Abstract
This study aims to analyze, understand, and extract lessons from the transfer of
subdistrict health promoting hospitals to provincial administrative organizations, with a focus
on examining the extent to which the concepts of network building and management and
diffusion of innovation can effectively and sustainably support primary care service delivery
based on the principles of family medicine within an area-based management context. The
study employed action research in conjunction with developmental evaluation, covering 10
provinces in Thailand: Mukdahan, Narathiwat, Pathum Thani, Chonburi, Songkhla, Phichit, Khon
Kaen, Yala, Samut Sakhon, and Sisaket. The research utilized a “mentor researcher”
mechanism to provide support in knowledge, innovation, and good practices, alongside “local
researchers” who co-created learning processes through hands-on, research-based practice.
The study also adopted a quasi-experimental research design, specifically a multiplegroup pre-test–post-test design, to assess the development of the primary health care system
following the transfer of subdistrict health promoting hospitals to provincial administrative
organizations in the 10 provinces listed above. Mixed methods were used for data collection.
Quantitative data were obtained from the Ministry of Public Health’s Health Data Center (HDC)
system before and after the intervention, using 21 population health indicators. Qualitative
data were collected through in-depth interviews with 40 participants and workshops involving
895 participants. Quantitative data were analyzed using descriptive statistics and pre–post
mean comparisons, while qualitative data were analyzed using content analysis.
The findings indicate that the transfer of subdistrict health promoting hospitals to
provincial administrative organizations was not merely a structural administrative change, but
also created learning spaces and opportunities for growth among local stakeholders. This, in
turn, enabled the design of primary health care systems that are more responsive to local
contexts. Flagship projects in the study areas shared a common goal of improving access,
quality, and continuity of primary health care services. Salient examples include the
development of population health data dashboards to support policy decision making,
integration of care networks for non-communicable diseases (NCDs), development of
continuing care and palliative care systems, and efforts to expand community-based dental
public health networks.
In terms of effectiveness, the study found that integrated primary health care delivery
under PAOs led to a significant increase in service outputs, particularly in screening and followup of patients with diabetes and hypertension, as well as in childhood vaccination coverage.
While population health outcomes showed improvement in some indicators, statistically
significant effects were not observed overall. Regarding efficiency, there was a positive trend
in total factor productivity and returns to scale, driven primarily by the adoption and
application of research, innovation, and empirical evidence rather than by increases in input
resources alone.
Analysis using the World Health Organization’s Six Building Blocks of a Health System
framework reflects structural changes across all dimensions, particularly the emerging role of
referral hospitals as academic support centers and the importance of distributed, networkbased leadership. The study concludes that the transfer of subdistrict health promoting
hospitals to provincial administrative organizations represents a critical opportunity for primary
health care system reform, provided that all stakeholders can jointly build an area-based
health ecosystem driven by data, evidence, and continuous collaborative learning.
