Primary Health Care Systems PRIMASYS - Thailand

PRIMARY HEALTH CARE SYSTEMS
(PRIMASYS)
Case study from Thailand
PRIMARY HEALTH CARE SYSTEMS
(PRIMASYS)
Case study from Thailand
Thira Woratanarat,a Patarawan Woratanarat,b Charupa Lekthipa
a. Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University

b. Faculty of Medicine Ramathibodi Hospital, Mahidol University
WHO/HIS/HSR/17.25
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PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

Contents
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
Background to PRIMASYS case studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
1. Overview of primary health care system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
2. Data collection methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
3. Timeline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
4. Governance and PHC-related infrastructure in Thailand . . . . . . . . . . . . . . . . . . . . . . . . . . 13
5. Financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
6. Human resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
7. Planning and implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
8. Regulatory processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
8.1 Regulation and governance of providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
8.2 Human resources planning and registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
8.3 Regulation and governance of pharmaceuticals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
8.4 Entry of pharmaceuticals to the market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
8.5 Quality of medicines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
8.6 Pricing and market access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
8.7 Regulation of medical devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
8.8 Regulation of capital investment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
9. Monitoring and information systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
10. Policy considerations and ways forward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Annex 1. Key informants on primary care system in Thailand . . . . . . . . . . . . . . . . . . . . . . . . 28
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
CASE STUDY FROM THAILAND

Figures
Figure 1. Timeline of PHC development and relevant policies in Thailand . . . . . . . . . . . . . . . . 11
Figure 2. Region-based health services system in Thailand . . . . . . . . . . . . . . . . . . . . . . . . . 13
Figure 3. Governance and PHC-related services infrastructure . . . . . . . . . . . . . . . . . . . . . . . 14
Figure 4. Financial flows of PHC services in Thai health system . . . . . . . . . . . . . . . . . . . . . . . 16
Figure 5. Family medical care team and its components . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Tables
Table 1. Key demographic, macroeconomic, and health indicators in Thailand . . . . . . . . . . . . . .4
Table 2. Thailand’s demographic, macroeconomic, and health profiles and relevance to
primary health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Table 3. Key PHC developments in Thailand: barriers and enablers . . . . . . . . . . . . . . . . . . . . . 12
Table 4. Health care spending profiles, percentage of total health expenditure . . . . . . . . . . . . . 15
Table 5. Health care spending by source of fund, percentage of total health expenditure . . . . . . 15
Table 6. Profiles of physicians, nurses, community health workers, and traditional
practitioners in Thailand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Table 7. Characteristics of governance structures of three main insurance schemes in Thailand . . . 21
Table 8. Policy-related topics for primary care system development in Thailand . . . . . . . . . . . . 27

iv
Acknowledgements
The authors would like to thank all key informants and information sources for this case study. Special thanks
go to Associate Professor Dr Vitool Lohsoontorn, Head of Department of Preventive and Social Medicine,
Faculty of Medicine, Chulalongkorn University, for his kindness on time allowance for this work. Also, we are
deeply grateful for advice and viewpoints on the primary care services system from a group of Thai patients
from the Thailand Chronic Diseases Network.

1
Abbreviations
ASEAN Association of Southeast Asian Nations
CPIRD Collaborative Project to Increase Rural Doctors
DALY disability-adjusted life-year
GDP gross domestic product
NCD noncommunicable disease
OECD Organisation for Economic Co-operation and Development
PHC primary health care
PRIMASYS Primary Health Care Systems

2
Background to PRIMASYS case studies
Health systems around the globe still fall short of The Alliance has developed full and abridged versions
providing accessible, good-quality, comprehensive of the 20 PRIMASYS case studies. The abridged
and integrated care. As the global health community version provides an overview of the primary health
is setting ambitious goals of universal health care system, tailored to a primary audience of policy-
coverage and health equity in line with the 2030 makers and global health stakeholders interested in
Agenda for Sustainable Development, there is understanding the key entry points to strengthen
increasing interest in access to and utilization of primary health care systems. The comprehensive case
primary health care in low- and middle-income study provides an in-depth assessment of the system
countries. A wide array of stakeholders, including for an audience of researchers and stakeholders who
development agencies, global health funders, policy wish to gain deeper insight into the determinants
planners and health system decision-makers, require and performance of primary health care systems
a better understanding of primary health care in selected low- and middle-income countries.
systems in order to plan and support complex health Furthermore, the case studies will serve as the basis
system interventions. There is thus a need to fill the for a multicountry analysis of primary health care
knowledge gaps concerning strategic information systems, focusing on the implementation of policies
on front-line primary health care systems at national and programmes, and the barriers to and facilitators
and subnational levels in low- and middle-income of primary health care system reform. Evidence from
settings. the case studies and the multi-country analysis will
in turn provide strategic evidence to enhance the
The Alliance for Health Policy and Systems
performance and responsiveness of primary health
Research, in collaboration with the Bill & Melinda
care systems in low- and middle-income countries.
Gates Foundation, is developing a set of 20 case
studies of primary health care systems in selected
low- and middle-income countries as part of an
initiative entitled Primary Care Systems Profiles
and Performance (PRIMASYS). PRIMASYS aims to
advance the science of primary health care in low-
and middle-income countries in order to support
efforts to strengthen primary health care systems
and improve the implementation, effectiveness
and efficiency of primary health care interventions
worldwide. The PRIMASYS case studies cover key
aspects of primary health care systems, including
policy development and implementation,
financing, integration of primary health care into
comprehensive health systems, scope, quality and
coverage of care, governance and organization, and
monitoring and evaluation of system performance.

3
1. Overview of primary health care system
With a population of over 68 million, Thailand has population of Thailand has been ageing rapidly over
a multi-level health care system aiming to improve the last half century due to declines in both fertility
geographical access to health services and to and mortality. The total fertility rate declined from 4.9
optimize system efficiency through rational use births per woman in 1985/1986 to 1.5 in 2005/2006,
of services. Thailand has gone through significant along with a declining birth rate. The reproductive
epidemiological transitions, evolving from a high health situation in Thailand has improved over time
fertility and high mortality pattern to low fertility based on three indicators – infant mortality rate,
and low mortality. The low fertility rate (below under-5 mortality rate, and maternal mortality ratio.
replacement level) and low crude mortality rate In 1980, the infant mortality rate was nearly 50 per
have profound impacts on health service and social 1000 live births, while the under-5 mortality rate was
service development and financing, including the 60. These rates gradually reduced to 11 for infant
need to respond to a rapidly ageing society (1). mortality and 13 for under-5 mortality in 2010. The
maternal mortality ratio also fell from 42 per 100 000
Demographically, the population growth rate
live births in 1990 to 26 in 2010. Contributory factors
slowed from 3% in 1970 to 0.4% in 2015, as a result
include improvements in maternal and child health
of an effective family planning programme since the
services and vaccine coverage (Table 1) (2–4).
1970s. There are slightly more females than males,
with the male–female ratio changing from 0.996 As a result of population growth, the population
in 1970 to 0.967 in 2014 (1). The percentage of the density in Thailand increased from 67.1 people
population aged 0–14 years decreased from 45.1% per square kilometre in 1970 to 128.5 people per
to 19.6% during 1970–2010, while the percentage square kilometre in 2010. The proportion of the
of people aged 65 years and over increased rural population residing in non-municipal areas
continuously, more than tripling from 3.1% in 1970 decreased from 86.8% in 1970 to 56.6% in 2010.
to 11% in 2016 (approximately 7.5 million people). Rapid urbanization has occurred, with the urban
The oldest population group (aged 80 years and population increasing from 18.7% in 1990 to 43.4%
over) more than tripled over a 40-year period in 2010. In 2015, the data showed that those living in
from 0.5 million in1970 to 1.7 million in 2010. The urban areas had increased to 50.4% (1).
Table 1. Key demographic, macroeconomic, and health indicators in Thailand

Results by year
Indicator 1970 1980 1990 2000 2010 Others Source
Total population 34 427 000 44 824 000 54 548 000 60 916 000 63 827 000 68 147 000 National
of country (2016) Statistical Office
(1)
Sex ratio: 0.996 0.992 0.984 0.972 0.953 0.967 (2014)
male–female
Population 3.1 3.0 2.2 1.2 0.5 0.4 (2015)

growth rate (%)
Population 67.1 87.4 106.3 118.7 128.5 –

density 2
(people/km )
Distribution of 86.8/13.2 83.0/17.0 81.3/18.7 68.9/31.1 56.6/43.4 49.6/50.4

population (rural/ (2015)
urban, %)

4
Results by year
GDP per capita 710 1 480 2 720 1 930 4 150 5 977.4 (2014) Office of
(US$) National
Economic
GDP per capita, 1 050 2 800 4 550 4 800 8 120 – and Social
purchasing Development
power parity Board (2)
(PPP) (US$)
Income or wealth 44.2 45.3 43.5 42.8 40.0 –

inequality (Gini
coefficient)
Life M 62.7 69.3 68.6 68.8 70.6 – National

expectancy Statistical Office
at birth (1)
(years) F 68.4 75.8 76.1 76.5 77.4 –
Top 5 main 1.Circulatory 1.Circulatory 1. Malignant 1. Malignant Burden of

causes of diseases diseases neoplasms neoplasms disease,
death (ICD–10 (I00–I99) (I00–I99) (C00–C97) (C00–C97) Thailand, and
classification) 2.Infectious 2. Malignant 2. Circulatory 2. Circulatory Ministry of
and parasitic neoplasms diseases diseases Public Health,
diseases (C00–C97) (I00–I99) (I00–I99) Thailand (3, 4)
(A00–B99) 3. Infectious 3. Infectious 3. Infectious
3.Malignant and parasitic and parasitic and parasitic
neoplasms diseases diseases diseases
(C00–C97) (A00–B99) (A00–B99) (A00–B99)
4.Digestive 4.Digestive 4. Chronic 4. Chronic
diseases diseases respiratory respiratory
(K00–K93) (K00–K93) diseases diseases
5.Chronic 5.Chronic (J00–J99) (J00–J99)
respiratory respiratory 5.Transport 5.Transport
diseases diseases accidents accidents
(J00–J99) (J00–J99) (V00–V99) (V00–V99)
Total M – – – 236.7 204.8 –

mortality
rate, adult
(per 1000) F – – – 117.0 101.0 –
Infant mortality – 46.3 26.4 15.2 11.2 12 (2011)

rate (per 1000 live 9.504 (2016)
births)
– 25 (1995) 17 10 8 (2014) World Bank data
on Thailand (5)
Under-5 mortality – 60 31.8 17.7 13.0 – Ministry of

rate (per 1000 live Public Health (4)
births)
29 (1995) 20 11 10 (2014) World Bank
data (5)
Maternal – – 42 40 26 – Ministry of
mortality rate Public Health (4)
(per 100 000 live
births) 52 (1995) 25 – World Bank
data (5)
Immunization Measles 99%, DTP3 90%, hepatitis B3 46%, Hib3 90% (2013) Ministry of

coverage under Public Health (4)
1 year (%)
Total health – – – 3.8 3.8 3.9 (2012) Ministry of

expenditure as Public Health (4)
proportion of
GDP (%) 4 5 7 (2014) World Bank
data (5)
3.4 3.9 4.5 (2012) National Health

Accounts (6)
Continues…

5
Results by year
Public – – – 47 72 77 (2011) Ministry of
expenditure Public Health (4)
on health as
proportion of 61 82 86 (2014) World Bank
total expenditure data (5)
on health (%)
56 75 77 (2011) National Health
Accounts (6)
Out-of-pocket 12.4 (2011) Ministry of

payments as Public Health (4)
proportion of
total expenditure – – – 30 (2000) 10 (2010) 8 (2014) World Bank
on health (%) data (5)
Voluntary health 10.3 (2011) Ministry of

insurance as Public Health (4)
proportion of
total expenditure – – – 3 5.6 4.7 (2012) National Health
on health (%) Accounts (6)
Proportion of 5.4 (2000) Office of

households 2.0 (2006) National
experiencing Economic
catastrophic 3.9 (2009) and Social
health Development
expenditure (%) Board (2)
Life expectancy at birth has gradually increased, The Thailand economy has improved over time, as
reaching 70 years for males and 77 years for females in reflected in the increase in gross domestic product
the mid-2000s, with a period of stagnation due to the (GDP) per capita per year from US$ 700 in 1970
HIV/AIDS epidemic in the 1990s (7). Life expectancy to nearly US$ 6000 in 2014, and a decline in the
of females exceeds that of males, due to higher Gini coefficient (measuring income and wealth
mortality rate among men attributable to accidents, inequality) from 44.2 in 1970 to 40.0 in 2010. Total
risk-carrying work and unhealthy behaviours, though health expenditure as a proportion of GDP increased
women suffer more from disability (1). from 3.5% in 1998 to 6.5% in 2014. Regarding trends
in source of financing for health expenditure, before
Adult mortality has been declining over time for
the economic crisis in 1997, household out-of-pocket
both males and females. For males, the mortality
expenditure was the major contributor to health care
rate declined from nearly 240 per 1000 in 2000 to
spending, but that subsequently dropped from 44.5%
205 per 1000 in 2010. The mortality rate among
in 1994 to 12.4% in 2011, due to full implementation
females decreased from 117 per 1000 in 2000 to 101
of the Universal Coverage Scheme in 2002 (2, 5, 6).
per 1000 in 2010, though stagnation was observed
from 1997 to 2003, possibly due to HIV/AIDS. The Primary health services in Thailand are generally
decline in adult, infant and under-5 mortality rates provided through networks of health centres, mostly
indicate improved life expectancy at birth for both at subdistrict (tambon) level, termed “tambon
males and females (3, 4). Overall data indicate that health-promoting hospitals” and run by the Ministry
noncommunicable diseases have become the main of Public Health; and public health centres run by
causes of death, whereas infectious and parasitic the Bangkok Metropolitan Administration. The public
diseases have declined. health centres, which are available only in Bangkok,
are staffed by between one and three physicians
and allied health personnel, and provide curative,

6
preventive, and promotive (but rarely rehabilitative) 13th region (Bangkok Metropolitan Area) were still
services. The health centres or tambon health- incomplete, especially for the private sector (4).
promoting hospitals are usually located in the
With regard to health services utilization, unless
rural areas of provinces and are mainly staffed by
there is reimbursement through the national health
non-physician staff such as nurses or public health
insurance scheme and social security scheme, any
officers. Promotive and preventive services are the
patients in Thailand can, without any filtering by
main functions of these health centres. However,
general practitioners or family physicians, access
they also offer some basic curative and rehabilitative
medical specialists. Such a system is prone to
care to people living in their catchment areas (4).
inefficiency, redundancy, and unnecessary diagnosis
Throughout the 1970s and 1980s, Thailand and treatments. To increase the efficiency and
implemented reforms designed to increase effectiveness of the health system, the Ministry of
geographical access to primary health care (PHC) Public Health, following consultation with other
services by increasing and improving the rural major stakeholders, has announced a restructuring
health infrastructure and increasing the supply of of national health services, which involves
PHC providers outside the large urban centres. From implementation of district health systems to enhance
1982 to 1986, the Government of Thailand halted community-based and multisectoral collaboration,
new investments in urban hospitals and invested the introduction of service plans to strategically
money earmarked for these facilities into building rural counteract major health problems and strengthen
district hospitals and health centres. The government both infrastructure and the service system, and
built at least one PHC centre in all subdistricts in the establishment of primary care clusters with family care
country (9762 in total) and community hospitals in teams in the community, with the aim of providing
over 90% of districts, doubling the number of these better quality of essential health services (4, 8, 9).
hospitals by the mid-1990s (4).
The family care team is led by a family physician
In 2014, The Bureau of Policy and Strategy, under the working with a multidisciplinary team in the
Ministry of Public Health, electronically conducted community (4). The role of the family physician is to
the survey for Thailand’s public health resources provide primary and secondary care while reducing
report. Those resources included all 13 health the burden of tertiary care providers by preventing
service regional networks in accordance with unnecessary referral of patients to tertiary care. It is
the latest National Health Services System Policy. estimated that at least 6000 family physicians are
There were 13 357 health facilities providing public needed, and that target can be achieved in the next
health services at all health system levels (primary, 10 years.
secondary, and tertiary care), including 13 036
A summary of Thailand’s demographic, macroeco-
governmental health facilities (98%) and 321 in
nomic, and health profiles, and their relevance to
the private sector (2%). However, the data from the
PHC, is provided in Table 2.
Table 2. Thailand’s demographic, macroeconomic, and health profiles and relevance to primary health care
Profile Summary Relevance for primary health care
Demographic Thailand has evolved from a status of high fertility The ageing society will pose large long-term financial burdens on Thailand
profile and high mortality to low fertility and low mortality, and increase the critical needs of health care and long-term care systems.
with the fertility level of 1.6 in 2010 being below the Functional limitations and difficulties with self-care and other activities of
replacement level. This has had profound impacts on daily living increase sharply with age. Approximately 40% experience at
health service and social service development and least one such difficulty. Urbanization, with smaller family sizes, also requires
financing, which need to respond to a rapidly ageing advanced planning to handle challenges at community level through the
society. primary care system.
Continues…

7
Profile Summary Relevance for primary health care
Currently, major restructuring of the health services system is being undertak-
en in Thailand. The main changes include focusing on primary care provision
in the community through a multisectoral approach involving implemen-
tation of district health systems, aligning existing health services for more
effective and efficient processes through introduction of service plans, and
establishing multidisciplinary family care teams at the community level (7–9).
Macroeco- GDP per capita per year increased from US$ 700 Expanding health insurance coverage with a medicines benefit to the entire
nomic profile in 1970 to nearly US$ 6000 in 2014, while the Gini Thai population has increased access to essential medicines in primary
coefficient (measuring income and wealth inequality) care. However, increasing access is challenging for the government health
fell from 44.2 in 1970 to 40.0 in 2010. Total health facilities that serve most of the Thai population at primary care level, due to
expenditure as a proportion of GDP increased from their limited resources and related infrastructure. At present, government
3.5% in 1998 to 6.5% in 2014. Before the economic health facilities take most responsibility for the Universal Coverage Scheme
crisis in 1997, household out-of-pocket expenditure and the Civil Servants Medical Benefits Scheme, and nearly half of those
was the major contributor to health care spending, in the Social Health Insurance Scheme, which may be approximately
but that subsequently dropped from 44.5% in 1994 55–60 million people. However, the private sector is not heavily involved
to 12.4% in 2011, due to full implementation of the in the primary care market, and it may be a challenging task for Thailand to
Universal Coverage Scheme in 2002. develop an innovative care model of public-private partnership in coming
Despite favourable economic growth, income years.
distribution has not improved much – the Gini
index has never gone below 40. The fiscal space,
measured by a tax burden of 16–17% of GDP, though
not high compared to Organisation for Economic
Co-operation and Development (OECD) countries, is
slightly higher than the average of middle-income
countries, facilitating government spending on
health and education. Given the limited fiscal space,
investment in health infrastructure in the 1980s
and 1990s was only possible as a result of political
commitment and prioritized investment in district
health systems, and temporary slowing down of
investment in provincial health infrastructure.
Health profile Since 1999, the major causes of death have been The greatest public health benefits are gained through prevention.
noncommunicable diseases (NCDs). The proportions These benefits can be achieved if risk factors are identified and mitigated
of disability-adjusted life-years (DALYs) lost due to through appropriate interventions. If NCDs and other preventable illnesses
NCDs were 58.5%, 64.6% and 75.0% in 1999, 2004 are detected at an early stage and appropriate controls initiated, their
and 2009, respectively, while communicable diseases severity can be significantly reduced. The burden of NCDs usually falls
contributed 27.7%, 21.2% and 12.5% in the same disproportionately on the lower socioeconomic groups, who often face
years. The burden from a few preventable causes, higher exposure to risk factors and have limited access to health services.
such as traffic injuries, ischaemic heart diseases, Diseases such as diabetes and cardiovascular illnesses are often not detected
diabetes and alcohol dependence or harmful use, is until they reach advanced levels.
still high and challenging. In response to the increasing impact of NCDs, the Ministry of Public Health
has increasingly directed its attention to prevention and control initiatives,
such as identifying major behavioural risk factors classified by province,
collection and analysis of NCD and injury mortality and morbidity data,
monitoring trends, and evaluating the results of implemented interventions.
NCD and injury prevention and control programmes emphasize public
health and primary care approaches (rather than secondary and tertiary
treatment), which require effective multisectoral collaboration. Traffic
injury prevention and tobacco and alcohol control programmes cannot
be implemented by the health sector alone. The Royal Thai Government
has demonstrated a strong commitment to the control of tobacco use
and alcohol consumption by drafting legislation, particularly in the area
of advertisement. However, there remains the persistent challenge of
effectively reducing risky behaviour (smoking and alcohol consumption) and
increasing regular exercise and healthy diets. With respect to mental health,
the Department of Mental Health, Ministry of Public Health, is in the process
of developing the National Strategy on Mental Health based on the Tenth
National Health Development Plan. The success of these programmes is
reliant on effective planning, implementation, monitoring, and evaluation of
multisectoral interventions.

8
2. Data collection methods
Since the PHC system is of critical importance The PHC system in Thailand is closely integrated at
to modern-day Thailand, relevant stakeholders all levels. Key informants were therefore selected
have been engaged in research and development from among stakeholders representing a range
processes aimed at restructuring, reorganizing and of constituencies, including academia, PHC
strengthening the primary care system at all levels. system development, policy formulation and
For the purposes of this report, secondary data were implementation, health service planning, research
collected through searching available documents and development, and operational levels in both
from relevant databases, such as the Ministry of public and private sectors, thereby obtaining input
Public Health and its affiliates, the World Health from all aspects of the PHC system. Although the
Organization and the World Bank. Primary data public sector has mainly been responsible for PHC
collection was done through several meetings with provision in Thailand, there are increasing calls for
key informants to gather information on service greater private sector contribution. The process of
plans, health systems development and research. health system reform is very active in the country,
Annex 1 presents a list of key informants on the with major policy changes including introduction of
primary care system in Thailand. a region-based health services system, district health
system governance, and service plans for PHC.

9
3. Timeline
The Ministry of Public Health is the core agency in offices (named as “osot sapa”) were established in
the Thai public health system. The development of only some provinces. In 1932, rural health services
the ministry began in 1888 as the Department of were implemented in highly populated areas: first-
Nursing under the Ministry of Education. In 1918, level health centres with a physician (“suk sala”),
it became the Public Health Department under the and second-level health centres with no physician,
Ministry of Interior. The Ministry of Public Health was followed by several piloted projects in diverse areas
established in 1942 according to the Reorganization over a four-decade period aiming to expand more
of Ministries, Sub-Ministries and Departments Act, accessible health services to the population and to
B.E. 2485 (1942). Since then, there have been several respond to the challenge of emerging infectious
reorganizations, first in 1972, a second in 1974, a diseases (8).
third in 1992, and a fourth in 2002 (4, 8).
In order to strategically organize planning and policy
In 1999, the Decentralization Act was adopted by formulation for comprehensive health services, the
Parliament in order to transfer various activities Office of the Permanent Secretary was established in
held by central ministries, including education and 1972 at the Ministry of Public Health, and provincial
health services, to local government organizations. health offices were assigned to oversee both curative
However, in late 2002 all health care decentralization and preventive health infrastructures in each
movements were suspended because of changes province (4,8).
in government policy. During that time, the
During 1978, the year of the Alma-Ata Declaration
establishment of the National Health Security Office
on Primary Health Care, PHC was recognized as a
responsible for the Universal Coverage Scheme
national health development priority under the
resulted in a major shift of financial power from
Health for All Policy. Advocacy was considered as an
the Ministry of Public Health to the National Health
important factor in creating the Office of the Primary
Security Office. The conventional supply-side
Health Care Committee, implementing the Charter
financing through annual recurrent budget allocation
for Health Development, and strategic developments
to health care facilities owned by the Ministry
at community level, including introduction of village
of Public Health ended, with the service-related
health volunteers and village health communicators.
budget transferred to the National Health Security
An innovative public health tool that successfully
Office. Allocation was then based on the catchment
improved accessibility for the poor was founded
population for outpatient services and the service
in 1983 – the “health card”. Measures to combat
load for inpatient services. However, the ministry
shortages of human resources, money and materials
still retains responsibility in the areas of regulation,
and to counteract use of non-standardized methods
consumer protection, implementation of related
included such directed interventions as the PHC
public health laws, and health services provision. This
campaign with basic minimum needs, setting up
shift, splitting the role of purchaser (National Health
village development funds, and establishing an
Security Office) and provider (Ministry of Public
Association of Southeast Asian Nations (ASEAN)
Health), has had major ramifications for the ministry
training centre for PHC development with four
and its relationship with the National Health Security
regional training centres. Sociodemographic and
Office (4, 8).
political changes, as well as identified needs to unify
The development of PHC in Thailand is depicted the implementation processes toward health equity,
in Figure 1. In 1913, public health and medical coverage and access, prompted the Ministry of

10
Figure 1. Timeline of PHC development and relevant policies in Thailand
Thailand Primary Health Care System Development
1932
Starting Rural Health Services
1950
Tropical Diseases
Control Program 1964
Wat Boat project
1966
Sarapee and Banpai projects
1968
Health centers
1974
Lampang, Samoeng,
Nonethai projects 1975
Expanded community hospitals
1978
PHC as national health development strategy
under Health for All Policy 1979
Community of national PHC
1980
Office of PHC committee
The Charter for Health Development 1981
Village health volunteers (VHV) and Village health
1983 communicators (VHC)
Health card project
1984
• PHC campaign with basic minimum needs
1985 • Village development fund
7 projects for population quality of life • ASEAN Training Center for PHC Development
• 1984–6 Four regional training centers for PHC development
1991
Community PHC centers
1993
VHV clubs
1994
All VHCs were upgraded to VHVs
1997
• Regional center at Yala (very south of Thailand)
1998 • New constitution with economic crisis
National budget re-allocation
2001
• Decentralization Act
2002 • National health insurance Act/Universal Coverage Policy
• Village of health management • Thai Health Promotion Foundation
• Office of PHC turned into PHC division 2004
• Endorsement of Primary Care Services Policy PHC was transferred to be under local
2007 administrative organizations
• National Health Act
• Tambon health fund with strategic roadmap 2009
VHVs as community health managers
2010
Tambon health
management project 2011
Upgrade health centers to Tambon
2013 health promotion hospital (THPH)
Support essential materials
and resources to VHVs

11
Public Health to reallocate resources and restructure Decentralization Act endorsed the official roles of
significant community-based components, community-level actors, enhancing their ability
for example by upgrading all village health to contribute to health system development. In
communicators to village health volunteers (8). addition, projects and funds were implemented at
subdistrict (tambon) level, and health centres were
Several years after the introduction of the new
redefined as tambon health-promoting hospitals.
Constitution in 1997, the Decentralization Act,
District health systems were also formed to foster
National Health Insurance Act, Universal Coverage
local action through multisectoral collaboration in
Policy, and the Thai Health Promotion Foundation
health systems development (9). Table 3 assesses
were deployed in order to streamline the public
the barriers and enablers pertinent to key PHC
health and health care services system, and to
developments in Thailand.
ensure health security for the population. The
Table 3. Key PHC developments in Thailand: barriers and enablers
Development Barriers Enablers
Village health communicators, village Limited resources Health inequity

health volunteers, health centres Alma-Ata Declaration
Policy advocacy
Decentralization in health system Changes in government policy None

Balance of power among related stakeholders
Establishment of National Health Security Impact on Ministry of Public Health Policy advocacy
Office responsible for Universal Coverage administration and on balance of power between
Scheme purchase and provider, which has created
resistance and some friction
District health systems, service plans, None Policy advocacy

primary care clusters, family care teams Financial impact of Universal Coverage
Scheme on government health care facilities
Sustainable Development Goals and National
Economic and Social Development Plan
Sources: 8–11.

12
4. Governance and PHC-related infrastructure in Thailand
The Thai population is eligible for health services • District health system. Health management
financially covered by three main schemes – the at district level aims to coordinate and work
Universal Coverage Scheme, the Civil Servants effectively through multisectoral collaboration.
Medical Benefits Scheme, and the Social Health The district health system is the official mechanism
Insurance Scheme. Structurally, there is at least at local level to streamline Health in All Policies,
one tambon health-promoting hospital in each strengthen implementation and monitor progress,
subdistrict, which covers approximately 5000 as well as operating as a channel to co-invest
people. At the district level, there is at least one available resources from local stakeholders into
district hospital with 30–120 beds covering a health systems development (4).
population of around 50 000. At the provincial level, • Primary care cluster. Health prevention,
Three governance models have recently been implemented:
there is a general hospital covering a population of promotion, and other primary care services are
 Region-based health services system. Thirteen regional management offices have
approximately 600 000, and some general hospitals provided comprehensively through family care
been established in order to manage and reallocate available resources effectively and
have been upgraded to regional hospitals for teams comprising
efficiently (Figure 2) (4, 9).family physicians and local
referrals. At the top level of the system, there are multidisciplinary

District health system. health
Health personnel
management at(4, 9). level aims to coordinate and
district
11 medical school hospitals, five of them located work effectively through multisectoral collaboration. The district health system is the
The relationship
official mechanismamong
at localmajor stakeholders
level to streamline and
Health in their strengthen
All Policies,
in Bangkok. PHC in Thailand is mostly provided by
roles implementation
in PHC in Thailandand monitor progress, as well as operating as a channel to co-invest
is shown in Figure 3 (4, 8, 9).
government health care facilities at all levels. At available resources from local stakeholders into health systems development (4).
Most human resources are in the government-based
present, the Thai Government aims to control total  Primary care cluster. Health prevention, promotion, and other primary care services
system, except those in private hospitals and private
are provided comprehensively through family care teams comprising family
health expenditure and reduce the burden of work
clinics.physicians and local multidisciplinary health personnel (4, 9).
for higher-level health care facilities by strengthening
The relationship among major stakeholders and their roles in PHC in Thailand is shown in
PHC at community level (4, 8, 9). Figure 3 (4, 8, 9). Most human resources are in the government-based system, except those in
private hospitals
Figure and private clinics. health services system
2. Region-based
Three governance models have recently been
in Thailand
Figure 2. Region-based health services system in Thailand
implemented:
• Region-based health services system.
Thirteen regional management offices have been
established in order to manage and reallocate
available resources effectively and efficiently
(Figure 2) (4, 9).
17

13
Figure 3. Governance and PHC-related services infrastructure
MoPH
Region based health
NHSO services system
CSMBS MOI
SSO
FDA OPS
CSMBS DOH DDC
National Health Assembly and Civic Movement

Provision of
Funding for Sanitation and
Prevention Disease Control
Promotion
and Care Services
PHO
Social determinants of health

DHS/PCC
Environment control
RH/GH DHO DH Local Administrative Office
PCU/HC/THPH
Matching fund (NHSO)

LHF Matching fund
Private hospitals
Private clinics Community health and services THPF NHCO MONRE
Key: NHSO, National Health Security Office; MoPH, Ministry of Public Health; CSMBS, Civil Servants Medical Benefits Scheme; SSO, Social Security Office; FDA,
Office of Food and Drug Administration; OPS, Office of Permanent Secretary; DOH, Department of Health; DDC, Department of Disease Control; PHO, Provincial
Health Office; RH/GH, regional hospital/general hospital; DHO, district health office; DH, district hospital; PCU/HC/THPH, primary care unit/health centre/tambon
health-promoting hospital; LHF, local health fund; DHS/PCC, district health system/primary care cluster; THPF, Thai Health Promotion Foundation; NHCO, National
Health Commission Office; MONRE, Ministry of Natural Resources and Environment; MOI, Ministry of Interior.

14
5. Financing
The Thai health care system has been financed by and children aged under 12 years, and including
a mixture of health financing sources, including all previously uninsured people.
general taxes, social insurance contributions, private
Regarding the financing sources for PHC mentioned
insurance premiums and direct out-of-pocket
above, the public share of total health expenditure
payments. Health expenditure is income elastic; in
significantly increased while household out-of-
the 1997 Asian economic crisis, for example, health
pocket payments dramatically declined after the
spending was reduced by both the government
Universal Coverage Scheme was fully implemented
and households. The Universal Coverage Scheme,
in 2002 (Tables 4 and 5) (1, 8). Overall financial flows
which was fully implemented in 2002, significantly
are shown in Figure 4 (8, 9).
increased the public share of total health spending,
while household out-of-pocket payments strikingly
decreased. This is because the scheme is financed Table 4. Health care spending profiles,
by general taxation, with a huge coverage of more percentage of total health expenditure
than 75% of the total population. After achieving Health spending 1994 2000 2010 2012
universal coverage in 2002, there have been three Outpatient care 42.6 40.7 42.1 29.2
major public insurance schemes providing health
Ancillary services 0.0 0.1 0.1 0.2
insurance coverage for the entire population (9, 12):
Prevention and public 7.1 8.2 10.3 6.2
health services
• Civil Servants Medical Benefits Scheme, which
covers around 5.2 million people (as of early Source: National Statistical Office (1).
2010), specifically government employees and
their dependents (parents, spouses and children) Table 5. Health care spending by source of fund,
as well as pensioners; percentage of total health expenditure
• Social Health Insurance Scheme, which covers Health spending 1994 2000 2010 2012
approximately 13.9 million employees (as of early Government general 41.7 50.8 66.6 68.4
2016) in the formal sector for non-work-related expenditure
health care expenditures; Social health insurance 2.9 5.3 7.7 7.3
• Universal Coverage Scheme, which covers the Out-of-pocket 44.5 33.7 14.2 11.6
rest of the population, nearly 49 million people
Private voluntary 1.8 3 5.6 4.7
in 2016, and replaces all previous government- health insurance
subsidized health insurance schemes, namely the Traffic insurance 2.4 2.6 2.3 1.8
health card, voluntary health card or low-income
Employer benefit 6.2 4 2.1 1.6
card scheme for the poor, the disabled, the elderly,
Source: Thailand health systems review (8).

15
Figure 4. Financial flows of PHC services in Thai health system
Risk related contribution

Tripartite contribution and Payroll tax
Services
Patients Population General tax
General tax
Copayment
Public and Private
providers/contractor
networks
Budget with DRG (In-patient) Fee for services (Out-patient)

CSMBS
Standard benefit packages with capitation and global

UCS
Capitation
SHI
Fee for services

Voluntary private
insurance
(CMBS: Civil Servant Medical Benefit Scheme; UCS: Universal Coverage Scheme; SHI: Social Health Insurance)

16
6. Human resources
Over the last four decades, Thailand has directed fourth year of the Ministry of Health rural service
substantial investment and planning into programme, only 51% of CPIRD physicians and 44%
strengthening its PHC system to attain universal of non-CPIRD physicians remained (15).
health coverage. To achieve this goal, Thailand has
The distribution of physicians between rural and
recognized the need to reduce the high levels of
urban areas has fluctuated over time, influenced by
inequality between income groups and between
the rise in the number of private hospitals, which
rural and urban populations. Thailand’s health
are primarily in urban settings and serve wealthier
reforms have prioritized strengthening district
populations. In 2007, doctor density in Bangkok was
health systems with a strong pro-rural and pro-poor
10 times higher than that in the most rural areas of
focus. Many of Thailand’s reform initiatives were
the country. In response, to incentivize physicians
directed towards two major goals: (a) expanding the
to work in rural hospitals, the government created
geographical accessibility of effective primary health
a financial scheme that supplemented physician
care; and (b) protecting the poor from unaffordable
income with a monthly allowance, and in 2008,
health costs and improving the financial accessibility
physicians in rural areas received 10–15% more per
of primary health care (13).
month compared to new physicians in urban, non-
During 1960–1975, around 25% of physicians trained private hospitals (14).
in Thailand emigrated out of the country, primarily
To further expand the primary health care workforce
to the United States and the United Kingdom. This
in rural areas, Thailand introduced village health
created a shortage of physicians throughout the
volunteers to engage closely with people in the
country, particularly in rural areas. Starting in 1972,
community. Their responsibilities include promoting
Thailand required all graduates from public medical
primary health care across the country, helping
schools to work for three years in the public health
control communicable diseases, and providing basic
facilities in Thailand or pay a significant penalty fee
care services to the local areas. The village health
(14).
volunteers offer home visits to provide follow-
In the era of the Alma-Ata Declaration and Health up care and serve as a link between clinical care
for All, Thailand deployed physicians to rural areas, and community resources. At these home visits,
resulting in a fourfold increase in the number of village health volunteers might take the patient’s
rural-based physicians from 300 to 1162 by the mid- blood pressure, provide emotional and mental
1990s. To supplement those numbers and further support through family counselling and informal
incentivize physicians to work in rural locations, conversations, and provide information on healthy
the Collaborative Project to Increase Rural Doctors lifestyles. Additionally, they also help with various
(CPIRD) began in 1974, which provided medical community projects and connect residents with
education opportunities to those with a rural traditional medicine resources. The village health
background; students were recruited from rural volunteers are from the local community, which
regions, trained, and returned to their home area helps ensure that they fully understand the cultural
to practise. The CPIRD has been successful, with a context of their community’s health care needs and
rate of 14.9% of physicians leaving rural areas over can provide appropriate physical and emotional
an 11-year period, compared to 17.6% of physicians support to individuals and families. Up to now,
not under the CPIRD. However, long-term success there are approximately 700 000 trained volunteers
has still been challenging; it was found that in the throughout the country (12).

17
Thailand’s village health volunteers have proved Figure 5. Family medical care team and its
effective in contributing to successes in public health components
activities, such as HIV prevention and control, avian Family medical care team
flu surveillance, and oral health in children, to the
extent that the World Health Organization identified Family doctor
the programme as a global model for community-
based public health (12).
Other
health Nurse
However, it is widely accepted in Thailand that workers
information on the numbers and distribution of the
health care workforce are not reliable, and urgent
measures are needed to strengthen the information Home-based
care
system. Available data indicate that the numbers Occupational Physical
therapist therapist
of doctors, dentists, pharmacists and nurses have
increased over time. The number of health personnel
Dentist
per 1000 population was 0.39 for physicians (2014),
2.3 for professional nurses (2014), and 2.9 for
community health workers (2000) (14).
The Ministry of Public Health has restructured the
Table 6. Profiles of physicians, nurses,
primary care system by dividing the country into community health workers, and traditional
13 region-based health service areas, supported practitioners in Thailand
by district health systems that encompass
Variables Results
multisectoral collaboration (4). Each area is served
Number of physicians per 1000 2013 0.39
by a multidisciplinary team led by a family medicine population
2014 0.47
physician working with allied health professionals
Number of nurses per 1000 2013 1.97
in the form of a family care team, as defined in population
2014 2.30
Figure 5 (4, 9). However, the numbers of related
Estimated number of community 2013 497 037
professionals are still inaccurate, and are estimated health workers
2014 612 943
to be inadequate. For instance, 6000 family medicine
2015 679 476
physicians are needed in the system, but it will take
10 years to produce that number (4, 9). A summary of 2016 697 402
health personnel data in Thailand is shown in Table 6. 2017 696 018

2000 2.9 per 1000
(16) population
Relative Physi- Bangkok 2014 1:722
geographical cians
distribution Others 2014 1:1634 to 1:4153
(number Nurses Bangkok 2014 1:203
of health
personnel: Others 2014 1:373 to 1:653
number of
population) Com- Bangkok No data
munity
health Others Total, 696 018
workers 2017
Proportion of informal providers 2016 Approximately 10%

and practitioners of traditional (20 000:200 000)
complementary and alternative
medicine, out of the total health care
workforce
Sources: 8, 9, 15, 16.

18
7. Planning and implementation
Primary health care (PHC) under the Universal are under the Ministry of Public Health and their main
Coverage Scheme is delivered through contracting staff are junior sanitarians (two years of training) and
units for primary care, which have minimum staffing technical nurses (two years of training). However,
requirements and consist of networks of tambon after the implementation of the Universal Coverage
health-promoting hospitals and a district or other Scheme, numbers of registered nurses (four years of
hospital. In rural areas, where qualified staff are training) increased from 1766 in 2006 to 10 274 in
available only in hospitals, the health centres have 2011, though shortages of human resources are still
to collaborate with the district hospital to constitute encountered in many areas (8).
a contracting unit for primary care, which often
Private pharmacies in the community have served
consists of a network of public services in the
the population at the front line as a conveniently
district, so that one contracting unit is equivalent to
accessible self-care system with affordable out-
one district. In urban settings there could be several
of-pocket expenditure, but must be operated by a
hospitals in the same area and several doctors in
registered pharmacist. Population health promotion
health centres. Each contracting unit for primary
and preventive services in Thailand are mostly
care can comprise several health centres plus one
provided under the Universal Coverage Scheme. In
hospital, or a group of health centres or even private
addition, the Thai Health Promotion Foundation Fund,
clinics if they fulfil the human resources criteria.
financed by an additional surcharge on tobacco and
Private clinics have often formulated a contracting
alcohol excise tax, supports social determinants of
unit with only one PHC unit, and this contracted
health activities, managed by an autonomous public
PHC unit is called a “warm community clinic”. In
organization. Emergency medical services, including
2010, there were 937 contracting units for primary
pre-hospital and hospital accident and emergency
care and 11 051 contracted PHC units in the public
services, are now effectively universal and are fully
sector, and 218 contracting units for primary care
financed by general taxation, with patients able to
and 224 contracted PHC units in the private sector.
access the nearest emergency department when
Secondary care and tertiary care are provided by the
necessary. Pre-hospital care is divided into first
hospitals, mainly on referral up the system (from PHC
response, basic life support, intermediate life support
to district to provincial or regional). For the Social
and advanced life support. Access to rehabilitation
Health Insurance Scheme, patients must go to the
services and assistive devices has increased, but
registered health facility, whereas the Civil Servants
those in urban areas have much greater access than
Medical Benefits Scheme offers more flexible ways
those in rural areas. Dental and oral health services
for the patients to get access, by electronic payment
are available at all levels of the public health system,
at registered point of care or non-registered health
though there are still regional differences in dentist
facilities with later reimbursement (4, 8, 9).
availability. In Thailand, long-term care and palliative
The number of outpatient contacts per person per care are culturally considered as family members’
year increased continuously from 2.0 in 2004 to 3.6 in responsibility (spouse, children, and grandchildren).
2010. In 2009, the figures showed that PHC services Higher numbers of elderly and those patients in need
were provided through 10 347 health centres or of long-term care without access to family-based
tambon health-promoting hospitals, 17 671 clinics, care are an urgent issue for State and private care
992 outpatient departments of public hospitals, and provision, through home-based supportive services,
322 outpatient departments of private hospitals. All paid caregivers, or institutional care. More cases in
health centres or tambon health-promoting hospitals need of human rights protection are noted (8, 9).

19
In response to emerging health problems and the primary and holistic health care. Health facilities
major burden of disease in Thailand, the Ministry under the Ministry of Public Health use the 15
of Public Health has taken the lead in restructuring service plans as the basis for implementation of
the national health system by deploying three main their operational plans. The goals of the service
policies (4, 8, 9): plans include care provision by the family care
teams, establishment of long-term community
• Region-based health services system.
care systems, and health promotion for the elderly,
The aims of this policy are to facilitate better
disabled and vulnerable groups.
sharing of related resources within each region
• District health systems. These call for
– not only finances, but also human resources,
multisectoral collaboration in the community
information, medicines and technologies – and to
using such strategic approaches as “U-CARE” –
strengthen the referral system across care levels
an acronym denoting Unity district health team,
within regions to enable more efficient services.
Community participation, Appreciation, Resource
However, results from the Bureau of the Inspector,
sharing and human development, and Essential
Office of the Permanent Secretary, Ministry of
care provision. It is also believed that the district
Public Health, demonstrate high variability across
health system could be an active participatory
different regions and service plans.
model that can harmonize upstream and
• Health services development plans. These
downstream processes of the health services
plans, also known as service plans, comprise
system in Thailand.

20
8. Regulatory processes
Every health scheme has its own rules and regulations, • The Social Health Insurance Scheme is a part of
adding to the complexity of the health care system the comprehensive social security system, as
in Thailand. In 2008, nearly 77% of hospitals were mandated by the Social Security Act, 1990, for
public, mostly owned by the Ministry of Public non-work-related conditions; and the Workmen’s
Health, and a few by other ministries, while 22% were Compensation Act, 1972 (amended in 1974) for
private and 1% were state and local government work-related injuries, disabilities and mortality.
enterprises. There were 17 671 private clinics, mostly The Social Security Office of the Ministry of Labour
single practice, and 17 187 private pharmacies in manages the Social Health Insurance Scheme.
2009, almost all located in urban municipalities. • The Civil Servants Medical Benefits Scheme is
Each ministry and local government has its own mandated by the Royal Decree on Medical Benefits
regulation mechanisms for its own hospitals. of Civil Servants, 1980, and its major amendment
Private health medical institutions are licensed and in 2010. The Ministry of Finance Comptroller-
relicensed annually under the Sanatorium Act, 1998 General Department manages the scheme.
(Medical Premises License Act) in line with stipulated • The Universal Coverage Scheme is mandated by
quality and standards. The Bureau of Sanatorium the National Health Security Act, 2002. By law, the
and Art of Healing, Department of Health Services National Health Security Office is responsible for
Support, Ministry of Public Health, is responsible for managing the Universal Coverage Scheme.
overseeing all private health care providers (4).
The characteristics of the governance and
There are three public health financing schemes management structures of the three public health
covering the entire population (9). The Social Health insurance schemes are shown in Table 7 (8, 12, 17).
Insurance Scheme covers private sector employees Note that they are public agencies and use public
(without dependents, except for maternity benefits); funds, and are all are therefore subjected to financial
the Civil Servants Medical Benefits Scheme covers audit by an internal auditor and external audit by the
civil servants, pensioners and their dependents Auditor-General.
(including spouses, children aged under 20 years and
All services, diseases and health conditions are
parents); and the remaining population is covered by
covered by the health insurance schemes, with a few
the Universal Coverage Scheme. All schemes have
exceptions. The benefit packages differ as a result
been established by specific laws.
of different paces of historical evolution of these
schemes.
Table 7. Characteristics of governance structures of three main insurance schemes in Thailand

Universal Coverage Social Health Insurance Civil Servants Medical Benefits
Characteristics Scheme Scheme Scheme
Legal framework National Health Security Act, Social Security Act, 1990 Royal Decree, 1980, and amendment,
2002 2010
Type of organization Autonomous public agency Social Security Office under Ministry Bureau of the Comptroller-General
of Labour Department of the Ministry of Finance
Governing board Administrative board chaired by Administrative board chaired by the Advisory board chaired by the
Minister of Public Health Permanent Secretary of the Ministry Permanent Secretary of the Ministry of
of Labour Finance
Administrative budget 0.93% (2015) 8.11% (2015) Negligible

21
8.1 Regulation and governance of the implementation of the National Strategic Plan. It
providers also serves an advisory role to the Cabinet on human
resources for health issues (19).
Each ministry and local government has its own
regulation mechanisms for its own hospitals. The first National Medical Education Forum was
Private health medical institutions are licensed and convened in 1956. Since then, the forum has been
relicensed annually under the Sanatorium Act 1998 held every seven years to review progress and
(Medical Premises License Act) in line with stipulated redirect medical education in line with country health
quality and standards. The Bureau of Sanatorium and health system needs and the requirements of
and Art of Healing, Department of Health Services medical curriculum reforms. The forum includes
Support, Ministry of Public Health, is responsible medical education constituencies and the Ministry
for overseeing all private health care providers. of Public Health. As most decisions by the National
Historically, the Medical Premises License Act has Medical Education Forum have concentrated on
only applied to the private sector; all public providers medical curriculum reform, it has tended to lose sight
are exempt from licensing. At present, the Royal Thai of the increasing proportion of specialists, despite
Government is under the process of launching a concerns voiced by the Ministry of Public Health (8).
new Medical Premises Act to cover both public and All training institutions, public and private, must
private sectors by putting in place a national hospital be accredited by the Ministry of Education, while
accreditation system (4, 8, 9). curricula are accredited by concerned professional
8.2 Human resources planning and councils before student recruitment. The numbers of
training institutions and their graduates in 2009 are
registration summarized as follows:
Several agencies are involved in the planning and
management of human resources for health: the • Medical doctors: 19 medical schools (18
Ministry of Public Health, the main employer of the public, 1 private). The average annual number
health care workforce; the Ministry of Education, of medical doctor graduates between 2000 and
overseeing training institutions; the National 2009 was 1423.
Economic and Social Development Board, for • Dentists: 10 dental schools (9 public, 1 private).
macroeconomic policy; the Civil Service Commission, The average annual number of graduate dentists
for public sector employment and postgraduate between 2000 and 2009 was 415.
training; the Bureau of the Budget, overseeing the • Pharmacists: 14 pharmacy schools (11 public, 3
annual budget proposals; and the professional private). The average annual number of graduate
councils, responsible for the licensing or relicensing pharmacists between 2000 and 2009 was 1159.
of professionals. All these organizations work in • Nurses: 75 nursing schools (65 public, 10
isolation, lacking coordination and synergies (18). private). The average annual number of graduate
nurses between 2000 and 2009 was 5091.
In 2006, the Ministry of Public Health led the
development of the National Strategic Plan The professional councils – Medical, Dental,
for Human Resources for Health 2007–2016 in Pharmacy, and Nursing and Midwifery – are
consultation with partners. The plan was discussed responsible for their particular national licence
in the National Health Assembly, from where a examination, as required by all students to obtain a
resolution was submitted and endorsed by the licence for professional practice, in order to ensure
Cabinet in April 2007. A National Human Resources similar qualifications and professional standards
for Health Committee, comprising representatives of regardless of their training institutions.
all relevant organizations, was established to facilitate

22
8.3 Regulation and governance of and their amounts), and dossiers showing that the
pharmaceuticals products meet legal requirements. For new drug
products – that is, products containing new chemical
The Thai Food and Drug Administration of the Minis- entities, new combinations or those with new routes
try of Public Health is the national regulatory agency of administration – evidence from preclinical and
for pharmaceutical products, which, according to Thai clinical studies are mandatory submissions (4, 8).
laws, include modern and traditional medicines and
biological preparations (Drug Act B.E. 2510, 1967). Reg- Modern medicines are classified into three categories:
ulation of psychotropic substances and narcotics with over-the-counter drugs, dangerous drugs, and
therapeutic uses is under the responsibility of the Food specially controlled drugs. Over-the-counter
and Drug Administration. To undertake pre- and post- products can be distributed through any premises,
marketing control of all pharmaceuticals, the Food and without requirement for the qualifications of the
Drug Administration works closely with the Depart- sellers. Dangerous and specially controlled medicines
ment of Medical Sciences of the Ministry of Public are available only in pharmacies, clinics and hospitals,
Health, which is the national laboratory agency (4). and may only be dispensed by pharmacists or
medical doctors. Dispensing of specially controlled
8.4 Entry of pharmaceuticals to the drugs requires a physician’s prescription. The sale
market and dispensing of traditional medicines is allowed by
traditional drug stores under supervision of licensed
Market authorization is required for all
traditional doctors or pharmacists. Advertisement of
pharmaceuticals, either locally manufactured or
pharmaceutical products of all categories is regulated
imported. Exceptions have been given to importation
by the Food and Drug Administration. Advertising
and production managed by public agencies,
medicines requires Food and Drug Administration
including Ministry of Public Health departments,
approval of the materials, soundtrack and related
the Government Pharmaceutical Organization, the
scripts. Only over-the-counter and traditional drugs
Defence Pharmaceutical Factory and the Thai Red
can be advertised to the general public (4, 8).
Cross Society (4).
Production of medicines in hospitals and freshly 8.5 Quality of medicines
prepared products for individual patients are also Registration of all locally produced or imported
exempt from the regulations, as stated in Drug Act B.E. medicines requires that information on their
2510, 1967. However, the production of psychotropic specifications, including quality standards, protocols
substances and narcotics for any purposes has to for quality assurance and testing, be submitted to
follow the provisions of respective laws. It should be the Food and Drug Administration. Bioequivalence
noted that despite the exception, the Government data are required in the case of generic drugs whose
Pharmaceutical Organization – the Ministry of Public original products have obtained approval in the
Health-controlled state enterprise – voluntarily country since 1991. Product samples submitted
follows the market authorization requirements (4). with registration files are sent to the Department
of Medical Sciences laboratory for testing of their
Market approval of pharmaceutical products
quality and analysis (4).
generally involves assessments of their safety,
efficacy, effectiveness and quality. Importers or The quality of pharmaceutical products
manufacturers of particular products are required manufactured in Thailand is ensured through the
to submit application for registration, together with enforcement of good manufacturing practice.
the content of container labels and package leaflets, Compliance with good manufacturing practice
drug formulas (active and non-active ingredients standards among local drug producers is inspected

23
by Food and Drug Administration officials. Regarding health insurance schemes (Civil Servants Medical
foreign-based manufacturers, the Thai authorities Benefits Scheme, Universal Coverage Scheme and
request good manufacturing practice certificates Social Health Insurance Scheme). The formulation of
issued by national regulatory agencies in the country this list is undertaken by a subcommittee under the
of origin. At the post-marketing phase, Food and Committee for National Drug System Development.
Drug Administration inspectors and pharmacists The drugs to be listed must have market approval
in provincial health offices, in collaboration with by the Food and Drug Administration. The
Department of Medical Sciences scientists, monitor subcommittee reviews the safety, effectiveness and
the quality of pharmaceutical products on the market some elements concerning quality of the products,
through testing of samples from the shelves (4). in comparison with drugs of the same category.
Prices, health needs and burden of disease are also
Container labels, leaflets, expiration, registration status
taken into account. Cost–effectiveness and budget
and storage conditions are also inspected during the
impacts are analysed for expensive drugs (4).
official visits to drugstores. Pharmacovigilance as
recommended by the World Health Organization is At national level, there is no regulation regarding
overseen by the Food and Drug Administration as an generic substitution. Although guidelines on
integral part of post-marketing control of medicines. this practice exist in public and private hospitals,
Major sources of information on adverse drug reactions significant variations occur across settings (21). It has
are mandatory reports by all health care professionals been argued that the capitation payment applied
in hospitals, clinics and pharmacies. For new drugs, by the Social Health Insurance Scheme and the
the manufacturers and importers are responsible for Universal Coverage Scheme and its consequences
safety monitoring and reporting for at least two years for budget constraints encourages the use of generic
after market approval (20). The monitoring period will drugs, especially in hospitals; generic substitution is
be extended in cases where questions arise (4). de facto applied extensively for beneficiaries covered
by the Social Health Insurance Scheme and the
8.6 Pricing and market access Universal Coverage Scheme (22).
Price regulation of pharmaceutical products is not well
established in Thailand. There has been no mechanism 8.7 Regulation of medical devices
in place to control retail and wholesale prices and The Medical Device Control Division of the Food and
margins; however, price negotiations are conducted Drug Administration is responsible for regulating,
daily at different levels, such as the Subcommittee controlling and monitoring the use of medical
for the Development of the National List of Essential devices in Thailand. By law, a device is licensed in the
Medicines, the National Health Security Office, which market if it achieves the performance intended by
is responsible for the Universal Coverage Scheme the manufacturer and meets standards for personal
as a strategic purchaser, and the pharmacy and safety. Unlike pharmaceutical products, there is no
therapeutic committees in individual hospitals. The requirement for clinical efficacy evaluation from
Reference Pricing Scheme for drugs on the National randomized control trials before market approval.
List of Essential Medicines is promulgated by the The Medical Device Control Division also controls
appropriate subcommittee under the Committee for post-marketing, such as inspection of manufacturing
National Drug System Development (4, 8). factories and implementation of appropriate
measures when unsafe medical devices are reported.
However, reference prices recommended by this
According to the revised Medical Device Act B.E.
scheme are effective only for drugs purchased by
2551 (2008), the assessment of the social, economic
government hospitals and health programmes. The
and ethical impacts of medical devices with a cost
National List of Essential Medicines is referred to as
exceeding 100 million baht (US$ 3.3 million) is
the pharmaceutical benefit package by all three

24
mandatory before market authorization (23). The • Decade of Health Centre Development
Ministry of Public Health needs to designate health (1992–2001);
technology assessment units inside and outside the • Health Care Infrastructure Investment Plan under
country to conduct these assessments, the costs of the Economic Stimulus Policy (2010–2013) (25).
which shall be shouldered by the industry. There is
Before the implementation of the Universal Coverage
neither a price ceiling nor a reference set for medical
Scheme in 2002, the highest proportion of the capital
devices or services provided. Price is determined
investment budget to the total health budget was
entirely by market demand and supply. There is
34.0% in 1997, and the average proportion of the
no reimbursement list for medical devices. Their
capital investment budget to the total health budget
distribution is controlled implicitly by the suppliers.
during 1994–2001 was 21.16% (26).
The coverage of use of medical devices varies greatly
The Universal Coverage Scheme totally changed the
across the three public health insurance schemes.
planning and capital budget allocation. The budget
The Civil Servants Medical Benefits Scheme covers
for the scheme was calculated on a per capita basis
almost all medical devices using a fixed-rate fee-for-
(capitation rate). Part of the capitation budget covers
service payment, whereas the Universal Coverage
capital replacement or depreciation cost, calculated
Scheme and Social Health Insurance Scheme
as 10% of the budget for ambulatory and inpatient
include use of medical devices as part of their basic
care, and this was intentionally misinterpreted by the
health care packages and support based on prepaid
Bureau of the Budget as a capital investment budget
capitation. As a result, inequitable access to and use
and affected their capital investment plan for some
of expensive medical devices, for example computed
years. The National Health Security Office managed
tomography (CT) scans, magnetic resonance
this capital replacement budget by transferring part
imaging (MRI) and mammography, have been noted
of it directly to their contracted health care providers
between the beneficiaries of the three public health
and keeping some to manage at the central level to
insurance schemes (4).
strengthen health care infrastructure at the PHC level
8.8 Regulation of capital investment and some excellent centres, such as trauma, cardiac
and cancer centres, in consultation with the Ministry
During the early phase of health care infrastructure
of Public Health. This capital replacement budget was
development in Thailand, the National Economic and
reduced from 10% of the curative budget to 6% in
Social Development Board and the Ministry of Public
2012. The Ministry of Public Health complained that
Health played a pivotal role in planning for capital
the new system operated after the establishment
investment through the use of the five-year National
of the Universal Coverage Scheme substantially
Economic and Social Development Plan (4, 8). As a
decreased its total capital investment budget. The
result, Thailand rapidly built up good geographical
Bureau of the Budget then allowed the Ministry of
coverage of rural health care infrastructure in the 25
Public Health to request a capital investment budget
years between the first plan (1961–1966) and the
directly from the government (4, 12).
fifth plan (1982–1986) (24). A capital investment plan
was developed later based on the demand of public Private sector investment in infrastructure is usually
hospital managers, or local resources mobilized by focused in urban provincial areas, where people have
reputable monks, with reference to criteria such as high purchasing power. The government has a policy
standards of hospitals at different levels. During the to support private investment in poorer areas where
last two decades, the government has established there are inadequate health care facilities through
specific policies to improve health care infrastructure, corporate income tax incentives for eight years and
and these have led to a substantial increase in the import duty exemption for major medical devices
capital investment budget. These policies included: (4, 22).

25
9. Monitoring and information systems
In 2016 a report from the Bureau of the Inspector, by different financing sources (including the three
Office of the Permanent Secretary, Ministry of public health insurance schemes) (4, 9).
Public Health, indicated that the information
Recently, the Ministry of Public Health has established
system should be strengthened in order to
an online health data centre to act as a centrally
achieve more effectiveness and efficiency of PHC
located database that archives key health indicators
services. Information on PHC implementation in
and performance indicators to help monitor progress
nongovernmental sectors was lacking and not well
in the operation of all health facilities. This tends to
organized. Additionally, some reflections from private
be more uniform and synchronized than previous
sector representatives showed that the primary care
systems.
level was not attractive from the business viewpoint
due to the limited profit margins – one reason
why most of the primary care services in Thailand
have been the responsibility of government health
care facilities. Only small to medium-sized private
hospitals currently provide primary care services
to their clients, whilst others mostly invest their
resources in strengthening specialized care (3, 7).
Health information management has been carried
out through two subsystems: population-based
and facility-based. The population-based health
information system includes household surveys
regularly conducted by the National Statistical
Office, and civil registration. The facility-based
health information system includes clinical, health,
and management information systems. However,
clinical and health information systems are yet to be
strengthened, since registries are scattered among
health care facilities and linking them remains a
challenge. For the information management system,
facilities within the Ministry of Public Health have
both 12-file and 18-file standard data as electronic
databases, but using different software. Exchange
of data between health care facilities is limited and
can be done only for administrative data, especially
claim data and some health service activities. In
practice, the primary health care indicators collected
at operational health facilities (tambon health-
promoting hospitals) are mostly in the form of
outputs with limited outcomes, and reliability is still
questionable. This may be due to frequent changes
in policy level and different IT systems implemented

26
10. Policy considerations and ways forward
Studies by Woratanarat et al. in 2015/2016 showed system and primary care cluster implementation,
that primary care services were understood differently and in the region-based health services system,
by health professionals, academics and the general need to be closely monitored in the context of
public (27). The surveys of nearly 3000 people under increasing concerns about health equity, calls
the Civil Servants Medical Benefits Scheme and for harmonizing benefits among different health
the Social Health Insurance Scheme demonstrated schemes, and limited resources in the government
that they expected primary care services to have sector. During implementation in the community,
six essential services to accommodate their needs: serious concerns have been raised by experts that
(a) treatment for general illnesses; (b) emergency current obstacles faced in the primary care system
medical services; (c) health promotion services; (d) are related to system governance and community
preventive services; (e) continuous care for chronic self-reliance rather than clinical competency issues.
diseases; and (f ) rehabilitative services. However, it It is recommended that system managers at national,
did not matter to those surveyed whether all services regional, and local levels explore how to enhance the
were provided at one place or only at traditional horizontal relationship among major stakeholders
health facilities (8, 9, 27). and decentralize tasks and decisions to those in the
community. Important policy-related topics to be
A call for innovative service models was raised
explored for primary care system development are
in order to make PHC services more culturally
summarized in Table 8. At present, Thailand is moving
appropriate, more efficient, more participative, and
toward a context-based and people-centred health
more widely adopted. Effective coverage should also
system in order to improve effectiveness, efficiency,
be considered as a metric for measuring services
and equity for all.
system performance. Weaknesses in district health
Table 8. Policy-related topics for primary care system development in Thailand

Priorities Type of respondent Health system level
Innovative models for primary care services Public health experts and academicians Regional and national
Governance model to ensure self-reliance and Public health experts, academicians, and District, regional, and national
community participation for sustainability community
Effective interventions and effective coverage Public health experts, academicians, and District and regional
in each area community

27
Annex 1. Key informants on primary care system in Thailand
Name and position Main area of Main constituency Level of health Source
expertise represented system at which
active
Ms Rati Sanguanrat Health services system Department of Health District, regional and Knowledge exchange
administration Services Support, Ministry national forum on primary care
of Public Health and noncommunicable
disease service plans
Research manager Health research Health Systems Research District, regional and
management Institute national
Dr Pornpimol Tantrathiwut Hospital Private Hospital Regional and national

administration Association
Deputy Secretary-General Public health National Health District, regional and

Commission national
Dr Jakrit Ngowsiri, Deputy Health insurance and National Health Security District, regional and
Secretary-General management Office national
Mr Thanapol Dokkaew, Networking Chronic Disease Patient Community

Chairman Network
Ms Aree Khumpitak Networking AIDS Access Foundation Community
Ms Yuwadee Akaniwan Social Health Social Security Office District, regional and
Insurance Fund national
management
Ms Worawan Arparat Health promotion Thai Health Foundation District, regional and
national
Dr Suphatra Sriwanichakorn, Primary care Office of Community- District, regional and Forum on health services
Director based Health Care national system development
Research and towards continuity and
Development coordinated care
Dr Worawut Kowachirakul, Hospital Sansai Hospital, Chiang District

Director administration Mai province, Ministry of
Public Health
Dr Aree Nisapanan, Director Hospital Satuk Hospital, Buriram District

administration province, Ministry of
Public Health
Dr Somchart Sujaritrungsri, Hospital Don Pud Hospital, District

Director administration Saraburi province,
Ministry of Public Health
Dr Orawan Tavetipong, Hospital Khao Yoi Hospital, District

Director administration Phetchaburi province,
Ministry of Public Health
Dr Patara Saenchaisuriya Community care Faculty of Public Health, District, regional and
Khon Kaen University national
Director and Research Health systems Health Systems Research District, regional and Forum on research for
Manager research Institute national strengthening primary
care system
Dr Supachok Vejapunbhesaj Health care Bureau of Policy and District, regional and
administration Strategy, Ministry of national
Public Health
Dr Komatra Chengsatiansup, Anthropology Society and Health District, regional and

Director Institute national
Dr Taweekiat Health policy National Health District, regional and

Boonyapaisalcharoen Commission national

28
References
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2. Office of National Economic and Social Development Board (http://www.nesdb.go.th, accessed 4 June 2017).
3. Burden of disease, Thailand (http://bodthai.net, accessed 4 June 2017).
4. Ministry of Public Health, Thailand (http://www.moph.go.th, accessed 4 June 2017).
5. World Bank data on Thailand (http://www.worldbank.org/en/country/thailand/research, accessed 4 June 2017).
6. National Health Accounts, International Health Policy Program, Thailand (http://ihppthaigov.net, accessed 4 June 2017).
7. Knodel J et al. The situation of Thailand’s older population: an update based on the 2014 Survey of Older Persons in Thailand. Report
15–847. Institute for Social Research, University of Michigan; October 2015.
8. The Kingdom of Thailand: health systems review. Health Systems in Transition. 2015;5(5).
9. Bureau of Policy and Strategy, Ministry of Public Health (http://bps.moph.go.th, accessed 4 June 2017).
10. Garabedian LF, Ross-Degnan D, Ratanawijitrasin S et al. Impact of universal health insurance coverage in Thailand on sales and market
share of medicines for non-communicable diseases: an interrupted time series study. BMJ Open. 2012;2:e001686. doi:10.1136/
bmjopen-2012–001686.
11. Huntington D, Hort K. Public hospital governance in Asia and the Pacific: comparative countries study. Volume 1, Number 1. Asia Pacific
Observatory on Health Systems and Policies; 2015.
12. Thailand health financing review. Thai Working Group on Observatory of Health Systems and Policy; 2010.
13. Wibulpolprasert S, Pengpaibon P. Integrated strategies to tackle the inequitable distribution of doctors in Thailand: four decades of
experience. Human Resources for Health. 2003;1(1):12.
14. Rohde J, Cousens S, Chopra M, Tangcharoensathien V, Black R, Bhutta ZA et al. 30 years after Alma-Ata: has primary health care worked in
countries? Lancet. 2008;372(9642):950–61.
15. Pagaiya N, Kongkam L, Sriratana S. Rural retention of doctors graduating from the rural medical education project to increase rural doctors
in Thailand: a cohort study. Human Resources for Health. 2015;13:10.
16. Health Data Centre, Thailand Ministry of Public Health (http://hdcservice.moph.go.th/hdc/main/index.php).
17. Primary health care performance initiatives (http://phcperformanceinitiative.org/promising-practices/thailand).
18. Jindawatana A, Jindawatana W et al. Planning for human resources for health. Journal of Health Systems Research. 1996;226–34.
19. National Strategic Plan for Human Resources for Health 2007–2016. Nonthaburi: Bureau of Policy and Strategy, Ministry of Public Health; 2009.
20. Jirawattanapisal T, Kingkaew P et al. Evidence-based decision making in Asia-Pacific with rapidly changing health-care systems: Thailand,
South Korea, and Taiwan. Value Health. 2009;12(Suppl. 3):S4–S11. doi:10.1111/j.1524–4733.2009.00620.x.
21. Tantai N, Yothasamut J. Panel session: Using evidence to support the use of appropriate drugs at right costs. 13th HA National Forum,
Impact Arena, Muang Tong Thani, 2012.
22. Tarn YH, Hu S et al. Health-care systems and pharmacoeconomic research in Asia-Pacific region. Value Health. 2008;11(Suppl. 1):S137–55.
doi:10.1111/j.1524–4733.2008.00378.x.
23. Teerawattananon Y, Tantivess S et al. Historical development of health technology assessment in Thailand. International Journal of
Technology Assessment in Health Care. 2009;25(Suppl. S1):241–52. doi:10.1017/S0266462309090709.
24. Wibulpolprasert S, editor. Thailand health profile 1999–2000. Nonthaburi: Bureau of Policy and Strategy, Ministry of Public Health; 2002.
25. Health Care Infrastructure Investment Plan under Economic Stimulus Package phase 2: 2010–2013. Nonthaburi: National Economic and
Social Development Office, Ministry of Public Health; 2009.
26. NaRanong V, NaRanong A. Capital investment for universal coverage. Nonthaburi: National Health Security Office; 2005.
27. Woratanarat T, Woratanarat P, Yamchim N et al. Primary care services system in urban setting. Health Systems Research Institute; 2016
(http://kb.hsri.or.th/dspace/handle/11228/4457).

29
This case study was developed by the Alliance for Health Policy and Systems Research, an international partnership hosted by the
World Health Organization, as part of the Primary Health Care Systems (PRIMASYS) initiative. PRIMASYS is funded by the Bill & Melinda
Gates Foundation, and aims to advance the science of primary health care in low- and middle-income countries in order to support
efforts to strengthen primary health care systems and improve the implementation, effectiveness and efficiency of primary health care
interventions worldwide. The PRIMASYS case studies cover key aspects of primary health care systems, including policy development
and implementation, financing, integration of primary health care into comprehensive health systems, scope, quality and coverage
of care, governance and organization, and monitoring and evaluation of system performance. The Alliance has developed full and
abridged versions of the 20 PRIMASYS case studies. The abridged version provides an overview of the primary health care system,
tailored to a primary audience of policy-makers and global health stakeholders interested in understanding the key entry points to
strengthen primary health care systems. The comprehensive case study provides an in-depth assessment of the system for an audience
of researchers and stakeholders who wish to gain deeper insight into the determinants and performance of primary health care systems
in selected low- and middle-income countries.
World Health Organization

Avenue Appia 20
CH-1211 Genève 27
Switzerland
alliancehpsr@who.int
http://www.who.int/alliance-hpsr

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PRIMARY HEALTH CARE SYSTEMS

Thira Woratanarat,a Patarawan Woratanarat,b Charupa Lekthipa

a. Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

CASE STUDY FROM THAILAND

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

CASE STUDY FROM THAILAND

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

CASE STUDY FROM THAILAND

Table 1. Key demographic, macroeconomic, and health indicators in Thailand

Population 3.1 3.0 2.2 1.2 0.5 0.4 (2015)

Population 67.1 87.4 106.3 118.7 128.5 –

Distribution of 86.8/13.2 83.0/17.0 81.3/18.7 68.9/31.1 56.6/43.4 49.6/50.4

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

Income or wealth 44.2 45.3 43.5 42.8 40.0 –

Life M 62.7 69.3 68.6 68.8 70.6 – National

Top 5 main 1.Circulatory 1.Circulatory 1. Malignant 1. Malignant Burden of

Total M – – – 236.7 204.8 –

Infant mortality – 46.3 26.4 15.2 11.2 12 (2011)

Under-5 mortality – 60 31.8 17.7 13.0 – Ministry of

Immunization Measles 99%, DTP3 90%, hepatitis B3 46%, Hib3 90% (2013) Ministry of

Total health – – – 3.8 3.8 3.9 (2012) Ministry of

3.4 3.9 4.5 (2012) National Health

CASE STUDY FROM THAILAND

Out-of-pocket 12.4 (2011) Ministry of

Voluntary health 10.3 (2011) Ministry of

Proportion of 5.4 (2000) Office of

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

CASE STUDY FROM THAILAND

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

CASE STUDY FROM THAILAND

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

Thailand Primary Health Care System Development

CASE STUDY FROM THAILAND

Table 3. Key PHC developments in Thailand: barriers and enablers

Development Barriers Enablers

Village health communicators, village Limited resources Health inequity

Decentralization in health system Changes in government policy None

District health systems, service plans, None Policy advocacy

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

referrals. At the top level of the system, there are multidisciplinary

CASE STUDY FROM THAILAND

National Health Assembly and Civic Movement

Social determinants of health

Matching fund (NHSO)

Private clinics Community health and services THPF NHCO MONRE

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

CASE STUDY FROM THAILAND

Risk related contribution

Budget with DRG (In-patient) Fee for services (Out-patient)

Standard benefit packages with capitation and global

Fee for services

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

CASE STUDY FROM THAILAND

health personnel data in Thailand is shown in Table 6. 2017 696 018

Proportion of informal providers 2016 Approximately 10%

Sources: 8, 9, 15, 16.

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

CASE STUDY FROM THAILAND

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

Immunization Measles 99%, DTP3 90%, hepatitis B3 46%, Hib3 90% (2013) Ministry of

health personnel data in Thailand is shown in Table 6. 2017 696 018