (2018). Service Plan. Ministry of Public Health. (http://49.231.15.21/crhfileload/upload/files/ nurseF256211180709218536.pdf, accessed 26 January 2024). O-charoen N (2017). Road accidents... severe economic damages to the Thai economy. (https://tdri.or.th/2017/08/econ_traffic_accidents/, accessed 30 May 2023). OECD (2020). Unmet needs for health care: comparing approaches and results from international surveys. The Organisation for Economic Co-operation and Development. (https://www.oecd.org/health/health- systems/Unmet-Needs-for-Health-Care-Brief-2020.pdf, accessed 26 January 2024). 264 OECD (2021). Length of hospital stay. The Organisation for Economic Co- operation and Development. (https://data.oecd.org/healthcare/length- of-hospital-stay.htm, accessed 8 April 2023). Office of Insurance Commission (2007). Insurance Business Regulation and support Act B.E. 2550. (https://www.oic.or.th/web-upload/1xf f0d34e409a13ef56eea54c52a291126/filecenter/files/362-5141.pdf, accessed 26 July). Office of National Higher Education Science Research and Innovation Policy Council (2017). Research and development investment in Thailand B.E. 2543 - 2560. (https://stiic.sti.or.th/stat/ind-rd/rd-t001/, accessed 23 May 2023). Office of National Higher Education Science Research and Innovation Policy Council (2022). NXPO revealed that Thailand’s R&D investment continuously growing, even in the COVID-19 pandemic. (https://www. nxpo.or.th/th/11221/, accessed 23 May 2023). Office of Permanent secretary (2010). Guideline for increasing salary and special renumeration of civil servants of the Office of Permanent secretary, Ministry of Public Health. (https://ayo.moph.go.th/personal/ file_upload/subblocks/ว14มค54_แนบคู่มือเลื่อนเงินเดือนข้าฯ.pdf, accessed 8 April 2023). Office of Permanent Secretary (2020). Organization chart B.E. 2563. (https:// ops.moph.go.th/public/index.php/aboutus/structure, accessed 22 May 2023). Office of the Decentralization to the Local Government Organization Committee (2021). Annual report B.E. 2564. (https://odloc.go.th/เอกสาร เผยแพร่/รายงานประจำาปี/, accessed 26 January 2024). Office of the National Economics and Social Development Council (2023). Loan for COVID-19 responses: three programmes allocation. (http:// thaime.nesdc.go.th/, accessed 10 May 2023). Osornprasop S, Phulkerd S, Gowachirapant S (2018). Lessons learned from Thailand’s obesity prevention and control policies. The World Bank. (https://documents1.worldbank.org/curated/en/397481548340562764/ pdf/Lessons-Learned-from-Thailands-Obesity-Prevention-and- Control-Policies.pdf, accessed 26 January 2024). Oxley H, MacFarlan M (1994). Health care reform controlling spending and increasing efficiency. (https://www.oecd-ilibrary.org/content/ paper/338757855057, accessed 26 January 2024). 265 Pagaiya N, Kongkam L, Worarat W, Sriratana S, Wongwinyou K (2012). Rural retention of medical graduates trained by the collaborative project to increase rural doctors (CPIRD). Journal of Health Systems Research. 6(2):219-27. Pairojkul S (2021). Network of Primary Palliative Care in Thailand: A Prototype Driven by Education. In: Silbermann M editor Palliative Care for Chronic Cancer Patients in the Community: Global Approaches and Future Applications. Springer International Publishing; 521-31. (https://doi.org/10.1007/978-3-030-54526-0_47 Pangma A (2012). Past-present-future of emergency medical system in Thailand (presentation slides). International conference on trends in emergency, trauma and prehospital care 25-27 April 2012 in Phuket, Papanicolas I, Rajan D, Karanikolos M, Soucat A, Figueras J (2022). European observatory health policy series. In: Papanicolas I, Rajan D, Karanikolos M, Soucat A, Figueras J editors. Health system performance assessment: A framework for policy analysis. European Observatory on Health Systems and Policies; Patanavanich R, Glantz S (2021). Successful countering of tobacco industry efforts to overturn Thailand’s ENDS ban. Tob Control. 30(e1):e10-e9. https://doi.org/10.1136/tobaccocontrol-2020-056058 Patcharanarumol W, Panichkriangkrai W, Sommanuttaweechai A, Hanson K, Wanwong Y, Tangcharoensathien V (2018). Strategic purchasing and health system efficiency: a comparison of two financing schemes in Thailand. PLOS ONE. 13(4):e0195179. https://doi.org/10.1371/journal. pone.0195179 Patcharanarumol W, Tangcharoensathien V, Chotchoungchatchai S, Rajan D, Siddiqi S (2022). Chapter 29 - embedding people’s voice and ensuring participatory governance. In: Siddiqi S, Mataria A, Rouleau KD, Iqbal M editors. Making Health Systems Work in Low and Middle Income Countries: Textbook for Public Health Practitioners. Cambridge University Press; https://www.cambridge.org/core/books/abs/ making-health-systems-work-in-low-and-middle-income-countries/ embedding-peoples-voice-and-ensuring-participatory-governance/ D360287920A51A9CCEDF04EFA54E5FD2 Patcharanarumol W, Tangcharoensathien V, Limwattananon S, Panichkriangkrai W, Pachanee K, Poungkantha W, et al. (2011). Why and how did Thailand achieve good health at low cost? In: Balabanova D, McKee M, Mills A editors. “Good health at low cost” 25 years on. What makes a successful health system? ed. London School of Hygiene & Tropical Medicine; 193-223. 266 Patcharanarumol W, Thammatacharee N, Kittidilokkul S, Topothai T, Thaichinda C, Suphanchaimat R, et al. (2013). Thailand’s HIV/AIDS program after weaning-off the global fund’s support. BMC Public Health. 13(1):1008. https://doi.org/10.1186/1471-2458-13-1008 Petrakaat P, Taweerat R, CHankitiwat V (2010). Thai traditional medicine and alternative medicine care policy. In: Thai traditional medicine and alternative health profile B.E. 2552-2553. https://www.hiso.or.th/hiso/ picture/reportHealth/report/ThaihealthProfileT2010.pdf Pharmacy Council of Thailand (2022). Certificate of doctor of pharmacy accredited by the Pharmacy Council of Thailand in 2023. (https://www. pharmacycouncil.org/index.php?option=content_detail&menuid=35&ite mid=2874&catid=0, accessed 31 March 2023). Pharmacy Council of Thailand (2023). The office of community pharmacy accreditation (Thailand) (https://papc.pharmacycouncil.org/index.php?o ption=aboutus&subpage=aboutus, accessed 30 May 2023). Phonsuk P, Vongmongkol V, Ponguttha S, Suphanchaimat R, Rojroongwasinkul N, Swinburn BA (2021). Impacts of a sugar sweetened beverage tax on body mass index and obesity in Thailand: a modelling study. PLoS One. 16(4):e0250841. https://doi.org/10.1371/ journal.pone.0250841 Phulkerd S, Thongcharoenchupong N, Chamratrithirong A, Soottipong Gray R, Prasertsom P (2020). Changes in population-level consumption of taxed and non-taxed sugar-sweetened beverages (SSB) after Implementation of SSB excise tax in Thailand: a prospective cohort study. Nutrients. 12(11):3294. https://doi.org/10.3390/nu12113294 Phumart P, Phodha T, Thamlikitkul V, Riewpaiboon A, Prakongsai P, Limwattananon S (2012). Health and economic impacts of antimicrobial resistant infections in Thailand : a preliminary study. Journal of Health Systems Research. 6(3):352-60. Pinna C, Kaewkungwal J, Hattasingh W, Swaddiwudhipong W, Methakulchart R, Moungsookjareoun A, et al. (2020). Evaluation of immunization services for children of migrant workers along Thailand-Myanmar border: compliance with global vaccine action plan (2011-2020). Vaccines. 8(11):68. https://doi.org/https://doi.org/10.3390/ vaccines8010068 Pinyopornpanich B, Suchatsoonthorn C, Ruangrattanatrai W (2022). The national public health reforms and the challenges of primary care service systems. Disease Control Journal. 48(3):667-79. https://doi. org/10.14456/dcj.2022.56 267 Piromchai P, Jaruchinda S, Atchariyasathian V, Yimtae K, Nivatwongs S, Sirirattanapan J, et al. (2022). Cochlear implants registry in Thailand – phase 3. Institute HSR. https://kb.hsri.or.th/dspace/ handle/11228/5757?locale-attribute=en, Pitayarangsarit S, Tangcharoensathien V (2002). Private health insurance. In: Pramualratana P, Wibulpolprasert S editors. Health insurance systems in Thailand. Health Systems Research Institute; 94–112. https://kb.hsri. or.th/dspace/handle/11228/946?src=%2Fdspace%2Fdiscover%3Frpp% 3D10%26etal%3D0%26query%3DHealth%2Binsurance%2Bsystems%2 Bin%2BThailand%26group_by%3Dnone%26page%3D2&offset=5&firstI tem=&lastItem= Pochaisan O, Pattanarattanamolee R, Pongphuttha W, Chadbunchachai W, Nakahara S (2021). Development of an emergency medical services system in Thailand: roles of the universal health coverage and the national lead agency. Emergency Medicine Australasia. 33(14):756-8. https://doi.org/10.1111/1742-6723.13794 Pongpirul K (2020). Village health volunteers in Thailand. In: Bugembe H editor Health for the People: National Community Health Worker Programs from Afghanistan to Zimbabwe. CHW Central; 335-404. https://chwcentral.org/wp-content/uploads/2021/11/Health_for_the_ People_Natl_Case%20Studies_Oct2021.pdf Pongutta S, Suphanchaimat R, Patcharanarumol W, Tangcharoensathien V (2019). Lessons from the Thai Health Promotion Foundation. Bull World Health Organ. 97(3):213-20. https://doi.org/10.2471/blt.18.220277 Post Reporters (2023). Calls for reforms to retain Thai nurses. (https://www. bangkokpost.com/thailand/general/2588044/calls-for-reforms-to- retain-thai-nurses, accessed 26 January 2024). Prakongsai P, Limwattananon S, Tangcharoensathien V (2009). The equity impact of the universal coverage policy: lessons from Thailand. Adv Health Econ Health Serv Res. 21:57-81. Prakongsai P, Pachanee K, Wongphan T, Mahawithitwong P, Kositamongkol P, Janrungsee S, et al. (2020). Economic evaluation of liver transplantation for moderate to severe liver cirrhosis patients in universal health coverage. (https://kb.hsri.or.th/dspace/handle/11228/ 5204?src=%2Fdspace%2Fhandle%2F11228%2F1%2Fdiscover%3Fquery %3Dliver%2Btransplantation%2B%26term%3D1&offset=2&firstItem=& lastItem=, accessed 22 May 2023). 268 Prakongsai P, Patcharanarumol W, Tisayatikom K, Tangcharoensathien V (2002). Capitation rate of the universal health care coverage for the fiscal year B.E.2546. Journal of Health Science. 11:599–613. https://www.ihppthaigov.net/publication/ capitationrateoftheuniversalhealthcarecoverageforthefiscalyear2546 Prakongsai P, Suthiart A, Sirirat B (2016). Thailand health profile 2011- 2015. (https://www.hiso.or.th/hiso5/report/thp2015thai.php, accessed 8 April 2023). Primary Health Care Division (2021). Benefit package and welfare (for village health volunteer). (http://phc.moph.go.th/www_hss/ frontend/theme/view_information.php?Submit=Clear&ID_Inf_Nw_ Category=24#a_0000000024_0040, accessed 12 May 2023). Rajan D, Mathurapote N, Putthasri W, Posayanonda T, Pinprateep P, Courcelles Sd, et al. (2017). The triangle that moves the mountain: nine years of Thailand’s national health assembly (2008-2016). https://www. who.int/publications/i/item/WHO-UHC-HGF-HGS-2017.1, World Health Organization, Rajaratnam JK, Marcus JR, Levin-Rector A, Chalupka AN, Wang H, Dwyer L, et al. (2010). Worldwide mortality in men and women aged 15–59 years from 1970 to 2010: a systematic analysis. The Lancet. 375(9727):1704-20. Rajatanavin N, Tuangratananon T, Suphanchaimat R, Tangcharoensathien V (2021). Responding to the COVID-19 second wave in Thailand by diversifying and adapting lessons from the first wave. BMJ global health. 6(7):e006178. Rajatanavin N, Witthayapipopsakul W, Vongmongkol V, Saengruang N, Wanwong Y, Marshall AI, et al. (2022). Effective coverage of diabetes and hypertension: an analysis of Thailand’s national insurance database 2016-2019. BMJ Open. 12(12):e066289. https://doi. org/10.1136/bmjopen-2022-066289 Rasanathan K, Posayanonda T, Birmingham M, Tangcharoensathien V (2012). Innovation and participation for healthy public policy: the first national health assembly in Thailand. Health Expect. 15(1):87-96. https://doi. org/10.1111/j.1369-7625.2010.00656.x Regional Office for South-East Asia (2017). WHO country cooperation strategy, Thailand: 2017–2021. (https://apps.who.int/iris/handle/10665/255510, accessed 12 May 2023). 269 Riewpaiboon A, Chatterjee S, Riewpaiboon W, Piyauthakit P (2011). Disability and cost for diabetic patients at a public district hospital in Thailand. International Journal of Pharmacy Practice. 19(2):84-93. Riewpaiboon A, Riewpaiboon W, Ponsoongnern K, Van den Berg B (2009). Economic valuation of informal care in Asia: a case study of care for disabled stroke survivors in Thailand. Social science & medicine. 69(4):648-53. Riewpaiboon W, Chuengsatiansup K, Gilson L, Tangcharoensathien V (2005). Private obstetric practice in a public hospital: mythical trust in obstetric care. Soc Sci Med. 61(7):1408-17. https://doi.org/10.1016/j. socscimed.2004.11.075 Rohde J, Cousens S, Chopra M, Tangcharoensathien V, Black R, Bhutta ZA, et al. (2008). 30 years after Alma-Ata: has primary health care worked in countries? Lancet. 372(9642):950-61. https://doi.org/10.1016/s0140- 6736(08)61405-1 Rojanapithayakorn W, Pokpermdee P, Suchatsoonthorn C (2019). Thailand health profile 2016-2017. (https://www.hiso.or.th/hiso5/report/ thp2017thai.php, accessed 8 April 2023). Roma W, Kloyiam S, Sookawong W, Kaew-Amdee T, Tunnung A, Khampang R, et al. (2019). Thai health literacy survey (THL-S) of Thais aged 15 years and above, 2019. Health Systems Research Institute. (https://kb.hsri. or.th/dspace/handle/11228/5216). Royal Thai Government Gazette (1992). Road Accident Victims Protection Act B.E. 2535. (http://web.krisdika.go.th/data/outsitedata/outsite21/file/ Road_Accident_Victims_Protection_Act_BE_2535_(1992).pdf, accessed 30 May 2023). Royal Thai Government Gazette (2003). Elderly Act B.E. 2546. (https://www. dop.go.th/download/laws/regulation_th_20160807155130_1.pdf, accessed 30 April 2023). Royal Thai Government Gazette (2005a). Emergency decree on public administration in emergency situation, B.E. 2548. (http://web.krisdika. go.th/data/document/ext810/810259_0001.pdf, accessed 12 May 2023). Royal Thai Government Gazette (2005b). Regulation issued under section 9 of the emergency decree on public administration in emergency situations B.E. 2548 (No. 15). (https://www.prd.go.th/th/content/ category/detail/id/37/iid/6350, accessed 12 May 2023). 270 Royal Thai Government Gazette (2007a). Disaster Prevention and Mitigation Act B.E. 2550. (https://faolex.fao.org/docs/pdf/tha89587.pdf, accessed 12 May 2023). Royal Thai Government Gazette (2007b). Powerment of Persons with Disabilities Act B.E. 2550. (http://web1.dep.go.th/sites/default/ files/files/law/EMPOWERMENT%20OF%20PERSONS%20WITH%20 DISABILITIES%20ACT%2C%20B.E.%202550%20%282007%29.pdf, accessed 30 April 2023). Royal Thai Government Gazette (2008a). Medical Device Act B.E. 2551. (http:// nih.dmsc.moph.go.th/law/pdf/001.pdf, accessed 26 January 2024). Royal Thai Government Gazette (2008b). The second decentralization action plan B.E.2551. Office of Prime Minister. (https://odloc.go.th/plan/, accessed 24 January 2024). Royal Thai Government Gazette (2009). Ministerial regulations on determining damage to be compensated with initial compensation amount, request for and payment of initial compensation (second edition) B.E. 2552. (http://www.supremecourt.or.th/assets/files/eco/กฏกระทรวง%20กำาหนด ความเสียหายที่จะได้รับค่าเสียหายเบื้องต้น.pdf, accessed 12 March 2024). Royal Thai Government Gazette (2012a). Announcement of Ministry of Public Health on individuals who are exempted from copayment B.E. 2555. (https://www.ratchakitcha.soc.go.th/DATA/PDF/2555/E/134/43.PDF, accessed 26 January 2024). Royal Thai Government Gazette (2012b). Announcement of National Health Security Office on copayment B.E. 2555. (https://dl.parliament. go.th/bitstream/handle/20.500.13072/326812/550901_52_134งพิเศษ. pdf?sequence=1, accessed 26 January 2024). Royal Thai Government Gazette (2015). Communicable Diseases Act B.E. 2558. (https://ddc.moph.go.th/uploads/ckeditor/ c74d97b01eae257e44aa9d5bade97baf/files/001_2gcd.pdf, accessed 12 May 2023). Royal Thai Government Gazette (2017a). Annoucement of Ministry of Labour regarding the provincial offices of the Social Security Office. (http:// www.oic.go.th/FILEWEB/CABINFOCENTER2/DRAWER056/GENERAL/ DATA0000/00000305.PDF, accessed 26 January 2024). Royal Thai Government Gazette (2017b). Ministerial regulation on a division of the administrative units of the Office of the Permanent Secretary B.E. 2560 (https://opdc.moph.go.th/uploads/rules/44820_แบ่งส่วนราชการ%20 สป.สธ..pdf, accessed 22 May 2023). 271 Royal Thai Government Gazette (2017c). National strategy 2018-2037. (http:// nscr.nesdc.go.th/wp-content/uploads/2019/10/National-Strategy-Eng- Final-25-OCT-2019.pdf, accessed 22 May 2023). Royal Thai Government Gazette (2018). Budgetary Procedures Act B.E. 2561. (http://www.bb.go.th/topic-detail.php?id=5649&mid=791&catID=0, accessed 12 May 2023). Royal Thai Government Gazette (2018 ). National Vaccine Security Act B.E. 2561. (http://nvi.go.th/AboutNVI/Regulation/2563/63_09_law_1_1_2. pdf, accessed 26 January 2024). Royal Thai Government Gazette (2019a). Amendment to the Ministry, Departments, and Bureaus Act 2019. (https://www.nxpo.or.th/th/ wp-content/uploads/2019/06/01_พ.ร.บ.ปรับปรุงกระทรวง-ทบวง-กรม-ฉบับที่-19- พ.ศ.-2562.pdf, accessed 8 April 2023). Royal Thai Government Gazette (2019b). Announcement of the primary health care system committee on the characteristics of health facilitie and network of health facilitie to be registered, registration, and zoning for primary care unit or primary care network B.E. 2562. (https://ratchakitcha.soc.go.th/documents/17110366.pdf, accessed 26 January 2024). Royal Thai Government Gazette (2019c). Central budget expenditure List of reserves for emergency or necessary expenses, B.E. 2562. (http://www.buengkandla.go.th/system_files/248/ d0e4d6a778b04ba70f4700f46b9d0145.pdf, accessed 12 May 2023). Royal Thai Government Gazette (2019d). Medical Device Act (second edition) B.E. 2562. (https://www.nstda.or.th/rqm/images/ PoliciesRegGuidelines/FDA/MedicalDevices-ACT2562.pdf, accessed 26 January 2024). Royal Thai Government Gazette (2019e). Primary Health Care System Act B.E. 2562. (https://ratchakitcha.soc.go.th/documents/17087273.pdf, accessed 26 January 2024). Royal Thai Government Gazette (2020a). Announcement of Ministry of Public Health on the procurement of vaccines for the prevention of COVID-19 or coronavirus disease B.E. 2563. (https://ratchakitcha.soc.go.th/ documents/17148192.pdf, accessed 12 May 2023). Royal Thai Government Gazette (2020b). Emergency decree on the provision of financial assistance for entrepreneurs affected by the COVID-19 pandemic B.E. 2563. (https://www.tilleke.com/insights/thailand- exempts-sme-soft-loans-mortgage-registration-fee-requirements/, accessed 12 May 2023). 272 Royal Thai Government Gazette (2020c). Order of the prime minister no. 5/2563 on the establishment of the special unit according to the emergency decree on public administration in emergency situation, B.E. 2548. (https://www.nsc.go.th/wp-content/uploads/2020/05/CV19- 05.pdf, accessed 12 May 2023). Royal Thai Government Gazette (2020d). Regulations issued pursuant to section 9 of the emergency decree B.E. 2548 (Volumn 1). (https:// www.nsc.go.th/wp-content/uploads/2020/05/CV19-06.pdf, accessed 12 May 2023). Royal Thai Government Gazette (2022a). Announcement of the 13th national economic and social development plan (B.E. 2566-2570). (https:// www.nesdc.go.th/download/Plan13/Doc/Plan13_Final.pdf, accessed 22 May 2023). Royal Thai Government Gazette (2022b). Announcement of the national health security committee regarding the types and coverage of public health services B.E. 2565. (https://www.nhso.go.th, accessed 2 June 2023). Royal Thai Government Gazette (2023). Announcement of the Prime Minister’s Office on the master plan under the national strategy (B.E. 2566-2580) (additional revised version). (http://nscr.nesdc.go.th/ wp-content/uploads/2023/03/masterplan_updated2023_080363.pdf, accessed 22 May 2023). Sa-ringkan O, Boonthum A, Kongsin S, Jiamton S, Prakongsai P (2021). Cost per admission day of intermediate care among patients diagnosed with cerebrovascular diseases in a tertiary hospital. Journal of health systems research. 15(4):407-21. https://kb.hsri.or.th/dspace/ bitstream/handle/11228/5451/hsri-journal-v15n4-p407-421. pdf?sequence=1&isAllowed=y Sachdev S, Viriyathorn S, Chotchoungchatchai S, Patcharanarumol W, Tangcharoensathien V (2022). Thailand’s COVID-19: how public financial management facilitated effective and accountable health sector responses. The International Journal of Health Planning and Management. 37(4):1894-906. https://doi.org/https://doi. org/10.1002/hpm.3464 Sachs JD, Lafortune G, Kroll C, Fuller G, Woelm F (2022). Sustainable development report 2022 from crisis to sustainable development: the SDGs as roadmap to 2030 and beyond. Cambridge University Press. https://s3.amazonaws.com/sustainabledevelopment.report/2022/2022- sustainable-development-report.pdf 273 Sakamoto H, Aya I, Tangcharoensathien V, Witthayapipopsakul W, Marshall AI, Chotchoungchatchai S, et al. (2023). The role of the private sector: challenges and opportunities in Asia for achieving universal health coverage. New Delhi: World Health Organization Regional Office for South-East Asia (https://apo.who.int/publications/i/item/the-role- of-the-private-sector-in-asia-challenges-and-opportunities-for- achieving-universal-health-coverage, accessed Sakulbumrungsil R, Kessomboon N, Kanchanapibool I, Manomayitthikan T, Thathong T, Patikorn C, et al. (2020). The impact of drug financing system under Thailand universal health coverage (UHC) on the performances of drug system. Journal of Health Science. 29(Special issue):S59. https://www.hsri.or.th/sites/default/files/attachment/JHS- journal-v29-p59.pdf Samutachak B, Ford K, Tangcharoensathien V, Satararuji K (2023). Role of social capital in response to and recovery from the first wave of COVID-19 in Thailand: a qualitative study. BMJ Open. 13(1):e061647. https://doi.org/10.1136/bmjopen-2022-061647 Sinam P, Julchoo S, Phaiyarom M, Kunpeuk W, Pudpong N, Suphanchaimat R (2021). A literature review of health status and agreements or laws for urban refugees and asylum seekers in Thailand. Journal of Health Systems Research 15(4):511-24. Sirilak S (2020). Thailand’s experience in the COVID-19 response 2020. (https://ddc.moph.go.th/viralpneumonia/eng/file/pub_doc/LDoc9.pdf, accessed 26 January 2024). Slutsky J, Tumilty E, Max C, Lu L, Tantivess S, Hauegen RC (2016). Patterns of public participation: opportunity structures and mobilization from a cross-national perspective. Journal of Health Organization and Management. 30(5). https://doi.org/10.1108/JHOM-03-2016-0037 Social Security Office (2017). In case of dental care (tooth extraction, dental filling, tooth scaling, wisdom tooth extraction, and dentures). (https://www.sso.go.th/wpr/main/privilege/กองทุนประกันสังคม_detail_ detail_1_125_0/24_24, accessed 18 March 2024). Social Security Office (2020). SSO annual report B.E. 2563. (https:// www.sso.go.th/wpr/assets/upload/files_storage/sso_th/ b5ccdc72a0f03b95b8e3ac1df3f80025.pdf, accessed 26 Jan 2024). Social Security Office (2021a). Complaint management standard operation procedure. (https://www.sso.go.th/wpr/assets/upload/files_storage/ sso_th/afb5ef97b5d2b3af365c24fda9536376.pdf, accessed 26 January 2024). 274 Social Security Office (2021b). SSO annual report B.E. 2553 - 2564. (https:// www.sso.go.th, accessed 30 May 2023). Social Security Office (2022). Part 8: compensation fund budget (https://www. sso.go.th/wpr/assets/upload/files_storage/sso_th/0f3dc33d831590a2d 3c71acc96f7aa38.pdf, accessed 12 Septermber). Soonthorn S, Ngamkham S, Tanglakmankhong K, Wattanakul B, Wattanakul S (2022). The evaluation of the mailed-order medication system for patients with diabetes mellitus during the COVID-19 pandemic in Thailand. (https://kb.hsri.or.th/dspace/handle/11228/5769?src=%2Fdsp ace%2Fhandle%2F11228%2F1%2Fdiscover%3Fquery%3DThe%2BEval uation%2Bof%2Bthe%2BMailed-order%2BMedication%2BSystem%2B for%2BPatients%2Bwith%2BDiabetes%2BMellitus%2B%26submit%3D &offset=0&firstItem=true&lastItem=true, accessed 30 May 2023). Sopitarchasak S, Adulyanon S, Lorthong T (2015). Thai Health Promotion Foundation: innovative enabler for health promotion. World Health & Population. 16(1):62-71. https://www.longwoods.com/product/24316 Southeast Asia Tobacco Control Alliance (2020). End cigarette smoking in Thailand (ECST). (https://timonitor.seatca.org/end-cigarette-smoking- in-thailand-ecst/, accessed 3 April 2023). Sriratanaban J, Ngamkiatpaisarn S, Charoenmukayananta S (2020). Association between hospital accreditation and outcomes: the analysis of in-hospital mortality from the national claims data of the universal coverage scheme in Thailand. Qual Manag Health Care. 29(3):150-7. https://doi.org/10.1097/qmh.0000000000000256 Srithamrongsawat S (2010). Assessment of financial mangement of CUP and developing information system for financial management of primary care. Health Systems Research Institute. (https://kb.hsri.or.th/dspace/ handle/11228/3341?locale-attribute=th, accessed 24 January 2024). Srithamrongsawat S, Bundhamcharoen K, Sasat S, Odton P, Ratkjaroenkhajorn S (2009). Projection of demand and expenditure for institutional long-term care in Thailand. Health Insurance System Research Office. (https://www.academia.edu/1351987/Projection_ of_demand_and_expenditure_for_institutional_long_term_care_in_ Thailand, accessed 30 May 2023). Strategy and Planning Division (2000). Report of public health resource B.E. 2543. Ministry of Public Health, Nonthaburi. Strategy and Planning Division (2011a). Public health statistics 2011. Ministry of Public Health. (https://spd.moph.go.th/wp-content/uploads/2022/11/ Hstatistic54.pdf, accessed 30 May 2023). 275 Strategy and Planning Division (2011b). Report of public health resource B.E. 2554. Ministry of Public Health. (https://spd.moph.go.th/wp- content/uploads/2022/12/Report-Health-Resource-54.pdf, accessed 15 May 2023). Strategy and planning Division (2012a). Handbook for sub-district health promotion hospital management. Ministry of Public Health. (http:// www.stopcorruption.moph.go.th/application/editors/userfiles/ files/รวมเอกสารเกี่ยวกับประวัติและความเป็นมา%20ของ%20รพ_สต.pdf, accessed 12 May 2023). Strategy and Planning Division (2012b). Report of public health resource B.E. 2555. Ministry of Public Health. (https://spd.moph.go.th/wp- content/uploads/2022/12/Report-Health-Resource-55.pdf, accessed 15 May 2023). Strategy and Planning Division (2013). Report of public health resource B.E. 2556. Ministry of Public Health. (https://spd.moph.go.th/public-health- resources-report/, accessed 8 April 2023). Strategy and Planning Division (2014). Report of public health resource B.E. 2557. Ministry of Public Health. (https://spd.moph.go.th/wp- content/uploads/2022/12/Report-Health-Resource-57.pdf, accessed 30 May 2023). Strategy and Planning Division (2015). Report of public health resource B.E. 2558. Ministry of Public Health. (https://spd.moph.go.th/wp- content/uploads/2022/12/Report-Health-Resource-58.pdf, accessed 30 May 2023). Strategy and Planning Division (2016). Report of public health resource B.E. 2559. Ministry of Public Health. (https://spd.moph.go.th/wp- content/uploads/2022/12/Report-Health-Resource-59.pdf, accessed 30 May 2023). Strategy and Planning Division (2018a). Report of public health resource B.E. 2561. Ministry of Public Health. (https://spd.moph.go.th/wp- content/uploads/2022/12/Report-Health-Resource-61.pdf, accessed 8 April 2023). Strategy and Planning Division (2018b). Twenty-year national strategic plan for public health (2017-2036) first revision 2018. Ministry of Public Health. (https://spd.moph.go.th/wp-content/uploads/2022/09/ Ebook-MOPH-20-yrs-plan-2017-Final-Eng-120961.pdf, accessed 22 May 2023). 276 Strategy and Planning Division (2020). Report of public health resource B.E. 2563. Ministry of Public Health. (https://spd.moph.go.th/wp- content/uploads/2022/12/Report-Health-Resource-63.pdf, accessed 30 May 2023). Strategy and Planning Division (2021a). Public health statistics 2021. Ministry of Public Health. (https://spd.moph.go.th/wp-content/uploads/2022/11/ Hstatistic64.pdf, accessed 23 May 2023). Strategy and Planning Division (2021b). Report of public health pesonels data B.E. 2564. Ministry of Public Health. (http://bps.moph.go.th, accessed 30 May 2023). Strategy and Planning Division (2021c). Report of public health resource B.E. 2564. Ministry of Public Health. (https://spd.moph.go.th/wp- content/uploads/2022/12/Report-Health-Resource-64.pdf, accessed 8 April 2023). Strategy and Planning Division (2022a). Key performance indicators of Ministry of Public Health fiscal year B.E. 2565. Ministry of Public Health. (https://spd.moph.go.th/wp-content/uploads/2022/08/PDF- File_3.pdf, accessed 26 January 2024). Strategy and Planning Division (2022b). Public health statistics B.E. 2546 - 2553 (2003-2010). Ministry of Public Health. (https://spd.moph.go.th/ public-health-statistics/, accessed 23 May 2023). Strategy and Planning Division (2022c). Report of public health resource B.E. 2554-2564 (2011-2021). Ministry of Public Health. (https://spd.moph. go.th/public-health-resources-report/, accessed 30 May 2023). Strategy and Planning Division (2022d). Report of public health resource B.E. 2565. Ministry of Public Health. (https://spd.moph.go.th/wp- content/uploads/2023/07/Report-Health-Resource-65.pdf, accessed 8 December 2023). Suchonwanich N, Laowahutannon T, Luangruangrong P, Techathawat S, Wongtangprasert S (2020). Drug procurement and distribution. Journal of Health Science. 29(Special Issue):S45-S58. https://kb.hsri.or.th/ dspace/bitstream/handle/11228/5243/JHS-v29-jan-feb2020.pdf. pdf?sequence=3&isAllowed=y Sumpradit N, Chongtrakul P, Anuwong K, Pumtong S, Kongsomboon K, Butdeemee P, et al. (2012). Antibiotics smart use: a workable model for promoting the rational use of medicines in Thailand. Bull World Health Organ. 90(12):905-13. https://doi.org/10.2471/blt.12.105445 277 Suphanchaimat R, Kosiyaporn H, Limwattanayingyong A (2019a). Migrant policies in Thailand in light of the universal health coverage: evolution and remaining challenges. OSIR Journal. 12(2):68-74. Suphanchaimat R, Nittayasoot N, Thammawijaya P, Teekasap P, Ungchusak K (2021). Predicted impact of vaccination and active case finding measures to control epidemic of Coronavirus disease 2019 in a migrant-populated area in Thailand. Risk Management and Healthcare Policy. 14:3197. https://pubmed.ncbi.nlm.nih.gov/34377040/ Suphanchaimat R, Prakongsai P, Limwattananon S, Mills A (2016). Impact of the health insurance scheme for stateless people on inpatient utilization in Kraburi hospital, Thailand. Risk Manag Healthc Policy. 9:261-9. https://doi.org/10.2147/rmhp.S117173 Suphanchaimat R, Pudpong N, Prakongsai P, Putthasri W, Hanefeld J, Mills A (2019b). The devil is in the detail-understanding divergence between intention and implementation of health policy for undocumented migrants in Thailand. Int J Environ Res Public Health. 16(6). https://doi. org/10.3390/ijerph16061016 Suphanchaimat R, Putthasri W, Prakongsai P, Tangcharoensathien V (2017). Evolution and complexity of government policies to protect the health of undocumented/illegal migrants in Thailand - the unsolved challenges. Risk Manag Healthc Policy. 10:49-62. https://doi. org/10.2147/rmhp.S130442 Suphanchaimat R, Wisaijohn T, Thammathacharee N, Tangcharoensathien V (2013). Projecting Thailand physician supplies between 2012 and 2030: application of cohort approaches. Human Resources for Health. 11(1):1-11. Surasiengsang S (2004). Private health insurance in Thailand In; Phoolcharoen W (Ed.), National workshop proceedings “wisdom: towards development of universal coverage in Thailand”: part 2: health insurance financing mechanism Health Systems Research Institute (https://kb.hsri.or.th/dspace/bitstream/handle/11228/954/hs1056. pdf?sequence=2&isAllowed=y Suriyawongpaisarn P (2009). Evaluation of emergency medical systems. Health Systems Research Institute, Nonthaburi,. Suwannaprom P, Suttajit S, Plodpai P, Prapaso N, Srisuphan V (2020). Pharmacy workforce: a call for professional cohesion to meet the rising healthcare demand. Journal of Health Science. 29(0):S141-S52. https://thaidj.org/index.php/JHS/article/view/8419 278 Taearrak P, Suksiri N, Kaewwichian R, Tae-arruk K (2008). Review of decentralization in public health, 1999–2007. Journal of Health Systems Research. 2(2):179–94. https://kb.hsri.or.th/dspace/ bitstream/handle/11228/97/hsri-journal-v2n2-p179-194. pdf?sequence=3&isAllowed=y Tangcharoensathien V, Supachutikul A, Lertiendumrong J (1999). The social security scheme in Thailand: what lessons can be drawn? Soc Sci Med. 48(7):913-23. https://doi.org/10.1016/s0277-9536(98)00392-x Tangcharoensathien V, Carroll D, Lekagul A (2022a). Resilient and equitable recovery from the COVID-19 pandemic. BMJ. 376:o311. https://doi. org/10.1136/bmj.o311 Tangcharoensathien V, Faramnuayphol P, Teokul W, Bundhamcharoen K, Wibulpholprasert S (2006). A critical assessment of mortality statistics in Thailand: potential for improvements. Bull World Health Organ. 84(3):233-8. https://doi.org/10.2471/blt.05.026310 Tangcharoensathien V, Harnvoravongchai P, Pitayarangsarit S, Kasemsup V (2000). Health impacts of rapid economic changes in Thailand. Social science & medicine. 51(6):789-807. Tangcharoensathien V, Limwattananon S, Prakongsai P (2007). Improving health-related information systems to monitor equity in health: lessons from Thailand. In: McIntyre D, Mooney G editors. The Economics of Health Equity. Cambridge University Press; 222-46. (https://doi.org/ DOI: 10.1017/CBO9780511544460.012 Tangcharoensathien V, Patcharanarumol W, Suwanwela W, Supangul S, Panichkriangkrai W, Kosiyaporn H, et al. (2020a). Defining the benefit package of Thailand universal coverage scheme: from pragmatism to sophistication. Int J Health Policy Manag. 9(4):133-7. https://doi. org/10.15171/ijhpm.2019.96 Tangcharoensathien V, Sachdev S, Viriyathorn S, Sriprasert K, Kongkam L, Srichomphu K, et al. (2022b). Universal access to comprehensive COVID-19 services for everyone in Thailand. BMJ Global Health. 7(6):e009281. Tangcharoensathien V, Thwin AA, Patcharanarumol W (2017). Implementing health insurance for migrants, Thailand. Bull World Health Organ. 95(2):146-51. https://doi.org/10.2471/blt.16.179606 279 Tangcharoensathien V, Tisayaticom K, Suphanchaimat R, Vongmongkol V, Viriyathorn S, Limwattananon S (2020b). Financial risk protection of Thailand’s universal health coverage: results from series of national household surveys between 1996 and 2015. Int J Equity Health. 19(1):163. https://doi.org/10.1186/s12939-020-01273-6 Tangcharoensathien V, Tisayaticom K, Suphanchaimat R, Vongmongkol V, Viriyathorn S, Limwattananon S (2020c). Financial risk protection of Thailand’s universal health coverage: results from series of national household surveys between 1996 and 2015. International Journal for Equity in Health. 19(1):163. https://doi.org/10.1186/s12939-020-01273-6 Tangcharoensathien V, Vandelaer J, Brown R, Suphanchaimat R, Boonsuk P, Patcharanarumol W (2023). Learning from pandemic responses: Informing a resilient and equitable health system recovery in Thailand. Front Public Health. 11:1065883. https://doi.org/10.3389/ fpubh.2023.1065883 Tangcharoensathien V, Witthayapipopsakul W, Panichkriangkrai W, Patcharanarumol W, Mills A (2018). Health systems development in Thailand: a solid platform for successful implementation of universal health coverage. The Lancet. 391(10126):1205-23. Tantivess S, Gill Walt (2008). The role of state and non-state actors in the policy process: the contribution of policy networks to the scale-up of antiretroviral therapy in Thailand Health Policy and Planning. 23(5):328–38. https://doi.org/10.1093/heapol/czn023 Tantivess S, Teerawattananon Y, Mills A (2009). Strengthening cost- effectiveness analysis in Thailand through the establishment of the health intervention and technology assessment program. Pharmacoeconomics. 27(11):931-45. https://doi.org/10.2165/11314710- 000000000-00000 Tanvejsilp P, Taychakhoonavudh S, Chaikledkaew U, Chaiyakunapruk N, Ngorsuraches S (2019). Revisiting roles of health technology assessment on drug policy in universal health coverage in Thailand: where are we? and what is next? Value in Health Regional Issues. 18:78-82. https://doi.org/https://doi.org/10.1016/j.vhri.2018.11.004 Tanwettiyanont J, Piriyachananusorn N, Sangsoi L, Boonsong B, Sunpapoa C, Tanamatayarat P, et al. (2022). Use of Andrographis paniculata (Burm.f.) Wall. ex Nees and risk of pneumonia in hospitalised patients with mild coronavirus disease 2019: a retrospective cohort study. Frontiers in Medicine. 9. https://doi.org/10.3389/fmed.2022.947373 280 Tarn YH, Hu S, Kamae I, Yang BM, Li SC, Tangcharoensathien V, et al. (2008). Health-care systems and pharmacoeconomic research in Asia-Pacific region. Value Health. 11 Suppl 1:S137-55. https://doi.org/10.1111/ j.1524-4733.2008.00378.x Teerawattananon Y, Tangcharoensathien V, Tantivess S, Mills A (2003). Health sector regulation in Thailand: recent progress and the future agenda. Health Policy. 63(3):323-38. https://doi.org/10.1016/s0168- 8510(02)00140-9 Teerawattananon Y, Tantivess S, Yothasamut J, Kingkaew P, Chaisiri K (2009). Historical development of health technology assessment in Thailand. Int J Technol Assess Health Care. 25 Suppl 1:241-52. https://doi. org/10.1017/s0266462309090709 Tejativaddhana P, sakunphanit T, Chiangchaisakulthai K, Khiaocharoen O, Pholpark A, Chuakhamfoo NN, et al. (2023). Research on the seamless provision of intermediate care (IMC) services pilot sites of the project on seamless health and social services provision for elderly persons (S-TOP). ASEAN Institute for Health Development MU. Tewarit Somkotra (2011). Socioeconomic inequality in self-reported oral health status: the experience of Thailand after implementation of the universal coverage policy. Community Dent Health. 28(2):136-42. https://doi.org/10.1922/CDH_2540Somkotra07 Thai Health Information Standards Development Center (2022a). Lit the FHIR in Thailand by SIL-TH. (https://www.this.or.th/blog/หนังสือ/, accessed 23 May 2023). Thai Health Information Standards Development Center (2022b). Thai medical laboratory terminology (TMLT). (https://www.this.or.th/blog/หนังสือ/, accessed 23 May 2023). Thai Health Information Standards Development Center (2022c). Thai medicines terminology (TMT). (https://www.this.or.th/blog/หนังสือ/, accessed 23 May 2023 ). Thai Health Information Standards Development Center (2022d). Thailand SNOMED CT handbook. (https://www.this.or.th/blog/หนังสือ/, accessed 23 May 2023). Thai Health Information Standards Development Center (2023). Thailand health data standards, foundation of the country digital health. (https:// www.this.or.th/en/this/, accessed 23 May 2023). Thai Health Promotion Foundation (2021). 20 years big changes. (https:// www.thaihealth.or.th/e-book/, accessed 23 May 2023). 281 Thai Health Promotion Foundation (2022). Anual report B.E. 2564. Thai health promotion foundation,. (https://www.thaihealth.or.th/?p=194176, accessed 26 January 2024). Thai Health Promotion Foundation (2022a). Impact of COVID-19 for the health of Thai people in 2022. (https://www.thaihealthreport.com/th/ indicators.php?id=214&y=2565&, accessed 5 May 2023). Thai Traditional Medical Council (2013). Thai Traditional Medical Professions Act, B.E. 2556. (https://thaimed.or.th/download/พรบ-วิชาชีพแพทย์แผนไทย- พ/?wpdmdl=7312&refresh=65d0a55b897b31708172635, accessed 26 January 2024). Thai Traditional Medical Council (2021a). List of institutions offering degree or equivalent certificate programs in applied Thai traditional medicine, accredited by the Thai Traditional Medical Council under the Thai Traditional Medical Profession Act B.E. 2556. (https://thaimed.or.th, accessed 30 May 2023). Thai Traditional Medical Council (2021b). List of institutions or health facilities authorized to transfer knowledge for training in the 330-hour course for Thai traditional medicine assistants. (https://thaimed.or.th, accessed 5 May 2023). Thai Traditional Medical Council (2022). List of institutions offering bachelor’s degree or equivalent certificate programs in Thai traditional medicine accredited by the Thai Traditional Medical Council under the Thai Traditional Medicine Profession Act B.E. 2556. (https://thaimed.or.th, accessed 5 May 2023). Thai Traditional Medical Council (2023). List of institutions or hospitals accredited to transmit knowledge: the institutions for professional training in Thai traditional medicine in accordance with the Thai Traditional Medicine Profession Act B.E. 2556. (https://thaimed.or.th, accessed 30 May 2023). Thailand Board of Investment (2021). A guide to the board of investment 2021. (https://www.boi.go.th/upload/content/BOI-A%20Guide_EN.pdf, accessed 26 January 2024). Thailand Nursing and Midwifery Council (2021). Competencies of registered nurses. (https://www.tnmc.or.th/images/userfiles/files/ Competencies%20of%20Registratered%20Nurses(1).pdf, accessed 12 May 2023). 282 Thailand Nursing and Midwifery Council (2022a). Lists of educational institutions accredited by Thailand Nursing and Midwifery Council (educational institutions with graduates). (https://www.tnmc.or.th/ images/userfiles/files/1_1(32).pdf, accessed 31 March 2023). Thailand Nursing and Midwifery Council (2022b). Lists of educational institutions accredited by Thailand Nursing and Midwifery Council (educational institutions with no graduates yet). (https://www.tnmc. or.th/images/userfiles/files/1_2(29).pdf, accessed 31 March 2023). Thairath Money (2023). The significant drop of social security fund. (https:// www.thairath.co.th/money/economics/thailand_econ/2708511, accessed 26 January 2024). Thammatacharee N, Tisayaticom K, Suphanchaimat R, Limwattananon S, Putthasri W, Netsaengtip R, et al. (2012). Prevalence and profiles of unmet healthcare need in Thailand. BMC Public Health. 12(1):923. https://doi.org/10.1186/1471-2458-12-923 The Insurance Premium Rating Bureau (2022). Overall loss ratio by line of business (2016–2021). (https://www.tgia.org/upload/NonLifeInsStat/1/ insure_2184.pdf, accessed 18 March 2024). The Nation (2023). Thai public healthcare system reeling with large number of resignations. (https://www.nationthailand.com/thailand/ general/40028278, accessed 26 January 2024). Thongkhamcharoen R, Phungrassami T, Atthakul N (2013). Palliative care and essential drug availability: Thailand national survey 2012. Journal of Palliative Medicine. 16(5):546-50. https://doi.org/10.1089/ jpm.2012.0520 Tobacco Reporter (2023). Activists urge Thailand to lift e-cigarette ban. (https://tobaccoreporter.com/2023/04/24/activists-urge-thailand-to- lift-e-cigarette-ban/, accessed 26 January 2024). Topothai C, Tangcharoensathien V (2021). Achieving global targets on breastfeeding in Thailand: gap analysis and solutions. Int Breastfeed J. 16(1):38. https://doi.org/10.1186/s13006-021-00386-0 Topothai T, Suphanchaimat R, Topothai C, Tangcharoensathien V, Cetthakrikul N, Waleewong O (2022). Thailand achievement of SDG indicator 4.2.1 on early child development: an analysis of the 2019 multiple indicator cluster survey. Int J Environ Res Public Health. 19(13). https://doi. org/10.3390/ijerph19137599 283 Tortermvasana K (2021). NT, GBDi join hands to launch national healthcare database. (https://www.bangkokpost.com/business/general/2186839/ nt-gbdi-join-hands-to-launch-national-healthcare-database, accessed 26 January 2024). Treerutkuarkul A (2008). Thailand’s unsung heroes. Bull World Health Organ. 86(1):5-6. Umeda S (2021). Thailand: abortion in first trimester legalized. (https://www. loc.gov/item/global-legal-monitor/2021-03-01/thailand-abortion-in- first-trimester-legalized/, accessed 24 April 2023). UNAIDS (2004). Thailand 2004 update. epidemiological fact sheets on HIV/ AIDS and sexually transmitted infections. (http://data.unaids.org/ Publications/Fact-Sheets01/thailand_en.pdf, accessed 30 July 2014). UNESCO Institute for Statistics (2022). School enrollment, primary (% gross) - Thailand. Institute for Statistics (UIS). (https://data.worldbank.org/ indicator/SE.PRM.ENRR?locations=TH, accessed 24 April 2023). United Nations Children’s Fund (2020). UNICEF data warehouse. United Nations Children’s Fund,. (https://data.unicef.org/resources/data_ explorer/unicef_f/?ag=UNICEF&df=GLOBAL_DATAFLOW&ver=1.0&dq=. ED_ANAR_L1..&startPeriod=2019&endPeriod=2023, accessed 2 May ). United Nations Children’s Fund (2023). Trends in estimates of maternal mortality ratio (MMR; maternal deaths per 100,000 live births) maternal deaths and lifetime risk of maternal death, 2000-2020. https://data.unicef.org/wp-content/uploads/2023/02/MMR-maternal- deaths-and-LTR_MMEIG-trends_2000-2020_released-Feb_2023.xlsx United Nations Commission on Human Rights (1990). Convention on the rights of the child., 7 March 1990, E/CN.4/RES/1990/74. (https://www. refworld.org/docid/3b00f03d30.html, accessed 30 May 2023). United Nations General Assembly (1948). Universal declaration of human rights. (https://www.refworld.org/docid/3ae6b3712c.html accessed 30 May 20232). United Nations General Assembly (1965). International convention on the elimination of all forms of racial discrimination, 21 December 1965, United Nations, Treaty Series, vol. 660, p. 195. (https://www.refworld. org/docid/3ae6b3940.html, accessed 30 May 2023). United Nations General Assembly (1966a). International covenant on civil and political rights, 16 December 1966, United Nations, Treaty Series, vol. 999, p. 171. (https://www.refworld.org/docid/3ae6b3aa0.html, accessed 30 May 2023). 284 United Nations General Assembly (1966b). International แovenant on economic, social and cultural rights, 16 December 1966, United Nations, Treaty Series, vol. 993, p. 3. (https://www.refworld.org/ docid/3ae6b36c0.html, accessed 30 May 2023). United Nations General Assembly (1979). Convention on the elimination of all forms of discrimination against women, 18 December 1979, United Nations, Treaty Series, vol. 1249, p. 13. (https://www.refworld.org/ docid/3ae6b3970.html, accessed 30 May 2023). United Nations General Assembly (2007). Convention on the rights of persons with disabilities : resolution / adopted by the general assembly, 24 January 2007, A/RES/61/106. (https://www.refworld.org/ docid/45f973632.html, accessed 30 May 2023). United Nations General Assembly (2017). Resolution adopted by the general assembly on work of the statistical commission pertaining to the 2030 agenda for sustainable development (A/RES/71/313), annex. (https:// documents.un.org/doc/undoc/gen/n17/207/63/pdf/n1720763.pdf?token =hx4uLTi5qWj6H6m48K&fe=true, accessed 26 January 2024). United Nations Geospatial (2009). Thailand. (https://www.un.org/geospatial/ content/thailand, accessed 3 April 2023). United Nations Office for Disaster Risk Reduction (2020). UNDRR annual report 2020. United Nations Office for Disaster Risk Reduction,. (https://www.undrr.org/publication/undrr-annual-report-2020, accessed 26 January 2024). United Nations Population Fund (2011). Impact of demographic change in Thailand. In. Bangkok: UNFPA. United Nations Population Fund (2021). Safe birth for all Thailand project. (https://thailand.unfpa.org/sites/default/files/pub-pdf/safebirthforall_ report_final.pdf, accessed 26 January 2024). United Nations Women, International Labour Organization (2020). Public attitudes towards migrant workers in Japan, Malaysia, Singapore, and Thailand (https://www.ilo.org/wcmsp5/groups/public/---asia/- --ro-bangkok/documents/publication/wcms_732443.pdf, accessed 3 April 2023). University of Notre Dame (2021). Rank countries by ND-GAIN country index, vulnerability and readiness. (https://gain.nd.edu/our-work/country- index/rankings/, accessed 26 January 2024). 285 Uphayokin P, Intralawan A, Udomsil T, Jenwarakul R (2005). Perception and media exposure to health care in Chiang Rai. Health Systems Research Institute. (https://kb.hsri.or.th/dspace/handle/11228/1539, accessed 26 January 2024). Valee-Ittikul S (2002). Social security scheme: experiences of capitation payment system. In: Pramualratana P WS, Kedsomboon N, Sakulbumrungsil R et al editor Research and systems development for national drug account. Health Systems Research Institute; 52-61. Vichathai C, Srithamrongsawat S, Riewpaiboon W, Kongsawat S, Thamroj N, Aeamnoi P, et al. (2009). Intermediate care services for rehabilitation and its costs under health insurance system. Health Systems Research Institute. (https://kb.hsri.or.th/dspace/handle/11228/3165?locale- attribute=th, accessed 26 January 2024). Viriyathorn S (2021). Communication with office of insurance commission. International Health Policy Program. Vongmongkol V, Viriyathorn S, Wanwong Y, Wangbanjongkun W, Tangcharoensathien V (2021). Annual prevalence of unmet healthcare need in Thailand: evidence from national household surveys between 2011 and 2019. International Journal for Equity in Health. 20(244). https://doi.org/10.1186/s12939-021-01578-0 Wacharapluesadee S, Kaewpom T, Ampoot W, Ghai S, Khamhang W, Worachotsueptrakun K, et al. (2020). Evaluating the efficiency of specimen pooling for PCR–based detection of COVID–19. Journal of medical virology. 92(10):2193-9. Wagstaff A, Bredenkamp C (2014). Module 4: progressivity analysis. World Bank Organization. (https://www.worldbank.org/content/dam/ Worldbank/document/HDN/Health/Module4ProgressivityAnalysis.pdf, accessed 26 January 2024). Wibulpolprasert S (1999). Inequitable distribution of doctors: can it be solved. Human resources for health development journal. 3(1):2-22. Wibulpolprasert S (2002). Thailand health profile 1999-2000. Nonthaburi: Ministry of Public Health (accessed 5 February 2015). Wibulpolprasert S (2005). Thailand health profile 2001-2004. (https://www. hiso.or.th/hiso/picture/reportHealth/report/ThaihealthProfileE2004.pdf, accessed 26 January 2024). 286 Wibulpolprasert S, Chokevivat V, Oh C, Yamabhai I (2011a). Government use licenses in Thailand: the power of evidence, civil movement and political leadership. Globalization and Health. 7(32). http://www. globalizationandhealth.com/content/7/1/32 Wibulpolprasert S, Pengpaibon P (2003). Integrated strategies to tackle the inequitable distribution of doctors in Thailand: four decades of experience. Human resources for health. 1(1):1-17. Wibulpolprasert S, Sirilak S, Ekachampaka P, Wattanamano N (2011b). Thailand health profile 2008-2010. (https://www.hiso.or.th/hiso/ picture/reportHealth/report/ThaihealthProfileT2010T.pdf, accessed 8 April 2023). Wong J, Tong R (2022). Medical regulatory affairs: an international handbook for medical devices and healthcare products. Jenny Stanford Publishing (accessed Wongchai Y, Krachangpue S, et al (2008). Consumer protection in health insurance systems. In. Nonthaburi: Health Insurance System Research Office. Working group on developing the national methodological HTA guidelines (edition 2019) (2021). National methodological health technology assessment (HTA) guideline (revised edition B.E. 2562). (https:// kb.hsri.or.th/dspace/bitstream/handle/11228/5320/hs2647. pdf?sequence=1&isAllowed=y, accessed 23 May 2023). World Bank (2019a). Labor force participation rate, female (% of female population ages 15-64) (modeled ILO estimate) - middle income, Thailand. (https://data.worldbank.org/indicator/SL.TLF.ACTI. FE.ZS?end=2020&locations=XP-TH&start=1990, accessed 26 January 2024). (english) World Bank (2019b). Total alcohol consumption per capita (liters of pure alcohol, projected estimates, 15+ years of age) - Thailand. (https://data. worldbank.org/indicator/SH.ALC.PCAP.LI?locations=TH, accessed 29 November 2023). World Bank (2019c). World development indicators. (https://databank. worldbank.org/source/world-development-indicators, accessed 2 May 2023). World Bank (2021a). Gini index - Thailand, China, Malaysia. (https://data. worldbank.org/indicator/SI.POV.GINI?locations=TH-CN-MY, accessed 3 April 2023). 287 World Bank (2021b). GNI per capita, atlas method (current US$) - Thailand. (https://data.worldbank.org/indicator/NY.GNP.PCAP.CD?locations=TH, accessed 11 May 2023). World Bank (2021c). Literacy rate, adult female (% of females ages 15 and above) - Thailand. Wolrd Bank. (https://data.worldbank.org/indicator/ SE.ADT.LITR.FE.ZS?locations=TH, accessed 26 January 2024). World Bank (2021d). Literacy rate, adult total (% of people ages 15 and above) - Thailand. (https://data.worldbank.org/indicator/SE.ADT.LITR. ZS?locations=TH, accessed 23 May 2023). World Bank (2021e). Literacy rate, youth total (% of people ages 15-24) - Thailand. (https://data.worldbank.org/indicator/SE.ADT.1524. LT.ZS?locations=TH, accessed 23 May 2023). World Bank (2021f). Literacy rate, youth total (% of people ages 15-24) - Thailand, upper middle income. (https://data.worldbank.org/indicator/ SE.ADT.1524.LT.ZS?locations=TH-XT, accessed 3 April 2023). World Bank (2021g). World development indicators (1980-2021). World Development Indicators. (https://data.worldbank.org/country/thailand, accessed 26 January 2024). World Bank (2021h). World development indicators (2000-2021). (https:// databank.worldbank.org/source/world-development-indicators, accessed 2 May 2023). World Bank (2022a). Current health expenditure per capita (current US$). (https://data.worldbank.org/indicator/SH.XPD.CHEX.PC.CD, accessed 6 May 2023). World Bank (2022b). Macro poverty outlook: country-by-country analysis and projections for the developing world. (https://thedocs.worldbank.org/ en/doc/77351105a334213c64122e44c2efe523-0500072021/related/ mpo-am22-eap.pdf, accessed 26 January 2024). World Bank (2023a). Hospital beds (per 1,000 people). (https://data. worldbank.org/indicator/SH.MED.BEDS.ZS?name_desc=false, accessed 8 April 2023). World Bank (2023b). Individuals using the internet % of population. (https:// data.worldbank.org/indicator/IT.NET.USER.ZS?locations=TH-1W, accessed 8 April 2023). World Bank (2023c). The World Bank in Thailand. (https://www.worldbank. org/en/country/thailand/overview, accessed 26 January 2024). 288 World Bank Group, Asian Development Bank (2021). Climate risk country profile: Thailand (https://www.adb.org/publications/climate-risk- country-profile-thailand, accessed 26 January 2024). World Health Organization (1998). Ethical criteria for medicinal drug promotion. WHO. (http://apps.who.int/medicinedocs/en/d/Js2273e/13.8 .1.html#Js2273e.13.8.1, accessed 24 September 2014). World Health Organization (2000). The world health report 2000: health systems: improving performance. (https://cdn.who.int/media/docs/ default-source/health-financing/whr-2000.pdf?sfvrsn=95d8b803_1&do wnload=true, accessed 26 January 2024). World Health Organization (2006). The world health report 2006: working together for health. (https://apps.who.int/iris/bitstream/ handle/10665/43432/9241563176_eng.pdf?sequence=1&isAllowed=y, accessed 8 April 2023). World Health Organization (2007). Monitoring the building blocks of health systems. (https://apps.who.int/iris/bitstream/hand le/10665/258734/9789241564052-eng.pdf, accessed 26 February 2024 ). World Health Organization (2016a). Global strategy on human resources for health: Workforce 2030. (https://apps.who.int/iris/bitstream/hand le/10665/250368/9789241511131-eng.pdf, accessed 8 April 2023). World Health Organization (2016b). International health regulations (2005), 3rd ed. (https://apps.who.int/iris/handle/10665/246107, accessed 12 May 2023). World Health Organization (2017, 2017). Tackling NCDs: ‘best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. World Health Organization. (https://iris. who.int/handle/10665/259232, accessed 26 January 2024). (enarzhka) World Health Organization (2020a). WHO mortality database (1980-2020). (https://platform.who.int/mortality/themes/theme-details/topics/topic- details/MDB/infectious-and-parasitic-diseases, accessed 3 April 2023). World Health Organization (2020b). WHO mortality database, Ill defined diseases (1980-2020). (https://platform.who.int/mortality/themes/ theme-details/MDB/ill-defined-diseases, accessed 3 April 2023). World Health Organization (2020c). WHO mortality database, injuries (1980- 2020). (https://platform.who.int/mortality/themes/theme-details/MDB/ injuries, accessed 3 April 2023). 289 World Health Organization (2020d). WHO mortality database, noncommunicable diseases (1980-2020). (https://platform.who.int/ mortality/themes/theme-details/MDB/noncommunicable-diseases, accessed 3 April 2023). World Health Organization (2021a). The global health observatory (2000- 2021). (https://www.who.int/data/gho, accessed 2 May 2023). World Health Organization (2021b). Progress report on covering every birth and death: improving civil registration and vital statistics in the WHO South East Asia Region: 2021 update. (https://www.who.int/ publications/i/item/9789290228851, accessed 26 January 2024). World Health Organization (2021c). WHO report on the global tobacco epidemic, 2021: country profile Thailand. (https://cdn.who.int/media/ docs/default-source/country-profiles/tobacco/who_rgte_2021_ thailand.pdf?sfvrsn=668fd7e1_5&download=true, accessed 3 April 2023). World Health Organization (2022a). Current health expenditure (% of GDP) - Thailand. World Health Organization,. (https://data.worldbank.org/ indicator/SH.XPD.CHEX.GD.ZS?locations=TH, accessed 2 May 2023). World Health Organization (2022b). Global health expenditure database. (https://apps.who.int/nha/database/Select/Indicators/en, accessed 24 July 2022). World Health Organization (2022c). Universal health preparedness review (UHPR). (https://cdn.who.int/media/docs/default-source/documents/ emergencies/universal-health---preparedness-review/uhpr_thailand. pdf?sfvrsn=7bb79e9e_1&download=true, accessed 30 May 2023). World Health Organization (2022d). World health statistics 2022: monitoring health for the SDGs, sustainable development goals. (https://www.who. int/publications/i/item/9789240051157, accessed 8 April 2023). World Health Organization (2023). Global health workforce statistics database (https://www.who.int/data/gho/data/themes/topics/health-workforce, accessed 8 April 2023). World Health Organization. Regional Office for South-East Asia (2021). Monitoring progress on universal health coverage and the health- related sustainable development goals in the WHO South-East Asia region: 2021 update. New Delhi: World Health Organization. Regional Office for South-East Asia (https://apps.who.int/iris/ handle/10665/344764, accessed 290 Worldometer (2022). Thailand COVID - Coronavirus statistics. (https:// www.worldometers.info/coronavirus/country/thailand/, accessed 26 January 2024). Wright M, Hamzah E, Phungrassami T, Bausa-Claudio A (2010). Hospice and palliative care in southeast Asia: a review of developments and challenges in Malaysia, Thailand and the Philippines. Oxford University Press (accessed Yan LD, Hanvoravongchai P, Aekplakorn W, Chariyalertsak S, Kessomboon P, Assanangkornchai S, et al. (2020). Universal coverage but unmet need: National and regional estimates of attrition across the diabetes care continuum in Thailand. PLoS One. 15(1):e0226286. https://doi. org/10.1371/journal.pone.0226286 Yang BM (2009). The future of health technology assessment in healthcare decision making in Asia. Pharmacoeconomics. 27(11):891-901. https:// doi.org/10.2165/11310280-000000000-00000 Yao J, Lim N, Tan J, Matthias Müller A, Martinus van Dam R, Chen C, et al. (2022). Evaluation of a population-wide mobile health physical activity program in 696 907 adults in Singapore. J Am Heart Assoc. 11(12):e022508. https://doi.org/10.1161/jaha.121.022508 Yothasamut J, Putchong C, Sirisamutr T, Teerawattananon Y, Tantivess S (2010). Scaling up cervical cancer screening in the midst of human papillomavirus vaccination advocacy in Thailand. BMC Health Serv Res. 10 Suppl 1(Suppl 1):S5. https://doi.org/10.1186/1472-6963-10-S1-S5 Youngkong S, Baltussen R, Tantivess S, Mohara A, Teerawattananon Y (2012). Multicriteria decision analysis for Including health interventions in the universal health coverage benefit package in Thailand. Value in Health. 15(6):961-70. https://doi.org/https://doi.org/10.1016/j.jval.2012.06.006 Zinboonyahgoon N, Srisuma S, Limsawart W, Rice ASC, Suthisisang C (2021). Medicinal cannabis in Thailand: 1-year experience after legalization. PAIN. 162:S105-S9. https://doi.org/10.1097/j.pain.0000000000001936 291 9.2 Useful websites Burden of Disease Thailand: http://bodthai.net/en/home/ Global health and UHC resource centre: https://www.resourceihpp. com/site/home Healthcare Accreditation Institute: http://www.ha.or.th/ Healthcare Information: http://www.chi.or.th/ Health Information Systems Development Office: http://www.hiso.or.th/ Health Intervention and Technology Assessment Program: http://www. hitap.net/en/ Health Systems Research Institute: http://www.hsri.or.th/ International Health Policy Program: http://www.ihppthaigov.net/ Ministry of Public Health: http://moph.go.th/ National Health Commission Office: http://en.nationalhealth.or.th/ National Health Security Office: http://www.nhso.go.th/ National Institute for Emergency Medical: http://www.niems.go.th/ National Statistical Office: http://www.nso.go.th National Vaccine Institute: http://nvi.go.th/ Social Security Office: http://www.sso.go.th/wpr/ Thai Health Promotion Foundation: http://www.thaihealth.or.th/ Tobacco Control Research and Knowledge Management: http://www. trc.or.th/en/ 9.3 HiT methodology and production Health Systems in Transition (HiT) reports are produced by country experts in collaboration with an external editor and the Secretariat of the Asia Pacific Observatory based in the WHO Regional Office for the Western Pacific in Manila, Philippines, or the European Observatory based in Brussels, Belgium (depending upon the country/region). HiTs are based on a template developed by the European Observatory on Health Systems and Policies that, revised periodically, provides detailed guidelines and specific questions, definitions, suggestions for data sources and examples needed to compile reviews. While the template offers a comprehensive set of questions, it is intended to be used in a flexible way to allow authors and editors to adapt it to their particular national context. 292 The most recent template is available online at: https://apps.who.int/iris/ handle/10665/208276. Authors draw on multiple data sources for the compilation of HiTs, ranging from national statistics, national and regional policy documents to published literature. Data are drawn from information collected by national statistical bureaus and health ministries. Furthermore, international data sources may be incorporated, such as the World Development Indicators of the World Bank. In addition to the information and data provided by country experts, WHO supplies quantitative data in the form of a set of standard comparative figures for each country, drawing on the Western Pacific country health information profiles (CHIPs) and the WHO Statistical Information System (WHOSIS). HiT authors are encouraged to discuss the data in the text in detail, including the standard figures prepared by the Observatory staff, especially if there are concerns about discrepancies between the data available from different sources. The quality of HiTs is of real importance since they inform policy-making and meta-analysis. HiTs are subject to wide consultation throughout the writing and editing process, which involves multiple iterations. They are then subject to the following: • A rigorous review process consisting of three stages. Initially, the text of the HiT is checked, reviewed and approved by the Observatory Secretariat. It is then sent for review to at least two independent experts, and their comments and amendments are incorporated into the text, and modifications are made accordingly. The text is then submitted to the relevant Ministry of Health, or appropriate authority, and policy-makers within those bodies to check for factual errors within the HiT. • There are further efforts to ensure quality while the report is finalized, which focus on copy-editing and proofreading. • HiTs are disseminated (hard copies, electronic publication, translations and launches). The editor supports the authors throughout the production process and, in close consultation with the authors, ensures that all stages of the process are taken forward as effectively as possible. 293 9.4 About the authors Authors of the Kingdom of Thailand Health System Review (2015) Pongpisut Jongudomsuk is the Assistant Secretary-General of the National Health Security Office (NHSO), Thailand. After graduating in medicine, he worked as a director in rural district hospitals for 10 years and got certificates in Preventive Medicine and Family Medicine from the Thai Medical Council. He studied MPH at the Institute of Tropical Medicine, Antwerpen, Belgium from 1993 to 1994. After graduation, he worked in the EU-funded Health Care Reform Project, which was the action research project and was the basis for the development of the universal health coverage system in Thailand. Recently, he worked as the Director of the Health System Research Institute (HSRI). Now he also works as part of the Technical Support Team of the Minister of Public Health. Samrit Srithamrongsawat is the Deputy Secretary-General of the National Health Security Office (NHSO), Thailand. He got his MD from Chulalongkorn University, Thailand in 1984, MPH from Mahidol University, Thailand in 1989, MSc in Health Service Management from the London School of Hygiene and Tropical Medicine (LSHTM) in 1995, and PhD in Health Policy and Financing from LSHTM in 2005. He has substantial experience in managing district and provincial health systems and public health insurance. He has been doing substantial research and development on health policy, health system, and health insurance systems. He was the former Director of the Health Insurance System Research Office (HISRO), Health System Research Institute (HSRI), Thailand. Walaiporn Patcharanarumol is the Director of Capacity Building for the Universal Health Coverage programme (CapUHC) and a senior researcher for the International Health Policy Program (IHPP), Ministry of Public Health, Thailand. A former hospital pharmacist, her main research areas include health systems and policy, with extensive knowledge and experience in health-care financing. She was awarded the Joint Japan/World Bank Graduate Scholarship Fund for her Master’s degree in Social Protection Financing from Maastricht University, the Netherlands from 2002 to 2003. Subsequently, she received the Dorothy Hodgkin Postgraduate Award in 2004 and her PhD in Public Health and Policy 2008 at the London School of Hygiene and Tropical Medicine, University of London. Supon Limwattananon is an Associate Professor at Khon Kaen University. He is also a part-time senior researcher at the Ministry of Public Health, International Health Policy Program (IHPP), Thailand. He earned a Bachelor of Pharmacy degree from Chulalongkorn University in 1982, Master 294 in Primary Health Care Management from ASEAN Institute for Health Development in 1991, and Doctor of Philosophy in Social and Administrative Pharmacy from the University of Minnesota in 2000. He was a Fulbright Scholar from 1993 to 1996 and received the US Health Care Financing Administration Dissertation Award in 2000. In 2008, he was seconded to the World Bank head office in Washington, DC as a Senior Health Specialist in the Human Development Network. His expertise is in the areas of health economics and micro-econometrics. Supasit Pannarunothai is a professor of community medicine at the Faculty of Medicine, Naresuan University. He earned a Doctor of Medicine from the Faculty of Medicine Ramathibodi Hospital, Mahidol University; Master of Science (Public Health) from National University of Singapore; and Doctor of Philosophy from the London School of Hygiene and Tropical Medicine. His research focuses on health equity, health-care financing, case-mix systems and universal health coverage. He was dean of the Faculty of Medicine, Naresuan University for two terms. He is now head of the Centre for Health Equity Monitoring. Patama Vapattanawong is one of the very few demographers in Thailand. She received her BSc in Nursing and Midwifery from Mahidol University, Thailand in 1983; MSc in Community Medicine from Chulalongkorn University, Thailand in 1993; and PhD in Demography from Mahidol University, Thailand in 2002. She is now an Associate Professor at the Institute for Population and Social Research, Mahidol University, teaching many courses related to demography such as Technique of Demographic Analysis; Indirect Technique for Demographic Estimation; Advances in Demographic Projection; Population, Health and Community Health Services Development. She is keen on using large datasets, particularly birth and death registration databases, to study demographic transition in Thailand. Her research interests are child and old age mortality. Krisada Sawaengdee earned her PhD in Population and Development from the National Institute of Development Administration, Thailand in 2009; Master‘s degree in Nursing from Mahidol University in 1988; and Bachelor’s degree in Nursing Sciences from Khon-Kaen University in 1983. Now she serves as the Deputy Director of the Praboromrajchanok Institute for Health Workforce Development, Ministry of Public Health, and is also the Vice President of the Thailand Nursing and Midwifery Council. She has 25 years of field experience in nursing administration. She has served as the principal investigator of a longitudinal study: Thai nurses cohort study and is co-investigator of several research projects related to health workforce 295 and health system policy at the International Health Policy Program (IHPP), Ministry of Public Health since 2010. Pinij Faramnuayphol is the director of the Health Information System Development Office (HISO), Thailand. After graduating in medicine, he worked as a director in two rural district hospitals for eight years and got certificates in Preventive Medicine from the Thai Medical Council. He studied for the MPH degree at the Institute of Tropical Medicine, Antwerpen, Belgium from 1999 to 2000. After graduation, he worked in a district hospital for another two years before working in the Bureau of Health Policy and Strategy as the director of the Health Information Division. In 2004, he worked as the manager of the Health Information System Development Programme supported by the Thai Health Promotion Foundation until 2010. He graduated with a PhD (Epidemiology) from Prince of Songkla University in 2008. Currently, he works as the manager of health information and statistics services on the website project and GIS-based health resources information system development project supported by the Thai Health Promotion Foundation. Viroj Tangcharoensathien is a Senior Expert in Health Economics at the Ministry of Public Health, Thailand and advisor to the International Health Policy Program of the MoPH. Trained in Medicine, he served for nine years in rural district hospitals in a poor northeastern province of Thailand and received the “Best Rural Doctor” award in 1986 from the Thai Medical Association. In 1990, he got a PhD in Health Planning and Financing at the London School of Hygiene and Tropical Medicine and earned the Woodruff Medal in 1991 for his outstanding PhD thesis on “Community financing: The urban health card in Chiangmai, Thailand”. He earned the Edwin Chadwick Medal from LSHTM in 2011 for contributions to the generation of evidence that improves health systems in the interests of the poor. As of 2015, he has published 147 articles in international peer-reviewed journals. Authors of Thailand Health System Review (2024) Kanitta Bundhamcharoen is a researcher in the Burden of Disease team under the International Health Policy Program (IHPP), Thailand. Watinee Kunpeuk is a researcher in the Non-Thai Population Research team under the International Health Policy Program (IHPP), Thailand. Shaheda Viriyathorn is a researcher in the Health Financing and Universal Health Coverage team under the International Health Policy Program (IHPP), Thailand. 296 Somtanuek Chotchoungchatchai is a researcher in the Health Financing and Universal Health Coverage team under the International Health Policy Program (IHPP), Thailand. Jomkwan Yothasamut is a researcher in the Health Security and Policy Evaluation team under the International Health Policy Program (IHPP), Thailand. Angkana Lekagul is a researcher in the Antimicrobial Resistance and Sustainable Development Goals team under the International Health Policy Program (IHPP), Thailand. Walaiporn Patcharanarumol is a senior researcher for the International Health Policy Program (IHPP), Nonthaburi, Thailand. Viroj Tangcharoensathien is a senior researcher for the International Health Policy Program (IHPP), Nonthaburi, Thailand. Contributors: Rapeepong Suphanchaimat, International Health Policy Program (IHPP), Nonthaburi, Thailand Rugsapon Sanitya, International Health Policy Program (IHPP), Nonthaburi, Thailand Nuttapat Makka, International Health Policy Program (IHPP), Nonthaburi, Thailand Divya Lakhotia, International Health Policy Program (IHPP), Nonthaburi, Thailand Pispasinee Pisansin, International Health Policy Program (IHPP), Nonthaburi, Thailand Khanit Pisawong, International Health Policy Program (IHPP), Nonthaburi, Thailand Krisada Sawaengdee, Thailand Nursing & Midwifery Council Sriveing Pirojkul, Karunruk Palliative Care Center, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University Dangfun Promkhum, National Institute for Emergency Medicine (NIEM), Nonthaburi, Thailand 297 Noppakun Thammatacharee, Health Systems Research Institute (HSRI), Nonthaburi, Thailand Voramon Agrasuta, Bureau of Dental Health, Department of Health (DoH), Ministry of Public Health, Nonthaburi, Thailand Rutchanee Chantraket, Technical and Planning Division, Department of Thai Traditional and Alternative Medicine (DTAM), Ministry of Public Health, Nonthaburi, Thailand Asia Pacific Observatory on Health Systems and Policies (APO) publications to date Health Systems in Transition (HiT) review (20 countries) • The Fiji Islands (2011) • The Philippines (2011; 2018) • Mongolia (2013) • Malaysia (2013) • New Zealand (2014; 2022) • Lao People’s Democratic Republic (2014) • The Republic of the Union of Myanmar (2014) • Solomon Islands (2015) • The Kingdom of Cambodia (2015) • Bangladesh (2015) • Republic of Korea (2015) • The Kingdom of Thailand (2015) • The Kingdom of Tonga (2015) • People’s Republic of China (2015) • The Republic of Indonesia (2017) • The Kingdom of Bhutan (2017) • Japan (2018) • Independent State of Papua New Guinea (2019) • Sri Lanka (2021) • India (2022) HiT policy notes (four countries) • The Republic of the Union of Myanmar (2015) #1. What are the challenges facing Myanmar in progressing towards Universal Health Coverage? #2. How can health equity be improved in Myanmar? #3. How can the township health system be strengthened in Myanmar? #4. How can financial risk protection be expanded in Myanmar? • The Kingdom of Cambodia (2016) Increasing equity in health service access and financing: health strategy, policy achievements and new challenges • The Kingdom of Thailand (2016) Health system review: achievements and challenges • Bangladesh (2017) Improving the quality of care in the public health system in Bangladesh: building on new evidence and current policy levers Policy brief (16 series) • Direct household payments for health services in Asia and the Pacific (2012) • Dual practice by health workers in South and East Asia (2013) • Purchasing arrangements with the private sector to provide primary health care in underserved areas (2014) • Strengthening vital statistics systems (2014) • Quality of care (2015) • The challenge of extending universal coverage to non-poor informal workers in low- and middle-income countries in Asia (2015) • Factors conducive to the development of health technology assessment in Asia (2015) • Attraction and retention of rural primary health-care workers in the Asia-Pacific region (2018) • Use of community health workers to manage and prevent noncommunicable diseases (2019) • Strategies to strengthen referral from primary care to secondary care in low- and middle-income countries (2019) • ASEAN mutual recognition arrangements for doctors, dentists and nurses (2019) • Strengthening primary health care for the prevention and management of cardiometabolic disease in LMICs (2019) • Overseas medical referral: the health system challenges for Pacific Island Countries (2020) • Use of e-health programmes to deliver urban primary health-care services for noncommunicable diseases in middle-income countries (2021) • Integrated care for tuberculosis and diabetes mellitus comorbidity in Asian countries: health system challenges and opportunities (2022) • Digital health and universal health coverage: opportunities and policy considerations for Pacific Island health authorities (2022) Comparative country studies (seven series) • Public hospital governance in Asia and the Pacific (2015) • Case-based payment systems for hospital funding in Asia: an investigation of current status and future directions (2015) • Strategic purchasing in China, Indonesia and the Philippines (2016) • Health system responses to population ageing and noncommunicable diseases in Asia (2016) • Resilient and people-centred health systems: progress, challenges and future directions in Asia (2018) • Moving towards culturally competent, migrant-inclusive health systems: a comparative study of Malaysia and Thailand (2021) • Integrated care for chronic diseases in Asia Pacific Countries (2021) • The role of private sector in Asia: challenges and opportunities for achieving universal health coverage (2023) • Use of routine health information systems for policy making towards universal health coverage in decentralized countries (2024) The APO publications are available at https://apo.who.int

Thailand Health System Review Health Systems in Transition Vol. 13 No. 1 2024 H ealth System s in Transition Vol. 13 N o. 1 2024 Thailand Health System Review The Asia Pacific Observatory on Health Systems and Policies (the APO) is a collaborative partnership of interested governments, international agencies, foundations, and researchers that promotes evidence-informed health systems policy regionally and in all countries in the Asia Pacific region. The APO collaboratively identifies priority health system issues across the Asia Pacific region; develops and synthesizes relevant research to support and inform countries' evidence-based policy development; and builds country and regional health systems research and evidence-informed policy capacity. ISBN-13 978 92 9062 045 7