Abstract
Background: Thailand's health system has Health promotion hospitals (HPHs) that serve as primary
care units (PCUs). These units are the first point of access to health services and the main structure
for the primary health care (PHC) system. The reform under the Decentralisation Act B.E. 2542 had
led to structural changes in the governance of PHC systems. This research aims to support the
development of PHC systems that align with the local context and community, following the
principles of family medicine.
Objective: To analyse family physician team cost, evaluate family physician network systems, and
synthesise system-level policies for developing Health Promotion Hospitals (HPHs) transferred to
Local Administrative Organizations (LAOs).
Methods: This implementation research was conducted in four provinces, Khon Kaen, Rayong,
Lamphun, and Tak, in 2024, applying the primary health care theory of change. Interventions
included 1) capacity building for family physicians, 2) strengthening PHC systems development
through participatory learning, 3) developing continuous learning mechanisms to improve capacity
in primary care delivery via digital health technology, and 4) developing monitoring and evaluation
mechanisms using the Primary Care Assessment Tool (PCAT) and a 43-file database under National
Systems. This research employed a participatory action learning approach and analysed data using
a mixed-methods approach for data collection and analysis.
Results: The implementation has led to the creation of a network of family physicians at multiple
levels: 1) A network of family physicians interested in developing PHC systems in areas under the
decentralisation process, comprising 77 members from 19 provinces, with 24 individuals receiving
certificates and intended to apply the knowledge in their provinces. 2) A network of physicians and
interdisciplinary professionals for the care of complex patients, consisting of 327 members from 54
provinces, resulting in improved capacity and outcomes in managing complex patients. 3) A
network of academics supporting the strengthening of PHC systems. 4) A network of family
physicians and interdisciplinary teams collaboratively developing primary care services. In
Lamphun, the network initiated a program for continuous care for patients with chronic diseases
and the elderly in the community, while in Rayong, there were projects developed to improve
management for complex diabetic cases, leading to better blood sugar control. 5) A network of
family physicians working with stakeholders in developing the provincial PHC system, with Khon
Kaen province, including participants from various sectors, had developed a research plan for the
second phase of PHC systems development in 2025.
The PCAT survey in the communities, under the responsibility of HPHs, registered by the Ministry of
Public Health's criteria, with a doctor-to-population ratio of 1:10,000, showed low scores in several
dimensions. This reflected limitations in service delivery, according to family medicine principles,
based on the current doctor-to-population ratio and service arrangement. Health data from the 43-
file system from 139,495 individuals receiving services from PCUs during the study period were
effective for vaccines and maternal and child health services. However, there were still limitations
in controlling non-communicable diseases, with less than 50% having controlled diabetes. These
findings on service quality align with the health system review's conclusions under the PHC theory
of change framework, which identified limitations at both strategic and operational levels.
The Primary Health System Act B.E. 2562 reflects a commitment to developing PHC; however,
there is currently limited policy and resource investment to support the development of primary
care services that would yield tangible health outcomes. Data from the National Health Security
Office (NHSO) in 2024 shows that the budget allocated to PUCs accounts for only 8.99% of the
total budget. It was found that the transfer of HPHs to LAOs has led to increased local investment
in developing PCUs. Additionally, having individuals with expertise in family medicine and health
systems collaborating with strategic teams is crucial for establishing a solid foundation for PHC
systems.
In terms of workforce, the network of family physicians is crucial for the retention of family doctors
within the public service. In addition to their role as healthcare providers, family physicians also
play a key role in supporting system development, bridging between different parties and capacity
building for both physicians and interdisciplinary teams. Furthermore, the health system includes
physicians and resources in the private sector at the primary care level, which the NHSO started to
reimburse under the National Health Insurance system. This presents an opportunity for further
development to connect public and private systems, ensuring sufficient resources for quality
primary care services.
Conclusion: The study highlights the urgent need to develop the PHC systems by fostering multisectoral participation, increasing investment, and strengthening horizontal integration using family
medicine principles. Support should be provided for developing family physician networks in each
province, utilising information technology to enhance primary care services through interdisciplinary
team coordination at the community level. Additionally, a monitoring and evaluation system that
reflects the value of family medicine is essential for service quality improvement.
