Abstract
The Phase III Project on Evaluating the Health Impacts on the Population Following the
Transfer of Sub-district Health Promoting Hospitals (SHPHs) to Provincial Administrative
Organizations (PAOs) in Fiscal Year 2023 aims to assess the health impacts on the population,
early warning signals or risk factors indicating potential health impacts, changes in resource
management, health service delivery, and public health operations; and system-level
management approaches required to establish a supportive public health ecosystem
surrounding SHPHs that is responsive to emerging health impact situations. The study employs
a mixed-methods approach conducted from December 2024 to November 2025, consisting of
two components: first, a retrospective cohort study using secondary data from the National
Health Security Office’s (NHSO) 43-file database. Data from fiscal years 2018–2022 serve as the
baseline, while fiscal years 2023–2024 represent post-transfer performance. Analyses cover
indicators related to service access, process effectiveness, and key health outcomes
connected to primary care and public health services, using individual-level data based on
each person’s registered primary care service unit under the Universal Health Coverage (UHC)
system. Second, provincial case studies across 14 selected provinces, including areas with full
transfer, partial transfer, and no transfer (control). Additional in-depth case studies focus on
specific topics such as nursing workforce management and pharmaceutical management. Data
collection methods include focus group discussions, interviews with responsible personnel,
and document review.
The findings reveal that provinces where SHPHs were transferred from the Ministry of
Public Health (MOPH) to PAOs experienced lower levels of population access to several
primary healthcare services compared with non-transferred areas. At the same time, inpatient
admissions due to major communicable diseases—particularly dengue fever—were higher.
The series of early warning signals and risk factors linked to the transfer of SHPHs may help
predict potential adverse health impacts: (1) size of SHPHs relative to population in their
catchment areas and their functional relationship with district hospitals within the primary care
network, (2) low proportion of transferred SHPHs within a given province, (3) allocation of
public health service funds and operational health budgets, (4) human resource management,
including rotation and medical staff support, the number and competency of nurses and SHPH
staff, and the PAO’s personnel administration system, (5) Support for medicines and medical
supplies, (6) capacity for integrated primary care service delivery within local areas, (7)
effectiveness of communicable disease control for major diseases of concern, (8) Performance
of village health volunteers (VHVs), (9) Capacity to supervise, monitor, and plan health services
based on required indicators at the local level, and (10) long-term trends in relative
performance between provinces, particularly for indicators that have not shown improvement
or remain below comparison areas—or both.
Our study strongly indicates an urgent need for the Ministry of Public Health, in
collaboration with the Ministry of Interior and the National Health Security Office, to review
and refine essential system-level management arrangements under the decentralization
context. This includes the strategic use of financial mechanisms, information systems, and
legal instruments to strengthen the public health ecosystem surrounding SHPHs, ensuring its
responsiveness to evolving health impact conditions.
