How did Thailand respond to the COVID-19 pandemic?

Starting in mid-March 2020, Thai health officials began to recommend individual behavior changes, such as masking in public and regular handwashing, to slow the spread of the COVID-19 virus. At the end of that month, they implemented nationwide mobility restrictions. They closed air and land borders and crowded public places, such as sports stadiums, cinemas, other entertainment facilities, massage parlors, department stores, and restaurants.^18,19 Officials asked (but did not require) people to stay home for the month of April 2020, ²⁰ and they canceled the national Songkran new year festival to limit large-scale movement and travel of the population.²¹

Public transportation continued to operate, but officials implemented policies, such as thermal screening (though it is worth noting that symptom screens and temperature checks have limited impact in the context of asymptomatic transmission) before entry and recommended face masking by passengers and operators.²²

By early April 2020, all kindergartens, schools, and universities were closed to in-person learning and nonessential employees were encouraged to work from home.

In April 2020, Google mobility data showed reductions in travel to workplaces (30% reduction) and in traffic in major transit coach and railway stations (60% reduction), as well as an increase in people staying in and near their homes (20% increase). ²⁰

Change in relative mobility in Thailand from March 2020 to December 31, 2021

By July 2020, given low case counts (Thailand went 102 days between May and September 2020 with no reported local transmission of COVID-19), officials had phased out most of these restrictions. Domestic travel and restaurants had reopened; events and informal gatherings were permitted; and schools and workplaces were reopened with strict physical distancing, masking, and hand hygiene measures in place. Despite the easing of restrictions, officials urged people to keep observing physical distancing, masking, and hand hygiene protocols in public places.

Even as case counts increased during the second wave of the pandemic starting in December 2020, officials did not reinstate nationwide lockdowns. Instead, they categorized provinces according to transmission rates and implemented different levels of restrictions accordingly.²³ Just five hot spot provinces banned domestic travel and closed schools, bars, massage parlors, spas, gyms, stadiums, and other businesses. Others were less restrictive.²⁰

From the start of the COVID-19 pandemic in Thailand, officials recommended that everyone wear face masks in public, avoid touching their noses and mouths, and adhere to strict hand hygiene through handwashing or the use of alcohol solutions. Masking was never mandatory,²⁰ but many people seemed to adhere to the government’s recommendations; for example, an April 2020 MOPH survey in Nonthaburi province just northwest of Bangkok showed that more than 90% of the population wore face masks in public as recommended.¹² These high rates of compliance may be associated with years of experience wearing masks to protect against air pollution and respiratory pathogens during previous epidemics, as well as generally high levels of trust in public officials and the health system.

This high level of compliance has decreased over time, however, because of general discomfort related to wearing face masks and misinformation about reinfection (e.g., misinformation suggesting there was no risk of reinfection from COVID-19 and thus face masks were useless after initial infection).²⁴ A 2022 survey conducted during the Songkran holiday period in April 2022 found that more than three-quarters of respondents saw people wearing masks incorrectly in crowded tourist areas and nearly one-quarter saw people not wearing masks at all.²⁵

PPE shortages from the early months of the pandemic made it difficult for some to comply with the government’s recommendations, but creative solutions abounded. For instance, VHVs sewed homemade cloth masks and companies made masks out of recycled plastic bottles for monks working in crematoriums.²⁶

Self-reported mask use in Thailand from March 2020 to December 2021

The COVID-19 pandemic exacerbated an economic slowdown that Thailand was already experiencing given pre-pandemic stagnation of exports and foreign investment. In 2020, the economy contracted by more than 6%,²⁷ unemployment rates increased in some parts of the country, and pay and working hours were decreased for many. A 2021 World Bank phone survey showed that 70% of household incomes had declined since March 2020.²⁸

A November 2021 World Bank survey showed that about 80% of Thai households (more in rural areas) had received some form of social assistance since March 2020.²⁸ Various programs provided financial assistance to informal workers, farmers, and low-income and vulnerable groups (such as older adults, people without smartphone access, and those confined to health facilities).²⁹

Other social assistance programs made funds available for public assistance to people and families across Thailand. For instance, officials reduced electricity and water bills across the board in early 2020 and gave some people electronic vouchers that could be used in registered stores.¹⁷ Officials also temporarily reduced the Social Security contribution rate for employers and employees and aimed public spending at boosting economic recovery in the hardest-hit sectors of the economy, such as food service and tourism.¹⁷

Thailand’s sophisticated public health surveillance system predated the COVID-19 pandemic and could be quickly reorganized and used to meet emerging needs. Early in 2020, officials deployed some 1,000 established surveillance and rapid response teams of field epidemiologists and public health nurses to identify provinces with clusters of infection and screen everyone who lived there.

VHVs likewise worked to assess risks in their communities. According to one study, VHVs went to more than 14 million households during March and April 2020. VHVs also identified and monitored over 809,000 unemployed workers returning to their hometowns. By mid-July 2020, the VHVs had referred about 3,340 symptomatic patients to hospitals.³⁰

In June 2020, as the country’s initial wave of cases was subsiding, Thailand performed active laboratory‐based sentinel surveillance in all 77 provinces. The surveillance focused on health workers; new prison inmates; workers in high-exposure occupational groups, such as public transport and postal delivery; and other groups prioritized by the provincial communicable disease control committee.³¹

Early in the COVID-19 pandemic, authorities in Thailand worked to scale up its laboratory capacity to perform polymerase chain reaction (PCR) tests. During the pandemic, health officials aimed to establish at least one PCR laboratory in each province (a minimum of 77 laboratories nationwide) so they could implement “one province-one laboratory-one day reporting.”²

In April 2020, there were 80 certified PCR laboratories in Thailand.²⁰ By June 2020, an additional 30 laboratories were functioning outside Bangkok, along with 12 regional MOPH laboratory centers that provided back-up testing with a 24-hour turnaround time. By October 2020, Thailand had 230 laboratories (154 public and 76 private) covering all 77 provinces.²⁰ As of March 2022, the country had more than twice that many laboratories equipped to perform PCR tests—half private and half public.

Facilities across the country implemented different strategies for specimen collection. Some organized drive‐through testing³³ and others used mobile teams in locked‐down districts (such as Phuket province) where active contact tracing was in place.³⁴ To cut costs on large numbers of daily tests, officials introduced pooled saliva tests by combining samples from 5 or 10 different individuals in Bangkok and Samut Sakhon.^35,36,20

As Thailand reopened for international tourism in late 2021, travelers were subjected to a series of relatively onerous rules, including testing and quarantine (and eventually vaccination) requirements. For instance, travelers to the island of Phuket needed to show a vaccination certificate, negative PCR tests, and a medical insurance policy, among several other requirements.³⁷

By July 2022, Thailand had suspended almost all travel restrictions, giving a boost to its once flourishing tourism industry. (Before the pandemic, tourism contributed to nearly 20% of Thailand’s gross domestic product.³⁸) Travelers were only required to show either a COVID-19 vaccination certificate or proof of a negative antigen test taken within 72 hours of traveling. Unvaccinated travelers without a negative test result had to take, and pay for, a COVID-19 test at their point of entry (and travelers who tested positive had to pay their own medical bills).³⁹

In April 2020, the Thai company Siam Bioscience (owned by King Maja Vajiralongkorn) collaborated with the Department of Medical Sciences to develop the first Thai-made COVID-19 test.⁴⁰ These tests met standards by the WHO and were distributed to medical laboratories across the country.⁴¹

As they have done for past outbreaks of infectious disease, Thailand’s surveillance rapid response teams and VHV networks led the country’s COVID-19 contact-tracing efforts. During Thailand’s first COVID-19 wave in 2020, they:

• Identified index cases using case definitions produced and updated regularly by public health officials
• Traced and tested all high-risk contacts of the index cases
• Sent all diagnosed cases to hospitals for treatment
• Isolated patients in quarantine sites for at least 14 days from the onset of symptoms to prevent transmission¹⁹

Subsequent waves of the pandemic demonstrated the need to use more active and targeted case-finding efforts.²⁰ This was partly because earlier efforts had not captured some especially vulnerable groups, such as undocumented migrant workers. For instance, researchers traced Thailand’s second pandemic wave to asymptomatic infections in migrant workers in a wholesale seafood market in Samut Sakhon. Retailers from other provinces who came to purchase goods at the market became infected and transmitted the virus when they returned home.²⁰

In an effort to avoid repeating the negative economic and social consequences of Thailand’s first nationwide lockdown—including job losses and reduced incomes, increased food insecurity (a World Bank phone survey found that 60% of low-income households had run out of food during the first year of the pandemic²⁸ ), and interruptions to essential health services delivery—officials adopted a more targeted strategy for social distancing and movement restrictions in subsequent pandemic waves. Instead of a nationwide lockdown, officials concentrated on active case finding and implementing public health measures in specific areas where infections were prevalent.

Beginning at the end of December 2020, they divided the country into three “warning” categories—red (strict controlled areas), orange (controlled areas), and yellow (areas under stringent surveillance)—according to weekly case counts.^23,42,43 These categories determined the geographic focus of contact-tracing efforts and public health and social measures, such as restrictions on mobility and social gatherings, business closures, and working from home. Later in 2021, the country introduced even further restrictions in dark-red zone provinces, or maximum and strict controlled areas, where case counts were rising quickly.⁴⁴

Contact tracing system through surveillance and rapid response teams and village health volunteers

In January 2021, the Department of Disease Control issued a new strategic plan, Managing the New Wave of the Covid-19 Epidemic, which outlined a two-stage COVID-19 vaccine management plan.²³ The goal was to vaccinate 70% of the country’s population by the end of 2021.⁴⁵ “Vaccines,” the prime minister wrote in a 2021 Facebook post, “will be the key to reopening the country to tourism, to rehabilitating the economy and returning to normal life.”⁴⁵

Thailand’s first phase of vaccine delivery, designed for a period of limited vaccine supply, started in February of 2021.⁴⁶ It aimed to reduce COVID-19 mortality rates and maintain a functional health system. This phase prioritized clinical and health personnel and frontline workers, people with underlying conditions that made them more vulnerable to severe illness from COVID-19 (including severe chronic respiratory diseases, such as chronic obstructive pulmonary disease or poorly controlled asthma; cardiovascular disease; some types of chronic kidney disease; cerebrovascular disease; all types of cancer during chemotherapy, radiotherapy, and autoimmune therapy; diabetes; and obesity), and people ages 60 or older. The second phase of vaccine delivery, which began when the country had sufficient vaccine supply for everyone, aimed to boost the economy, stimulate herd immunity, and restore a “new normal.”²³

Policymakers wanted to promote the Thai pharmaceutical industry and guarantee that the country would not have to rely on others for its vaccine supply. In November 2020, Thai officials signed an agreement with AstraZeneca to begin large-scale manufacturing of COVID-19 vaccines in Thailand, in facilities owned by Siam Bioscience, for domestic distribution and export.⁴⁷ As part of that agreement, AstraZeneca also agreed to sell Thailand 26 million doses of the two-dose vaccine by 2023.⁴⁸ The company later agreed to provide a total of 61 million doses by the end of 2021, but delivery was dramatically delayed.⁴⁹

This strategy to promote domestic vaccine manufacturing left Thailand without sufficient vaccines as the pandemic worsened.⁵⁰ The country’s first shot was not delivered until February 28, 2021.⁴⁶ In March 2021, officials began to seek alternative suppliers—but by then, critics note, their only choice was Sinovac, whose efficacy against the delta variant was unclear.⁵¹In June and July 2021, the Thai government contracted to buy 20 million doses of the Pfizer vaccine and 5 million doses of the Moderna vaccine.⁴⁹

In June 2021, Thailand rolled out the second stage of its national vaccination campaign for the wider population.⁴⁵By then, the country had fully vaccinated just 2% of its population, a smaller share than its neighbors.⁴⁵ Most vaccines were administered in public and private hospitals.

Shortly after Thailand’s mass vaccination campaign began in June 2021, in response to a study that questioned the long-term efficacy of the two-dose Sinovac regimen, it became the first country to mix a first dose of the Sinovac vaccine and a second dose of the AstraZeneca vaccine. This is known as a heterologous immunization strategy. (Health officials offered a booster shot to all health workers who had already received both Sinovac doses.)⁵⁶

Despite the slow rollout and supply shortages that delayed Thailand’s COVID-19 vaccination campaign and undermined some of the early success of the country’s pandemic response, the push for mass vaccination has recovered. By August 2022, three-quarters of the country’s population had been fully vaccinated (received two vaccine doses) against the COVID-19 virus and more than 31 million booster doses had been administered. Thailand had the sixth-highest vaccination rate among the 10 Association of Southeast Asian Nations countries at that time, trailing Vietnam (84%) and Malaysia (82%) but ranking above Laos (70%) and Indonesia (62%).⁵⁷

Two decades of policymaking designed to accommodate the rapid increase in demand for health services following the implementation of universal health coverage in Thailand have built a health workforce that is robust and diverse. Between 2002 and 2018, the Thai government more than doubled the number of qualified nurses and midwives in the country⁹⁰ and almost tripled the number of qualified medical doctors.⁹¹ Officials also pushed to eliminate geographic inequities by introducing mandatory rural service for graduate doctors, nurses, pharmacists, and dentists; recruiting health students from rural backgrounds; adopting a training curriculum that included rural health problems; and giving financial incentives to those who practiced in underserved regions.^92,93

As in other countries, mobilizing surge capacity of health workers and specialists—including intensive care nurses and critical care specialists—during the COVID-19 pandemic was a challenge, but Thailand’s health system was designed to enable the strategic deployment and mobilization of human resources. For instance, in the pandemic’s early months, cases had been recorded in 68 of 77 provinces, but 87% of the country’s total cases were located in just 10 provinces. In response, MOPH officials shifted specialists, such as intensive care nurses and epidemiologists, from less affected provinces.¹² Likewise, during the Samut Sakhon clusters in December 2020 and July 2021, officials deployed doctors, nurses, and public health staff from the provincial and district public hospitals to support surveillance and provide care in field hospitals.²⁰

Some hospitals likewise deployed their own experienced nurses from nonintensive care units to train and support their colleagues in intensive care and infection prevention and control. As the pandemic continued, provinces with high caseloads and critical human resource shortages mobilized medical teams from other provinces, under the supervision of the MOPH.¹²

Official guidelines recommended that each hospital designate a team of workers specifically for the COVID-19 ward and prohibit their rotation to other wards. In some hospitals, medical teams were divided into two groups, one on duty and one off duty, which swapped every two weeks in case members of one team became infected and required 14-day quarantine. These policy adaptations, in theory, more efficiently delegated tasks between those providing care to COVID-19 patients and those delivering routine health services.¹²

The following sections outline other pandemic adaptations of the health care workforce.

Tailored support for the health care workforce

In April 2020, the Thai government appointed nearly 40,000 contract nurses, frontline health workers, and other short-term workers in the health sector to civil servant status.⁹⁴ This policy shift encouraged health workers to remain in their jobs and care for COVID-19 patients during an especially challenging time.

The government also supported health workers who became sick from COVID-19. For example, in 2020, the Thai cabinet adapted Article 6(4) of the Ministry of Finance 2018 regulation on compensation of health workers for work-related disabling events (including death or permanent disability, organ loss, and severe and less-severe injuries) to apply to COVID-19. It doubled the level of compensation for health workers infected with the COVID-19 virus and approved hazard allowances for those working in hospitals or quarantine facilities.¹²

In addition to these efforts, the MOPH supported the national White Gown Hero/Heroine campaign to celebrate health workers. Early in the pandemic, five minutes of applause was televised daily nationwide and public and private organizations donated food boxes and other commodities to workers in health facilities and quarantine centers.¹²

Personal protective equipment for health workers

Public demand for PPE rose sharply in March 2020, which led to critical shortages in health facilities and strained health workers in the initial phases of the pandemic. Between the first and second waves of the pandemic in Thailand, collaborations between the public and private sectors enabled facilities to stockpile PPE and medicines and install negative-pressure isolation rooms and intensive care units. These were essential preparedness measures for future outbreaks and surges.¹²

To maintain and even boost the delivery of health services—especially essential health services—in Thailand during the COVID-19 pandemic, officials made ongoing investments in the country’s already robust hospital and health facility infrastructure. These investments, such as scaling up and strengthening the county’s laboratory capacity to manage emerging infectious diseases, were bolstered by important partnerships between the public and private sectors. They will likely benefit Thailand long after the COVID-19 pandemic is under control.

New rooms and units for hospitals in need

Toward the end of 2020, between the first and second waves of the COVID-19 pandemic, it was clear that the installation of negative-pressure isolation rooms and intensive care units was an essential preparedness measure for future outbreaks and surges.^20,99 Public–private collaborations made this work possible; for example, some private companies provided resources to build new rooms and units for hospitals in need.^100,101

Field hospitals and “hospitels”

During the second pandemic wave in 2021, health officials began to establish field hospitals to receive asymptomatic COVID-19 patients and those with mild symptoms. For example, in August 2021, a 1,800-bed facility opened in a cargo warehouse at the international airport in Bangkok.¹⁰² At the same time, in an effort to support the struggling tourism sector, the Thai government rented several hotels and turned them into “hospitels” for asymptomatic or low-risk patients who could afford to pay the bill.¹⁰³

Separation of healthy and sick individuals in vaccine administration

Health facilities established “well-baby” and “well-adult” clinics in hospitals to sequester healthy people seeking routine vaccinations. Appointments were required, further separating the sick from the well.⁶⁵ Other similar innovations included drive-through vaccinations at private hospitals and at-home immunization services.