Why was Thailand selected?

Executive summary

Although Thailand was the first country outside of China to detect a case of COVID-19, in mid-January 2020, its quick and comprehensive response kept case and death counts relatively low during the first year of the pandemic. After an early spike in cases in February, March, and April, health officials and providers successfully controlled the transmission of the novel coronavirus: in fact, Thailand went without any reported local transmission of COVID-19 between May and September 2020.¹

Key factors that help explain the relative success of Thailand’s pandemic response include a strong health system supported by ongoing investments in infrastructure and human resources and a commitment to universal health coverage; tools and strategies developed for previous outbreaks, such as surveillance and rapid response teams; an integrated, whole-government response coordinated by policymakers at the national level; and innovations in service delivery that enabled the health system to maintain essential health services alongside its COVID-19 response.

How did we select the countries we studied?

Differences in testing, surveillance capacities, and reporting criteria² have made it difficult to quantify³ and compare the impact of COVID-19 in countries around the world. Yet some countries were able to strengthen and sustain health system capacity, maintain essential health services, and target public health and social measures to mitigate the overall impact of the COVID-19 pandemic. Identifying the strategies, policies, and practices that enabled these successes can give us a better understanding of health system resilience, adaptive health policies, and emergency response strategies that could be applied to other countries and future infectious disease outbreaks.

To select positive outlier countries with transferable lessons for pandemic preparedness and health system resilience, we used data from March 2020 through the end of 2020 to identify countries with best-practice responses to the early phases of the pandemic. This snapshot in time does not account for subsequent waves of the pandemic, nor for the later availability of COVID-19 vaccines in the selected countries.

The six countries were selected by evaluating COVID-19 indicators (including age-standardized deaths, cases, and testing) and essential health services indicators (including disruption to routine immunization) after screening for the availability of high-quality data and the transferability of the findings. After identifying potential Exemplar countries, we completed validation research including an examination of the COVID-19 epidemiological curve over time, testing policies and strategies, interventions to maintain essential health services, survey data, and interviews with local and regional health experts. The final six countries were selected after considering linguistic, demographic, and geographic diversity as well as government structure and data availability (see figure below).

For Thailand and the other five selected countries (Costa Rica, Dominican Republic, Ghana, Sri Lanka, and Uganda), we conducted a literature and policy review, key informant interviews, qualitative analysis, and quantitative analysis. We synthesized findings to develop key recommendations on health system resilience and pandemic preparedness. This country selection process reviewed indicators through the end of 2020, but the Exemplars research itself covers the time period through the end of 2021. It is important to note that the performance of the selected proxy indicators does not reflect the entire health system’s performance.

Several key interventions, summarized below and detailed in the following pages, contributed to Thailand emerging as a positive outlier in the COVID-19 response and the maintenance of essential health services.

Preexisting health system strengths

Decades of investment in public health insurance, infrastructure for delivering routine and emergency health services, and the health workforce enabled Thailand’s quick and early response to the COVID-19 pandemic. To accommodate the rapid increase in demand for services generated by the introduction of universal health coverage in 2002, Thailand has made significant investments in its health workforce and boosted the equitable distribution of health care providers across the country, ensuring that care at the community level is prioritized.⁴ These existing structures helped boost the pandemic response capacity of the country’s health workforce. Likewise, the country’s integrated, multilevel health system coordinated local and regional service delivery and COVID-19 response, enabling adaptive and responsive collaboration from the beginning of the pandemic.

Preexisting disease response capacities

In recent decades, Thailand has successfully controlled the spread of highly transmissible viruses including SARS in 2003, H1N1 in 2009, and MERS-CoV in 2016. These experiences helped authorities recognize the need for comprehensive preparedness and early action to manage emerging communicable diseases such as COVID-19. They also helped ensure the Thai health system had strong professional and training infrastructures already in place for a robust COVID-19 surveillance system, including nearly 1,000 surveillance and rapid response teams deployed to provincial health offices and district hospitals during the pandemic. SRRTs were established during an avian flu epidemic in 2004, and are deployed at the district level to detect and respond to emerging public health threats.

Health care workforce and workforce adaptations

Following the implementation of UHC in Thailand, the country has rapidly built a diverse and robust health workforce to meet increasing demand for health services. Between 2002 and 2018, the Thai government more than doubled the number of qualified nurses and midwives in the country and almost tripled the number of qualified medical doctors.⁵ To enable its health systems to have sufficient workforce during the COVID-19 pandemic, the Thai government appointed nearly 40,000 contract nurses, frontline health workers, and other short-term workers in the health sector civil-servant status. The government also support health workers who became sick from COVID-19, doubling workers’ compensation for health workers infected with the novel coronavirus.

Essential health services maintenance

Innovations before and during the pandemic strengthened the workforce capacity and supported the uninterrupted delivery of key essential health services across Thailand’s health system. In part as a result, research from the Institute for Health Metrics and Evaluation shows that the COVID-19 pandemic only slightly disrupted routine immunization coverage in Thailand with quick recovery.

Challenges

Thailand faced some persistent challenges during the COVID-19 pandemic. Policymakers and frontline health workers in Thailand noted several barriers to maintaining essential health service delivery for the country’s most vulnerable populations, including migrants and the urban poor. Thailand’s health system saw gaps in human resources coverage—especially among the specialty health workforce, such as intensive care nurses and critical care specialists—during pandemic surges.

As in many other countries, maintaining a consistent infrastructure for collecting and reporting data on COVID-19 testing and surveillance was a challenge, especially early in the pandemic. Later on, vaccine shortages and manufacturing hiccups delayed the reopening of the Thai economy, particularly the tourism sector.

Some adaptations to the delivery of essential health services, especially those that depended on access to the internet or mobile phones (such as telemedicine), did not serve the country’s entire population equitably. Thailand’s “digital divide” keeps many of its citizens, especially older and lower-income people, from embracing telehealth interventions.