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Context

The Exemplars in COVID-19 conceptual framework outlines key factors that could help explain countries’ COVID-19 burden and outcomes. These key factors are divided into two categories: (1) contextual and system factors (i.e., demographic, geographic, or environmental) and (2) policies and interventions. Contextual and system factors cannot easily be influenced in the near term, whereas policies and interventions factors can.

Exemplars in COVID-19 conceptual framework for assessing epidemic preparedness and response

Contextual Factors

Demographic indicators and pre-pandemic health context

IHME, World Bank

Underlying population-level health characteristics that shaped Thailand’s experience in the early months of the COVID-19 pandemic include:

Age structure

Thailand’s demographics have also changed significantly over the past few decades. World Health Organization (WHO) data shows that mortality has decreased and life expectancy has increased, from 55 years in 1960 to 77 in 2020.1,2,3 Birth rates have also declined,4 likely due to a combination of rising incomes, improved education, and a National Family Planning Program (NFPP) launched by the Ministry of Public Health in 1970.5 This has resulted in a rapidly aging society: in 2021, 14% of the population was older than 65, compared to 7% in 2000 (and 4% in 1970, when the NFPP began).6 This means there are fewer working-age people and a growing number of older adults who no longer participate in the labor force and may require constant care. Researchers expect the economic consequences of these demographic changes to increase over time.7

Elderly adults are significantly more likely to die from COVID-19 than younger adults and children.8 Countries around the world vary widely in their age structures: in some African countries, fewer than 2 percent of the population is 70 years or older, while in some European countries that share is more than 15 percent.9 Some research suggests that accounting for variation in age structure between countries may explain nearly 50 percent of the variation in COVID-19 mortality.10

 

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Chronic Health Conditions

In Thailand, mortality from infectious diseases such as tuberculosis and pneumonia has decreased substantially since the 1950s as a result of improved sanitation, better access to health care, and the introduction of routine childhood vaccination in 1977.11 According to the WHO Global Health Observatory, the top causes of death in Thailand in 2019 were heart disease, stroke, lower respiratory tract infection, kidney diseases, and liver cancer.12

Noncommunicable diseases and other chronic conditions are a major and growing cause of death, disability, and health care costs in Thailand: WHO data show that they cause nearly three-quarters of all deaths each year.13 Behavioral and metabolic risk factors for these conditions (such as poor diets, smoking, alcohol use, sedentary lifestyles, obesity, and high blood sugar) are highly prevalent.

A variety of chronic health conditions like high blood pressure, diabetes, and cardiovascular disease are associated with greater rates of mortality from COVID-19.8 HIV can make individuals susceptible to infectious diseases because of how it impacts the immune system. Similarly, cancer and cancer treatments like chemotherapy frequently disrupt the immune system, leaving individuals vulnerable to severe infection.14

Smoking prevalence and ambient air pollution

Before the COVID-19 pandemic, Thailand’s air quality was moderately unhealthy: the average PM2.5 concentration (μg/m³) in 2019 was 24.3 μg/m3.15 Air quality did improve during pandemic lockdowns, in part because vehicular emissions are a main source of pollution in cities.16 However, researchers argue that air pollution remains a problem in Thailand. One Greenpeace analysis found that the number of pollution-related deaths per capita in 2021 exceeded those from road accidents, drug use, and homicide combined.17

In the years leading up to the COVID-19 pandemic, Thai health officials encouraged high-risk groups such as motorcycle taxi riders, road cleaners, and traffic police to use high-quality N95 face masks to screen pollutants out of the air.15,18

There is relatively broad public awareness of the dangers posed by inhaling particulate matter and the implementation of successful tobacco-control policies in the 2000s and 2010s that have notably reduced overall smoking rates.19 Still, 2018 WHO data showed that almost half of adult men in Thailand continued to smoke tobacco, and more than one-third of adults and children were exposed to secondhand smoke at home.20

Fine particulate matter, especially matter small enough to reach the deepest part of the lungs, causes chronic pulmonary injury and inflammation.8,21  Individuals exposed to these particles may be more likely to be infected with respiratory pathogens and to have more severe outcomes.

Despite political instability over the past two decades, with two military coups and multiple changes of government,22 Thailand reached high-middle-income status in 2011.23 It has since become the second-largest economy in Southeast Asia, largely because of its manufacturing-oriented export sector. 24

Data from the World Bank shows that from the 1960s to the 1990s, Thailand’s economy boomed: the country’s gross domestic product (GDP) grew nearly 8% per year on average.25 ,26,27 This period also saw enormous improvements in education. School enrollment has increased significantly since 1980, and as of 2021, nearly 100% of the country’s children attend and complete primary school.28,29

Poverty rates also decreased considerably, from about 65% in 1988 to about 6% in in 2019.30 Very few people in Thailand live in extreme poverty (on less than US$1.90 per day). In 2019, the extremely poor comprised about 0.1% of the country’s population.

Thailand’s economy, especially the tourism and services sectors, was hit hard by the COVID-19 pandemic. GDP declined by more than 6% in 2020, the largest contraction since the Asian financial crisis in 1997.31 The World Bank estimated that about 70% of households’ incomes declined during the first year of the pandemic (low-income households and workers in the informal sector were hardest hit) 30 and unemployment rates kept increasing through 2021.32 Recovery has been slow, but eased COVID-19 restrictions in 2022 enabled tourism and other economic activity to resume.33

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The Thai health system has a wealth of experience with highly contagious respiratory pathogens, including SARS in 2003, H1N1 in 2009, and MERS-CoV in 2016,34,35 and controlling the spread of these communicable diseases. This is particularly true when officials detected the importation of a highly transmissible virus: there was, for example, no reported local transmission of SARS or MERS (which are also borne from coronaviruses) to health care workers in Thailand.34 Researchers argue that Thailand’s knowledgeable health workforce, the coordination and collaboration between the Ministry of Public Health and hospital infection control teams, and the quick and strategic deployment of key health workers kept these pathogens largely under control and enabled the health system to minimize their impact on the delivery of other services.36

In Thailand, village health volunteers, or community members providing care in settings that lack care and resources, have been mobilized to great effect during past epidemics, raising community awareness and supporting the prevention and containment of diseases including dengue and avian influenza. During the 2004 H5N1 avian influenza epidemic, local village health volunteer networks monitored abnormal death counts in domesticated birds and alerted health authorities. Their work helped Thailand detect, control, and contain the spread of avian influenza.

 

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In 2016, Thailand established an Emergency Operations Centre (EOC) to centralize the health system’s response to epidemics and other health emergencies37 and strengthened public health risk communication and community engagement efforts.15 Researchers from Thailand’s Department of Medical Services Foundation argue that in general, the country’s earlier experience with epidemic and pandemic diseases taught health officials to act quickly and intentionally to manage outbreaks. This experience has also helped shape preparedness tools such as disease control policies that can be rapidly mobilized in an emergency; models for risk communication; health worker comfort with key public health and social measures, such as personal protective equipment and handwashing; and public confidence in the ability of the health system to respond successfully to health emergencies.15

 

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System Factors

Beyond policy interventions, other modifiable factors under the short-term control of countries and governments that can help shape countries’ pandemic outcomes (such as testing strategies, disease surveillance, laboratory capacities, contact tracing programs, case management, mobility restrictions, and surge response coordination), it is also important to consider preexisting system factors, such as the strength and structure of a country’s health care system and supply chains, in any analysis of a country’s COVID-19 preparedness and response.

Manufacturing is one of the most important sectors in Thailand’s economy: it accounts for most of the country’s exports and millions of jobs.38 In addition to its infrastructure, technology, and raw materials, Thailand is a manufacturing hub because it has a substantial industrial labor force, including migrants from Southeast Asian countries with lower prevailing wages.

These strong manufacturing capabilities contributed to the country’s COVID-19 response. For example, in 2021, the country became the production center for AstraZeneca’s COVID-19 vaccine, Vaxzevria, in Southeast Asia. Initial production setbacks at Siam Bioscience, AstraZeneca’s local manufacturing partner, led to a shortage of vaccines available in Thailand and other countries in the region during a surge of infections in July and August of 2021,39 but since then it has ramped up production and bolstered domestic supplies.40

Thailand’s centralized, integrated public health system covers most of the country’s population. The Ministry of Public Health, the main authority for public health in Thailand, oversees health policy, regulation, and the implementation of public health laws as well as service provision, health promotion, and disease control and prevention.

The system splits the country’s 77 provinces into 12 different health regions plus Bangkok.41Ministry of Public Health administrators at the national level delegate parallel responsibilities to their counterparts in regional offices.42 The Provincial Health Office oversees each province’s regional, general, and district hospitals43 and health offices ; district health offices oversee health centers and coordinate with district hospitals. The system is integrated, which means that hospitals at different levels within each region cooperate to deliver medical care.

 

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Thai Health System Organizational Structure

WHO, "The Kingdom of Thailand Health System Review"

Within this hierarchy, Thailand’s system for delivering health care has five levels, with health promoting hospitals (formerly known as health centers) as the first point of care in the community. Nurses and public health officials are the main providers of primary care, with auxiliary support from village health volunteers on outreach, disease prevention, and treatment services at the subdistrict level. Medical doctors at district hospitals provide secondary and some tertiary care. These coordinated district health systems enable people to receive many types of health services close to home43 —which researchers believe contributes to high service utilization and low unmet need for outpatient and inpatient services.44

Because the facilities and providers within this system communicate and coordinate with one another, they can refer and transfer patients who require specialized care from health centers to district hospitals and from district hospitals to provincial hospitals (also known as general hospitals). In some cases, patients may then be referred to regional hospitals or academic excellence centers. 43

The referral network also allows patients to be transferred to facilities closer to home as their conditions improve, creating space at higher levels of the system for patients who are more seriously ill.43

Levels of the national health system in Thailand

Asian Disaster Preparedness Center (ADPC)

Thailand has provided universal health coverage since 2002. Before that, Thailand’s health coverage consisted of varying financial arrangements for different population groups. In 2002, the National Health Security Act introduced three public health insurance schemes that together cover almost the entire population.45,46 The coverage schemes are as follows:

  • The Civil Servant Medical Benefit Scheme covers public sector employees and their dependents, around 5.7 million people (10% of the population).
  • The Social Security Scheme covers private sector employees, around 12.3 million people (18% of the population).
  • The Universal Coverage Scheme covers the rest of the population, around 47.8 million people (72% of the population).

 

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About 2% of the population opts out of these schemes and buys private health insurance instead,45 ,46 and migrant workers in the informal sector can opt into the fee-based Health Insurance Card Scheme.47

These government insurance schemes cover preventive, curative, emergency, and palliative care—including expensive services such as renal replacement therapy, cancer treatment, and stem cell transplants.

Health Spending in Thailand, actual in 2018 vs. projected in 2050

IHME COVID-19 Projections

Universal health coverage in Thailand

According to the World Health Organization, universal health coverage means that “all people have access to the health services they need, when and where they need them, without financial hardship. It includes the full range of essential health services, from health promotion to prevention, treatment, rehabilitation, and palliative care.”48  Its service coverage index49 combines 14 tracer indicators for essential services, including reproductive, maternal, newborn and child health, infectious diseases, noncommunicable diseases, and service capacity and access among the general and the most disadvantaged populations.50

Since Thailand implemented these health insurance schemes, its universal health coverage index ranking has increased considerably: from 41/100 in 2000 to 83/100 in 2019.51Thailand has the second highest score among the 10 countries in the Association of Southeast Asian Nations, behind Singapore, which likely enabled the health system to maintain essential health services even while responding to a major health emergency such as COVID-19.52,53

Universal health care coverage Index for Thai health services

GBD 2019 Universal Health Coverage Collaborators

 

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In 2021, Thailand ranked fifth out of 195 countries included on the Global Health Security Index, which measures countries’ capacity to respond to health emergencies such as epidemics and pandemics.54 According to the index rankings, Thailand’s strengths include detection (including laboratory supply chains and real-time surveillance and reporting), response (especially emergency preparedness and response planning and risk communication), health care access, and established infection control practices and infrastructure.

WHO’s 2017 Joint External Evaluation of Thailand’s core capacities under the International Health Regulations 2005 recognized Thailand’s leadership in responding to regional health emergencies, including responding to specific aid requests and supporting ongoing capacity development in neighboring countries.55 However, the evaluation report urged Thai health officials to strengthen existing public health emergency management systems, especially those associated with responding to new and emerging infectious diseases.55 These capacities would prove essential to its COVID-19 response.

 

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Before the COVID-19 pandemic began, Thailand had established a top-down policy response to outbreaks of infectious disease that is managed at the central level and implemented through provincial authorities. It had also established key human resources and infrastructure, including a cadre of nurses trained in infection prevention and control measures56 ; surveillance and rapid response teams; epidemiologists trained by the national Field Epidemiology Training Programme; and trained village health volunteers.57

Surveillance and rapid response teams, established during an avian flu epidemic in 2004,58 are investigative teams tasked with detecting and responding to emerging public health threats and that are deployed at the district level.59 They perform outbreak surveillance and field investigations and act quickly to contain their spread.58 During the COVID-19 pandemic, nearly 1,000 of these teams were deployed to provincial health offices and district hospitals, where they worked to isolate cases, provide treatment, and trace and quarantine contacts.

The Field Epidemiology Training Programme (FETP) has trained thousands of experts in data-driven outbreak investigation and control since 1980. The FETP is the first “epidemic intelligence service” to be established outside of North America, and its investigations have led to the rubella vaccine’s inclusion in Southeast Asia’s routine immunizations; the elimination of mother-to-child transmission of HIV in Thailand; and the establishment of a national hepatitis B prevention program.60 Over the last two years, critical FETP personnel (including epidemiologists, laboratory technicians, and logisticians) have been strategically deployed to respond to COVID-19 clusters across Thailand. The FETP alumni network also proved to be a valuable resource for cluster investigations, contact tracing, and epidemiological data analysis.61

 

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Village health volunteers, a national network of 1.04 million trained community health workers, played an important role in COVID-19 surveillance, risk communication, and personal protective equipment distribution in local communities nationwide. They also helped maintain the uninterrupted delivery of essential health services.62

 

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Outbreak factors   

On January 13, 2020, Thailand reported the first case of COVID-19 to be detected outside of China, in a Wuhan resident who had traveled to Bangkok a few days before.57 The country’s first locally transmitted case was reported at the end of that month. After an initial wave of infections in February and March 2020 that were traced to superspreader events in nightclubs and stadiums, 63 officials declared a state of emergency and implemented stringent preventive measures.

Daily new confirmed COVID-19 cases per million people in Thailand, Asia and the world

Our World in Data

 

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By the end of April 2020, local transmission of the novel coronavirus was under control.57In mid-May 2020, the number of locally transmitted COVID-19 cases in Thailand reached zero and remained there for more than 200 days64; all cases reported in the country between May and December 2020 were diagnosed in international travelers in state quarantine.63

In December 2020, a second, much larger surge of infections began. Some of these came from Thai migrant workers returning home from jobs in Myanmar. Others clustered around large communities of migrants living and working near factories and seafood markets in Samut Sakhon province.63

This second pandemic wave subsided by the end of February 2021.

April 2021 saw a third wave of COVID-19 infections, this time from the highly transmissible alpha variant. Superspreading events took place in bars, karaoke lounges, and gambling venues across the country.65 Because government policy required everyone with a confirmed case of COVID-19 to be admitted to a health facility, this surge caused a shortage of hospital beds across Thailand.66 Officials opened temporary treatment facilities and converted some hotels into hospitals.

By the middle of 2021, the even more transmissible delta variant accounted for almost all diagnosed COVID-19 cases in Thailand.67 Case counts of people who were severely ill and on ventilators reached their peak that August.68

Cases and deaths decreased steadily through the rest of the year until early 2022, when the new omicron variant and subvariants led to another wave of infections. WHO data showed the omicron variant accounted for half of all reported cases in Thailand in the first five months of 2022,69 and by June it accounted for nearly all reported cases.

SARS-CoV-2 sequences by variant in Thailand

Our World in Data

The relative importance of the drivers of outcomes of interest during an epidemic or pandemic will depend on the nature of the specific pathogen. In the case of the COVID-19 pandemic, the SARS-CoV-2 virus is characterized by respiratory transmission by both symptomatic and asymptomatic individuals. The virus disproportionately impacts older adults and those with compromised immune systems and comorbidities. Although vaccines and therapies to reduce severe disease and fatal outcomes from SARS-Cov-2 were developed relatively quickly, this is not always the case for other pathogens with epidemic and pandemic potential.

For more information, please see How Does COVID-19 Compare With Past Epidemics and Pandemics?

Daily new confirmed COVID-19 deaths per million people in Thailand, Asia and the world

Our World in Data

Climate change has made abnormally wet and dry weather more severe and frequent in Thailand. Coastal communities, particularly in the southern part of the country, are especially vulnerable to rising sea levels.70 However, it is not possible to conclude what role these conditions may have played in the spread of COVID-19 in Thailand.

Respiratory viruses spread more easily through thin, dry air (and consequently at higher elevations) than through humid air. 71 In different climates, outdoor temperature ranges can lead to increased congregating in climate-controlled indoor settings that can increase viral transmission potential.8 All these factors may influence how rapidly COVID-19 spreads in different countries and at different times of the year.

As climate change worsens, the risk of infectious disease outbreaks has increased, with climatic conditions becoming increasingly fertile ground for pathogenic transmission.72 Research has shown that many infectious diseases are susceptible to climate variability, flooding, droughts, and the animal and human migratory impact of a changing climate, leading to a rise in vector, food, and water-borne illness.73

 

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