A Case Study on Resilience of the Local Health System in Thailand

Principle and Rational
The recent COVID-19 pandemic is only the last in a series of shocks to the Thai society, affecting the health status of people and the health system as much as the economic system. The consequences of the war in the Ukraine have already triggered worldwide consequences, which leads to new shocks in Thailand through decreasing economic growth, a slump in tourism and disrupted supply chains.
The unpredictable nature of shocks creates major challenges for policymakers, programme managers, health service managers, providers, and communities. Often, early warning systems are set up to enable crisis management when shocks hit. In Thailand, there are systems to monitor and ‘predict’ natural disasters such as floods, Tsunami and communicable diseases. The subsequent emergency response typically sets out to mitigate the impact of natural disasters on the population. Other shocks are more unpredictable in terms of timing, intensity, or geographical reach. These include disease outbreaks, political crises, financial meltdowns, and associated socioeconomic disruptions.
COVID-19 led to a renewed interest in the concept of resilience, which has been recognized in the field of ecology, urban studies, and engineering for a long time. The concept of resilience not only includes mitigation of impact and rapid adaptation of systems, but it also critically includes transforming systems so that they are better prepared for future shocks. The notion of health system resilience has a short history. It emerged among health system researchers and international agencies during and after the outbreak of Ebola in West Africa in 2014. Global warming, increasing inequity in health, and emerging new infectious diseases have only fanned the interest in the concept. It is widely acknowledged that health systems need to be resilient more than ever.
Thailand is one of many countries that underwent major crises in the 20th and early 21st centuries. Thailand has a population of approximately 72 million people (ESCAP 2024) and is situated in mainland Southeast Asia. The country changed its political system from an absolute monarchy to a parliamentary democracy in 1932. About 40 years ago, the military relinquished political power, and a multi-party political system emerged. During the last 70 years, Thailand’s economy has grown considerably, in the financing sector, the manufacturing industries, and the export of agricultural and seafood products 18,19. As a result, the World Bank classified Thailand as an upper-middle income country in 2011. The gross domestic product (GDP) per capita was 7,801 USD in Dec 2023. Half of the population lives in an urban setting. More than 90% of the people are Buddhists, and approximately 10% are Muslim or Christian.
During the last 25 years, several crises have affected the health system in Thailand at the local and national levels. Besides the economic crisis of 1997 and the political crisis of 2008 and 2014, the country was struck by natural disasters (the tsunami in 2004 20, and major floods in 2011 21) and disease outbreaks (Avian flu (H1N1) in 2003 9 , Swine flu (H5N1) in 2009, and COVID-19 in 2019) (Figure 1). These crises had a significant negative impact on the social determinants of health of groups of the Thai population and on their health status. In this PhD project, I will focus on the notion of multiple shocks and how sequences of shocks - serial shocks - impact the local health system (LHS). To do so, I will examine shocks that occurred during the period 2004 – 2020 in Thailand and the response to these serial shocks at the local health system level.
In the Thai health system, the local health system is the decentralized unit where health promotion, prevention, care and rehabilitation services are organized and provided to a population of around 30,000 – 50,000 inhabitants. It is managed by district health coordinating committee and consists typically of a district hospital and 10 - 20 health centres. Health districts coincide with the political-administrative boundaries and are overseen by a provincial health management team.
In 1996, the Thai economy started slowing down. Foreign debts increased and the stock market fell dramatically. In response to foreign speculators, the Thai government was forced to float the currency exchange rate. The devaluation pushed the crisis to a next level, which resulted in the economy's collapse in July 1997. This created, in turn, a window of opportunity for health system transformation. The political party that won the election in 1998 proposed universal health coverage as one of their innovative health policies. It initiated a health care reform project to reduce people’s health expenditures and set up social protection plans. Eventually, the financial shock was used by adept politicians and central-level health planners to adapt and transform the Thai health system. In 2002, Thailand achieved UHC.
The second shock was the 2004 tsunami, the most devastating natural disaster in modern history. It hit Thailand in the morning of Boxing Day, 2004. Around 230,000 people died as a result in Indonesia, Sri Lanka, and Thailand. The destruction of health facilities, loss of health workers, and shortage of medical supplies overwhelmed the health system. Public health facilities in nearby districts and provinces absorbed the workload as much as possible. Humanitarian aid came from over 30 countries, helping with the evacuation of injured patients, referral to provincial hospitals, identification of the deceased, and providing psychological support to the survivors. Thai citizens were financially protected under UHC and were ensured access to health services during this crisis. In the wake of the tsunami, lessons were learned, and new early warning systems were set up in areas prone to natural disaster across Thailand.
Thirdly, the floods of 2011 destroyed health facilities in the suburbs of Bangkok, cut off transportation and affected the Thai economy for more than six months. Many health facilities could not maintain their core functions during the flood. First-line health centers and volunteer physicians, nurses, other health professionals, and village health volunteers played important roles in delivering essential health services to people who were trapped in their houses.
Last but not least, in 2020 the COVID-19 pandemic struck Thailand. A shortage of medical supplies, health workers, and evidence-based data on the virus compounded the direct impact of the outbreak. Not only the Thai population but also low-skilled migrant workers were affected by the pandemic. More than 70% of migrant workers have public health insurance under the social security scheme (SSS) or migrant health insurance scheme, but barriers in access to health services persist. Language barriers, social stigma, and discrimination due to communicable diseases contribute to their vulnerability. In February 2021, the political instability and coup d’état in Myanmar compounded the problems, as refugees, asylum seekers, and workers migrated to Thailand. The local health system managed to absorb the increasing number of new cases among migrant workers, who were not financially protected, and to adapt their services to cope with the impact of COVID-19 in the communities. Multiple stakeholders collaborated to adapt the health service delivery and the health financing at the local level and to share resources.
It could be argued that the gradual development of the health and social security system (universal health coverage) and the sustained development of the health sector and perhaps, crucially, of the health workforce led to a situation where health and other managers effectively learned lessons after each shock that led to structural changes and thus transformation. Thailand has been considered as a success story in fighting with Covid-19, but is the Thai health system really resilient in the face of multiple shocks? Are local health systems resilient, and if so, why? Which factors contributed to this resilience?