Primary care service development to improve quality of life for stroke patients in the community is considered a major service activity for promoting health, reducing body impairment and disability along with promoting good quality of life. Several models for providing primary care services and care for patients are used in Bangkok communities where the factors promoting quality of life differ from rural societies. Furthermore, no clear assessments have been conducted to assess the effects of primary care service models on quality of life in Bangkok. This study was aimed at studying model of care, personal factors, social networks influencing quality of life, test causal correlations of service provision models with quality of life and discover problems and needs of associated persons in order to modify and improve the service provision model before testing model as a pilot study in Bangkok for functional recovery and quality of life. The sample was 450 patients who had survived ischemic or hemorrhagic stroke for no more than two years and were discharged from the hospital to return to the community along with primary care unit service providers. This study used quantitative and qualitative research methods. Data were collected by using questionnaires, focus groups and implementation of appropriate primary care service models. According to the findings, stroke patients in Bangkok (68.2%) were found to have not recovered after being discharged and returning home with medium-level quality of life (Mean + SD = 3.40 + 0.93). Most of the patients had access to care at home provided by Registered nurses (RN), followed by physical therapists and community nurses with social network support from village health volunteers or Care Givers (CGs) trained care of bedridden patients by Nursing Division Public Health BMA Department at 3 9 .6 percent. Patient’s factors most an effect on quality of life (QOL) was high functional disability score (ß = .57, p = .000), followed by depressive (ß = -.22, p = .000) cognitive impairment (ß = .20, p = .000) unable return to work after stroke (ß = -.12, p = .000) and hours to care for stroke patients (ß = -.07, p = .000), respectively. The results showed that 4 model of care such as Continuing care with nurse expert model provides the best recovery and quality of life for patients, followed by the Bangkok Metropolitan Administration (BMA) Home ward was a primary care service that can serve a large group of patients in community and use the most of community's resources for benefit of care. Continuing care from hospital to home was occurred by family management, and received necessary equipment of care which supported from the hospital. While family care has family supported and provided care to patient. The causal relationship model of the factors influencing functional recovery and quality of life among stroke patients was consistent with the evidence-based data (χ2 = 4.688, df = 6, p value = .584, χ2/df = .78, GFI = .997, RMR = .014, RMSEA = .025). Stroke patients’ quality of life was most influenced by functional impairment (ß = -.79, p = .000), followed by the continuing care model with nurse experts (ß = .13, p = .000) and the BMA home ward model (ß = .10, p = .008). Patients who received care support from only family members and community members were unable to reduce disability and improve quality of life. Concerning healthcare service needs and barriers, the recovery goals of patients and healthcare providers were found to be inconsistent. Patients looked at the destination and chances of survival, while healthcare providers looked at the process on the way toward self-management, stabilization of control over complications and comorbidities. Therefore, the services provided for stroke patients in the community were care for bedridden patients rather than care to stroke patients with neurological impairments return to a condition similar to before illness. Accurate recovery processes are needed for the development of clinical nursing practice guidelines for stroke patient in community and trial implementation with selective models. Synthesis new model of care by nurses and health personnel involved in trial implementation of the home ward for stroke care which has clinical nursing practice guidelines for stroke patient in community, patients were found to have less physical impairment and higher quality of life with statistical significance. Therefore, community nurses can implement service provision models and care guidelines for stroke patients in the community to improve quality of life among patients in the community for positive health outcomes. In the future, primary care services for Bangkok will be faced with population structure changes, different social determining factors from rural societies, few family care roles and distant social networks. Nurses are the crucial health personnel as consultants, help and take role play closely of nursing care at home. Meanwhile Bangkok Metropolitan Administration is unable to resolve shortage of nurses to support patients in hospitals and communities. Freelance nurses can provide solutions in promoting health among patients in communities to meet needs by developing freelance nurses and implementing good practice guidelines in communities to create quality care practices and support correct decision-making with stroke patients. Moreover, supported by volunteers in place of patients with family caregiver whose relatives have no time or readiness to provide care and volunteers who serve as patients’ family members with nurses while maintaining close relationships and care consistency can help reduce disability and improve quality of life. Therefore, policy-makers need to develop volunteer with knowledge and readiness to care for patients with complex conditions disease in the community in addition to creating new volunteers to replace old volunteers.


The present research examined the RDU Hospital/RDU Service Plan projects through an evaluation of the policy effects on quantitative outcomes using an analysis of facility-based, electronic drug and healthcare databases. The main approach was an interrupted, time-series analysis determining changes in levels and trends of selected indicators before and after the RDU policies. The RDU Hospital policy had a statistically non-significant effect on the use of antibiotics in target conditions and drugs to be concerned with safety conditions. The RDU Service Plan, however, was statistically associated with a decrease in the use of antibiotics and glibenclamide. Regarding patient outcomes, the RDU Hospital/RDU Service Plan policies were associated with a decrease in hospitalization with drug-induced hypoglycemia but were not associated with hospitalization with asthma. The policies did not decrease the expenditures for non-essential drugs that were reimbursed for outpatients under the Civil Servant Medical Benefit Scheme’s direct disbursement system. It was estimated that the RDU Hospital/RDU Service Plan policies could help saving the drug expenditures by 126 million Baht in total over the years 2015-2018, of which 104 million Baht was attributed to the RDU Service Plan in 2017-2018. As the RDU Service Plan policy was found to be effective in reducing the use of problematic drugs with a high baseline use rate, future interventions should focus on the use of inhaled corticosteroids for controlling asthma. Additional lists of drugs and conditions with priority concerns on safety should be established.


Background : Tuberculosis (TB) remains a major global public health issue. Thailand was classified by World Health Organization (WHO) as one of the fourteen countries with the highest burden of TB, multidrug resistant TB (MDR-TB) and TB/HIV coinfection. Addressing latent TB infection (LTBI) is one of the key factors to achieve TB elimination by 2035. LTBI treatment should be provided especially in high risk populations in order to reduce the risk of progression to active TB. It is a major challenge to control TB in correctional facilities (prisons). Many risk factors contribute to higher incidence of TB in prisons such as overcrowding, and limited access to health care services in prison settings. Inmates with LTBI may be at risk of developing active TB due to co-morbidities such as malnutrition and HIV infection. However, the data of LTBI in Thai prisoners is limited. The aims of this study were to determine the prevalence of LTBI and to evaluate the feasibility of providing the LTBI treatment for Thai prisoners at Klong Prem Central Prison in Bangkok, Thailand. Methods : A cross-sectional study was conducted in prisoners who agreed to participate by signing the informed consent. All participants who meet the eligibility criteria were interviewed using a questionnaire. LTBI was evaluated using Tuberculin skin test (TST). TST was read after 48-72 hours and indurations of ≥5 mm and ≥10 mm were considered positive among HIV-infected and HIV-uninfected participants, respectively. Serological testing for Anti-HIV, HBsAg, Anti-HCV and VDRL were performed for all participants. Additionally, interferon gamma release assay (IGRA) were tested among subgroup of 294 participants. Participants with positive TST or IGRA were considered as having LTBI. Isoniazid prophylaxis therapy (IPT) was offered to all LTBI participants. Initiation of IPT was dependent upon the readiness of the participants. The duration of IPT was 6 months for HIV-uninfected and 9 months for HIV -infected participants at a dosage of 300mg/day. Results : From August 2018 to November 2019, a total of 1,032 participants were enrolled. Thirty participants were excluded because of abnormal chest X-rays (n=25) and incomplete TST testing (n=5). Thus, 1,002 participants were included in the analysis. TST was positive in 359 (35.8%) participants and 181 out of 294 participants (61.6%) had positive IGRA, resulting in 466 (46.5%) participants that were considered to have LTBI. Interestingly, when we decreased the TST positive cut-off to ≥5 mm for all participants, the TST positivity increased to 70.3%. The sensitivity of TST positive at cut-off of ≥10 mm was 40.9% and at cut-off of ≥ 5 mm was 76.2% compared to IGRA. The risk factors associated with LTBI were history of incarceration (aOR 1.53, 95%CI, 1.16-2.01, p=0.002) and history of prior active TB (aOR 3.02, 95%CI, 1.74-5.24, p< 0.001). Majority of LTBI participants (n=383; 82.2%) agreed to take IPT. Among 356 (92.9%) participants completed treatment and 27 (7.1%) participants discontinued IPT due to the side effects of INH. Having HBV co-infection (aOR 4.92, 95%CI, 1.76-13.78, p= 0.002) and HCV co-infection (aOR 3.56, 95%CI, 1.12-10.59, p= 0.02) were associated with adverse events after IPT inititation. Aside from this, we found the prevalence of HIV, HBV, HCV and syphilis infections were high as 2.9%, 6.1%, 5.7% and 4.9%, respectively. Conclusion : In order to reduce TB incidence in Thailand, the assessment of tuberculosis in prisons is needed. This study showed a high prevalence of latent TB infection in prisons in Thailand. Almost half of the inmates have LTBI. Therefore, this population is at high risk for developing active tuberculosis. Moreover, the cut-off of TST ≥5 mm can increase the sensitivity of TST testing compared to IGRA. Our findings demonstrated that LTBI treatment in prison is feasible because 92.9% of them have completed treatment. However, after LTBI treatment, long-term follow-up for 3 years is warranted to determine the efficacy of IPT among prisoners. Given high prevalence of LTBI and high completion rate of IPT, LTBI treatment should be provided.


This quantitative study on “Muslim Widows and Physical Activity Spaces: Health Promotion in the Deep South Unrest” aimed to investigate collaborations of the Provincial Islamic Councils, the Mental Health Center 12, and other relevant authorities on Muslim widows’ physical activity spaces in the unrest context through the views of 348 sample Muslim widows. Their suggestions for their health promotion activity were also to be proposed. The obtained data were analyzed by using the SPSS program. The findings indicated the following. Collaborations of public authorities and private sectors were most found at a moderate degree on giving an opportunity to widows to join community activities (30.5%), followed by a high degree (30.2%). The collaboration on support of Muslim widows’ physical activities, such as attending religious lectures, were most found at a high degree (39.1%), followed by a moderate one (31.6%). A majority of views on collaborations in building Muslim widows’ awareness of physical activity engagement was at a high degree (33.3%). The collaborations covered public relations forms and provision of physical activities suitable to their ages and Muslim femininity. Collaboration in provision of physical activity tools was the most reported at a moderate degree. Provision of single sex spaces for physical activity were mostly found at the lowest degree (41.1%). Below are suggestions for promotion of Muslim widows’ physical activity. 1) Provision of a specific space for Muslim widows’ physical activity is needed to promote both their physical and mental health. 2) A policy should be specifically made for improvement in Muslim widows’ life quality focusing on their physical and mental health, promotion and development their living, and providing female physical activity spaces suitable to all ages in the Deep South. 3) Assistance covering promotion and development should be provided for both widows and their children. 4) Continuous mental health rehabilitation is required by integrating into usual public health services. Continuation is essential for healing them. 5) More activities and greater promotion of doing both voluntary and collaboration activities among Muslim women are required.


Every form of asbestos is carcinogenic. Workers and general population exposed to asbestos can suffer negative health effects. Although, the third National Health Assembly’s Resolution (2010) proposed asbestos ban measures and the cabinet on April 12, 2011 approved the resolution, asbestos is still in use in Thailand. Some government agencies have not followed the resolution arguing too few asbestos- related cases to reach cost-benefit of the asbestos ban. Recent data reveal the increased numbers of asbestos-related patients and new measures to reduce the risk of developing asbestos-related diseases. Therefore, it is necessary to revise the National Health Assembly Resolution at the twelfth National Health Assembly: Thailand’s asbestos ban measures.


Obesity is a globally and locally important problem as can be seen from the increasing prevalence every year. Physician is an occupation directly related to people’s healthcare. However, 40% of physicians are overweight. Half of the overweight physicians think that they are at normal weight. There are many contributing factors for weight gain such as stress, shift work, high calorie food intake and low workout. These factors are usually found in residents. Obesity may directly and indirectly affect patients through patient care process and competency. Therefore, the obesity problem among physicians must be emphasized and alleviated in order to prevent further complications.


Thailand achieved universal health coverage (UHC) since 2002. There are 3 main health insurance schemes with differences in agencies in charge, benefit packages, management, and payment mechanisms operationalizing UHC in Thailand. The aim of this study was to compare the differences in management of and benefit packages between the Social Security Scheme (SSS) and the Universal Coverage Scheme (UCS) in 2020. We applied a descriptive study, and reviewed related documents on 1 January 2020. The results indicated that there were 11 different benefit packages between SSS and UCS. UCS had 7 more benefit packages than SSS, while SSS had 2 more benefit packages than UCS. However, the similar 20 benefit packages had different management. Seven benefit packages of SSS had special management or higher rate of reimbursement than UCS whereas 13 benefit packages of UCS had special management or higher rate of reimbursement than SSS. Furthermore, when compared results with the similar study in 2011, SSS changed inpatient payment mechanisms from capitation to diagnosis related groups (DRGs), implemented special drug management system and increased annual budget per person and reimbursement rate for inpatient higher than UCS. SSS added 27 new benefit packages and added new equipment and prostheses from 81 to 291 items. UCS added 30 new benefit packages and added new equipment and prostheses from 270 to 316 items. The differences in benefit packages between 2 schemes reduced from 15 services in 2011 to 11 service in 2020 and the differences in the similar benefit packages but different management reduced from 26 services in 2011 to 20 service in 2020. In conclusion, UCS had more special management and benefit packages than SSS whereas SSS had higher budget per person per year and higher rate of inpatient reimbursement than UCS. Further studies on access, cost effectiveness and quality outcome were recommended to compare between SSS and UCS. The set up of national organization to harmonize the health insurance schemes in Thailand as mandated in the latest constitution of the Kingdom of Thailand was also recommended


Background and Rationale: Thailand had the highest road traffic mortality in South-east Asia at 32.7 out of every 100,000 people. Chiang Mai was the 5th ranking in Thailand. Emergency medical service system (EMS) can help reduce mortality of the injured patients outside hospitals. Objective: To study survival of out-of-hospital cardiac arrest (OHCA) of traumatic patients who received emergency medical care from EMS. Methodology: Retrospective descriptive study was conducted by collecting survival data from electronic medical record, forensic data and the Pan-Asian Resuscitation Outcome Study database from 1 January 2017 to 31 December 2018 recruiting OHCA traumatic patients receiving emergency medical care from EMS before treating at Maharaj Nakorn Chiang Mai Hospital. Results: Among 45 cardiac arrest traumatic patients, 75.5% were men with an average age of 30.7±14.8 years. The majority of injuries (80%) were traffic accidents, 91.0% had blunt injuries, 35.6% were pulseless electrical activity (PEA) and asystole and 62.2% unknown electrocardiograph. 4.4% achieved return of spontaneous circulation (ROSC) at scene, 55.6% achieved ROSC in a hospital emergency department, 22.2% survived at 24 hours, 15.5% survived at hospital discharge, and 11.1% survived with a good cerebral performance category (CPC 1-2). The most common injuries were multiple system injuries (51.1%), 21.7% of this group survived at 24 hours, 13.0% survived at hospital discharge, and 8.7% survived with a good cerebral performance category (CPC 1-2). Head injury was the most common single organ injury (35.6%), 18.8% survived at 24 hours, 18.8% survived at hospital discharge and 12.5% survived with a good cerebral performance category (CPC 1-2). Survival rate of head injury was highest. 8 patients who received chest compressions from bystanders achieved significantly higher ROSC than those who had not received chest compressions (87.5 and 48.6; p = 0.028). Patients underwent surgery (10 patients) survived at hospital discharge significantly higher than those without surgery (50.0 and 5.7; p = 0.003). Conclusion: Chest compression conducted by bystanders increased the likelihood of ROSC in the EMS OHCA injured patients. In addition, surgery also increased the chance of survival at hospital discharge of these patients.


Background: As the north of Thailand is bordered to Myanmar and Laos, and the east to Laos and Cambodia, the high migration of populations between border areas leading to a high risk of an outbreak of contagious diseases and emerging diseases due to people’s migration. The surveillance system of disease control and prevention at border areas did not entirely cover and reach the standard in five systems as well as lacking information in all five dimensions. In order to improve surveillance system of disease control and prevention at border areas, Thailand International Cooperation Agency (TICA) launched a pilot project in five provinces from 2015 to 2018 to build up awareness and preparedness for better border health. Objectives: To evaluate outcomes of the project and lesson learnt from work systems in the study areas. The results will be used to make a decision for budget support in the second phase and to investigate the factors related to the processes for successful project. Methods: This study was an evaluation research design by using both quantitative and qualitative methods consisting of questionnaire, focus group and group discussion. The study tools were developed to cover the CIPP model. The data were obtained from purposive sampling in five groups of people covering board of directors, public health staff, Thai public health volunteers, non-Thai health volunteers (border countries), stakeholders and immigrant workers in the six parallel border areas. The data were analyzed by using percentage, mean, standard deviation (descriptive study) and by content analysis and triangulation (qualitative study). Results: The quantitative study showed that Tak province had the highest overall knowledge scores at 16.07, followed by Vientiane, Nong Khai, and Chiang Rai, respectively. For the knowledge of health volunteers, the village health volunteers showed the highest knowledge scores (the first rank) while the home health volunteers, border community health workers and lay people after training in the surveillance and disease control and prevention were ranked in the second, third, fourth, respectively. The results by CIPP model revealed that the outcomes from the project were completely processed from context and policy and received a great support from Thai – Laos - Cambodia border areas. For the input factors, all personnel demonstrated an effective working and operation from all border areas, however the lack of budget and equipment was still the weak process in the three border areas. Product part, all borders developed the processes for surveillance system of disease control and prevention at both provincial and district levels based on the context of each area. Conclusion: The outcomes of the operation in three border areas varied upon the context and extent of experiences exchanges among volunteers, health workers and health providers in both provincial and district levels through co-learning and sharing as well as integrating their work with other organizations. Good cooperation between communities at parallel border areas was strong at Nong Khai province; health strategy was prominent in both border areas in Tak province; patient referral systems were established in Chiang Rai and Ubon Ratchathani provinces between two borders; and strategic personnel development was formed at Sa Kaeo province. In order to improve border health care system in a sustainable way, the crucial key components include intensive support and policy from the executive committee at ministry and local areas to effectively guiding the working in a timely manner on the strategy of emerging diseases and surveillance system of disease control and prevention at cross border areas.


Dengue is a communicable disease transmitted by Aedes mosquitoes causing a significant problem in the tropical zone and humid regions of the world, including Thailand. The signs and symptoms of dengue are similar to other diseases making diagnosis more complicate. Dengue virus infection test kit (DENV NS1) is crucial for virus detection and diagnosis. This cross-sectional study aimed to study the use of DENV NS1 test kit among reported cases according to the diseases surveillance system (Report 506) in Bangkok between 2013 and 2017. The sample group of this study was 33 of hospitals in Bangkok. The data were collected in March 2019 by self-administered questionnaire and analyzed by descriptive statistics and Chi-square test. The result showed that the trend of using DENV NS1 test kit was increased following the disease situation. The highest positive results of DENV NS1 were 30.1 percent, concurrent with the number of 11,881 reported dengue cases in 2015. Furthermore, the reported cases in the diseases surveillance system (R. 506) was less than the positive result from the test kit (87.8%) and the number of using dengue rapid test kit increased every year. The use of 1 to 2-days screening test kit constantly increased from 2014 to 2017. The uses of DENV NS1 test kit results were associated with the types of dengue reported in the disease surveillance system (p < 0.001). It is recommended that the hospital should develop a surveillance system to report patients to fill out the results of using the test kit or laboratory result.


Community pharmacy is a health service that provides drug distribution and primary health services in the community. Proper distribution of community pharmacies in each area will allow people to access pharmacy services resulting in safe drug use. This study aimed to examine the distribution of community pharmacies in relation to health needs by health region of Thailand. Secondary data obtained from relevant government agencies:  the number of population, the number of patients with ambulatory care sensitive conditions (ACSC), gross provincial product (GPP) per capita, modern pharmacy (type I), accredited pharmacy and type II pharmacy along with other public and private health establishments, were analyzed using descriptive statistics. The results showed that in 2016, there were 16,053 community pharmacies in Thailand. Health region 13 (Bangkok) had the most community pharmacies (4,774 stores), representing 29.74 percent of the country total. In provincial area, Health region 4 had the highest number of community pharmacies (1,780), representing 11.09 percent and Health region 3 with the least community pharmacies (333) representing 2.07 percent. When considering the distribution of community pharmacies in relation to health needs, Thailand had 2.47 stores per 10,000 population and 2.72 stores per 10,000 cases of patients with ACSC. The number of community pharmacies was positively correlated with gross provincial product (GPP) per capita. In provincial area, majority of community pharmacies located in municipal area. The study showed unequal distribution of community pharmacies in Thailand. These may affect unequal access to medicines and pharmacy services.


Background & Rationale: The peritrochanteric hip fracture or hip fracture in an elder is one of the most fatal orthopedic trauma which needs surgical correction and appropriate rehabilitation after surgery until the patient can live an independent living. This condition causes a prolonged postoperative hospital stay increases postoperative cost crowds out other patients to limited hospital bed and overloads hospital workforces. The intermediate postoperative care project has been developed between the regional and district hospitals in Chiang Rai province to increase the capability of postoperative hip fracture care in district hospitals. The hip fractures patients after surgical treatment in Chiangrai Prachanukroh Hospital will be referred back to district hospitals for inpatient rehabilitation. This was the way to decrease the postoperative hospital stay and increase clinical outcomes in elderly with hip fractures in Chiang Rai province. Objective: The objective of this study was to compare the clinical outcomes of peritrochanteric hip fracture in the intermediate postoperative care project between the regional hospital and district hospitals in Chiang Rai province. Methodology: This study was a prospective cohort study recruiting hip fractures elderly patients who were assigned to intermediate postoperative care in Chiangrai Prachanukroh Hospital and district hospitals from February to June 2019. The population in this study covered 91 patients of two medical benefit schemes. There were 27 patients taken care in Chiangrai Prachanukroh Hospital and 64 patients taken care in district hospitals. Results: The average ages of the elderly patients with hip fractures taken care in Chiangrai Prachanukroh Hospital and district hospitals were 76.2 and 76.6 years respectively. Most of them (70.4 and 62.5 percent respectively) were suffered from the intertrochanteric area fractures. The percentages of the patients who were operated by the proximal femoral nail antirotation (PFNA) fixation were 59.3 and 64.1. The average length of postoperative hospital stay in Chiangrai Prachanukroh Hospital was statistically significant lowered from 5.4 to 3.5 days (p=0.001). There were no significant differences in postoperative complications (p=0.305). The activity of daily living scores (Barthel’s index) of the elderly patients on discharge date were 13.6 and 13.3, and at 6 weeks after discharge were at 17.0 and 17.2 respectively (p=0.874). Conclusion: The clinical outcomes of peritrochanteric hip fracture in the intermediate postoperative care project treated at the regional and district hospitals in Chiang Rai province were not different. The project lowered the average length of postoperative hospital stay in Chiangrai Prachanukroh Hospital.


In 2019, approximately more than 3 million migrants were working in Thailand. Major labor source countries (2,816,241 migrants) were the neighbouring countries including Myanmar, Cambodia and Laos. Occupational health (OH) problems among migrants were often found as a result of language and cultural barriers to health care access, and documentation status. This study was conducted to develop the occupational health services model (OHS) for migrant employees. This action research consisted of three stages including the situation analysis, formation and institutionalization. In the first stage, existing OHS situations were explored among participated agencies using both quantitative and qualitative methods. Data were collected from safety officers or human resources personal among 48 factories in Samut Prakan and Samut Sakhon using the structured questionnaire. Among them, 52 migrant employees were selected to participate. Then, qualitative data were collected from stakeholders using in-depth interviews and focus groups methods. In the second stage, Delphi technique was used to develop a friendly-migrant OHS model following the data from 21 experts who worked in occupational health field. In the institutionalization stage, some OHS activities of such model were chosen to launch in 4 pilot factories. Quantitative data were analyzed using frequency, percentage, Chi-square test and Fisher Exact test. In addition, qualitative data were analyzed using Thematic analysis. Results showed that among participated factories, most of them were food, beverages and drinking water factories (37.5%) which had 100 – 499 employees (37.5%). Only the large factories (employees >1,000) which had the number of migrants higher than Thais. Most of factories (97.9%) had safety officers (professional level). The interpreters were employed in 32 (66.7%) factories. Only 10 (20.8%) factories had migrant health volunteers who were interpreters as well. Occupational injuries and occupational diseases (OD) were found in 35 (72.9%) and 3 (6.2%) factories, respectively. The study found the association between number of migrant employees and accident statistics (P<0.001). The size of factories also associated with interpreter employment (P=0.017) and existing OH volunteers (P=0.040). Of 52 migrant employees, they were female (57.7%) aged 20-29 years old (53.8%). Myanmar was the most proportion (92.3%) who had worked for 1-5 years (53.8%). Most of such employees (70%) were trained on the topic influencing safety at work. Few of them had been trained to prevent OD, communicable diseases or family planning. Animated media which could access through internet were most preferred among participated employees. For the government side, related agencies which are under Ministry of Labor provided the services for employers and employees following the own legislations. In Samut Sakhon province, the provincial hospital could provide both passive and pro-active OHS to migrant employees. To be the effective services, hospital had a specific migrant clinic where had the interpreters whom employed to facilitate during services provision. In the same time, the provincial hospital in Samut Prakan provided services mostly for communicable diseases and health examination indicated for health insurance. Interpreters were available in Tuberculosis clinic offered by nongovernmental organization. According to the gap found from information in the first phase, OHS model was established to address on activities related to OH risk communication, coverage of some OHS services to migrant workers such as OD diagnosis and record, return to work management and health database development. Based on time constraint, this study selected some activities to perform addressed on the OH risk communication. OH migrant volunteer curriculum and training, 3 languages OH media, and self-health evaluation corner were launched in 4 factories. The core content of such curriculum was the OD and injuries protection. Immediately after the training, more than 60% of participants were very satisfied. However, after 3 months follow up, only trainees in 2 factories could partly organize OH and safety activities with related staff. The limitations of this study revealed as follow; 1) the generalization of the results was limited because of qualitative oriented data collection 2) the OHS model was developed based on the context of only formal migrant workers and 3) the curriculum was developed to train the migrant employees to be the OH volunteers but only few employees could perform the activities following their roles. This study recommended that the Ministry of Public Health should bring the OHS model to implement especially in the abundant migrants provinces. Additionally, the developed curriculum should be integrated with the existing one and details of OD protection should be addressed. The Ministry of labor should consider the quality of employed migrants and more enforce the factories to comply related conventions for improvement the occupational health and safety among such employees. The OHS model in the present study were addressed on formal migrant workers. Therefore, OHS for informal sector should be considered in further study.


The objective of this research was to test the physical fitness, evaluate physical well-being, analyze relationships and cluster analysis of physical fitness, and investigate indicators for physical fitness in Thai elderly throughout Thailand. The samples were self-help elderly consisting of males and females, aged 60-69 years old. They were recruited from 5 regional parts of Thailand, 400 participants in each region, including a total of 2,000 participants. The research instruments were two set. Set one was the physical fitness testing for Thai elderly in 6 categories including with body composition, cardiorespiratory endurance, muscular strength and endurance, agility and balance, flexibility, and reaction time and coordination. In addition, there were recordings of electromyograms (EMG). Set two was the physical well-being in elderly including with physical activity, nutrition, rest and sleep, and health problem and non-communicable disease (NCD). The analysis of general data were used with distribution of frequencies, percentages, means and standard deviations, classifying by genders and regions. The classifications of physical fitness groups in Thai elderly were used with cluster analysis and physical fitness indicators. The results demonstrated that the physical fitness groups of the elderly were classified into four groups composed of the 522 participants in very good group (26.14%), the 770 participants in good group (38.56%), the 478 participants in fair group (23.93%) and the 227 participants in risk group (11.37%). The cluster results revealed that the waist circumference could be best used to classify (F = 669.732), followed by the VO2 max from the six-minute walk test, body weight and body mass index (BMI) respectively. The results of indicators were 12 assessment criteria including 30-s block transfer test, reaction time, sit and reach test, TUG time, distances in six-minute walk test, body fat percentage, hip circumference, and waist circumference. In conclusion, the physical fitness test of Thai elderly and assessing the physical well-being of most Thai elderly. This information can be used for health promotion planning for Thai elderly.


Background: Dementia, diabetes, chronic kidney disease and cardiovascular disease (CVD) share common pathophysiology, possibly through metabolic stress. Multifactorial individual-level interventions including lifestyle modification have been reported to reduce risk of diabetes and CVD, mainly in high risk population and many done in clinic settings. Attempts to prevent dementia / Alzheimer’s disease (drugs and supplements) in individuals have not been successful. Little evidence exists to describe the effect of community-based lifestyle interventions on risk of dementia and such NCDs in intermediate risk middle-age and elderly populations. The objective of the project in Year 3 was to investigate the impact of community-based lifestyle modification program on health behaviors, physiologic and biochemical variables and the risk of diabetes, chronic kidney disease and CVD over 2 years of follow-up. This study also aimed to examine the economic impact of such the intervention. Methods: In this cluster randomized controlled trial, 60 villages were selected using multistage stratified random sampling from 25 districts of Ubon Ratchathani. Men and women aged 45-75 years without the above preexisting diseases were invited to participate. A sample size of 4,000 individuals is required to attend screening at baseline to assure approximately 3,600 individuals enrolled in the study (1,800 individuals in the Intervention and Control groups). Main interventions to enhance physical activity and healthy diet were developed and tested before enrollment of participants. After baseline assessment, multi-module multi-level Interventions to address four health behaviors (physical activity, diet, smoking and alcohol consumption) at four different levels (individual, household, group/ knowledge management and community levels) were given in the Intervention group. Site monitoring visits were performed to assure the quality of data collection and intervention. Primary outcome was incident dementia at 10 years. In Year 3 (Follow-up Year 2), we investigated the impact of the above interventions on health behaviors, physiologic and biochemical variables and the risk of diabetes, chronic kidney disease and CVD, reporting relative risk (95%confidence interval) and relative risk reduction. Intention-to-treat data analysis was performed. Incremental cost-effectiveness ratio (ICER) were calculated. Results: Based on multi-stage stratified random sampling (described in Year 1), a total of 60 villages were selected for this trial and randomly divided into two groups: Intervention group which received the above-mentioned 4x4 lifestyle modification intervention and Control group which received healthcare in normal practice. In Year 3 refresher course for key research assistant team from 60 villages, which included 60 nurses and health care officers, 120 health volunteers and 60 community leaders, were undertaken. Enrolment started on 1st March 2016 and, up to July 2017, a total of 3,983 individuals aged 45-75 years were screened, with 3,505 participants meeting the inclusion/ exclusion criteria. There were 1,767 and 1,738 participants in the Intervention and Control groups respectively. Participants in both groups were comparable according to their socio-demographic characteristics, personal and family history, and key laboratory results (e.g. fasting plasma glucose, HbA1c, and LDL cholesterol). Due to unexpected changes in central laboratories and severe flooding, Year 3 data collection were delayed. A total of 3,314 participants (94.5%) attended Year 3 follow-up, including 1,650 and 1,664 participants in the Intervention and Control groups. Over 2 years of follow-up, participants in the Intervention group reported better health behaviours (physical activity, diet and smoking) than the control group. Although there was no difference in anthropometric indices and physiologic variables, i.e. blood pressure, between the two groups, those in the intervention group had lower fasting plasma glucose and HbA1c than those in the control group (Fasting plasma glucose 84.4±13.0 vs 85.6±14.3 mg%, p=0.015 and HbA1c 5.58 (0.57)% vs 5.63 (0.58)%, p=0.021 respectively) They had lower total cholesterol and triglyceride than those in control group (Total cholesterol 186.6±37.1 vs 189.6±37.1 mg%, p=0.028 and Triglyceride 147.0±80.6 vs 160.0±102.7 mg%, p<0.001) Overall the Intervention and control groups had comparable risk of diabetes. However, in the very high risk defined as having family history of diabetes and pre-diabetes blood sugar levels, participants in the intervention groups had a 37% reduced risk compare to the control groups (2-year incidence of 14% and 19%, relative risk 0.63 (95%CI 0.35-1.09), one-tailed p-value 0.041). In all participants, there was no difference in risk of worsening kidney function (defined as >25% reduction of eGFR) between two groups. In a subgroup analysis in female participants, the intervention group had 59% reduced risk of worsening kidney function (2-year incidence of 1.1% vs 2.6%, Relative risk 0.41 (95%CI 0.20-0.87)). The risk of mild cognitive impairment was lower in the intervention than control groups, with 2-year incidence of relative risk of 2.1% และ 4.0% respectively (relative risk 0.53 (95%CI 0.36-0.78), p=0.003). There was no difference in CVD risk over 2 years. In base case scenario of cost-effectiveness analyses, community-based 4x4 lifestyle modification program resulted in an ICER of 21,196 Baht per one case of diabetes prevented compared to normal practice. The ICER was 145,721 Baht per one case of worsening renal function and 129,530 Baht per one MCI case prevented. Further, a qualitative study suggested that key success factors of the project included community leaders, healthcare officers and common interest and engagement of community members. Participants strongly suggested the project to continue. Discussion: Albeit some delay, key milestones in Year 3 data collection, provision of the designed interventions and outcome ascertainment were achieved. In this short follow-up, With changes in key health behaviours and metabolic variables, this community-based multi-module and multi-level lifestyle modification was effective in prevention diabetes, worsening kidney function and MCI in high risk and some other particular groups and this might be cost-effective. Lessons learned from this community-based disease prevention project may be extended and adapted for other communities in Thailand. Crucially, the sustainability of this kind of project may be enhanced by more community engagement and continuing financial and non-financial supports from local administrative organizations.


Background: Situations in the drug system in Thailand have been changing constantly over time, a study to analyze situations in the national level to assess up-to-date research questions in the area of drug system is necessary. Objectives: The primary objective of this study was to summary the situation of national drug system. The secondary objectives were 1) to summarise direct and indirect factors affecting the drug system and 2) to assess research questions for further developing the national drug system. Method: This study employed qualitative research methods including document analysis, semi-structured interview and focus group discussion. Results: The research questions were classified into four areas according to the national strategic plan on drug system: 1) developing the national drug control system, 2) supporting research and development to promote local pharmaceutical manufacturing, 3) promoting access to essential medicines among Thai people, 4) promoting rational drug use. Conclusion: Research questions from this study will be used for guiding potential research topics in the areas of national drug system and consumer protection in drugs.


Background: Adult-onset immunodeficiency syndrome (AOIS) due to anti-interferon-gamma (IFN-ϒ) autoantibodies has emerged in otherwise immunocompetent adults. Currently there is no specific treatment for the diseases. Immunosuppressive agents to inhbit antibody production are the mainstay treatment of several autoimmune diseases. This study aims to evaluate the effectiveness of bortezomib in decreasing level of autoantibodies (Abs) in patients with anti-IFN-ϒ auto-Abs. Methods: A pilot pre-and postintervention study of patients with anti-IFN-ϒ auto-Abs was conducted between February 2017 and June 2019 at Faculty of Medicine Siriraj Hospital. Five patients with high titer of anti-IFN-ϒ auto-Abs were selected to receive bortezomib at the dose of 1.3 mg/m2 body surface area (BSA) once weekly for a total of 8 weeks and cyclophosphamide at the dose of 1 mg/kg/day for the following 4 months. The primary outcome was the difference of autoanibody level at 8 and 48 weeks compared to baseline and any adverse event occurred during the study period. The clinical characteristics, the number of opportunistic infections (OIs) within 72 weeks of study enrollment and the inflammatory biomarker such as C-reactive protein or erythrocyte sedimentation rate were also evaluated. Results: A total 5 patients were enrolled, of which the median age was 46 years (34-53 years) and 2 patients were male. All patients had 3-5 OIs before enrollment. There was no significant difference in the mean (+SD) optical density (OD) values of autoantibody at 8 weeks (3.73 + 0.72) and 48 weeks (3.74 + 0.53) compared to baseline (3.84 + 0.49) (p=0.336 and p=0.555, respectively). No recurrence of infection was observed in the first 6 months. However, during the 72 weeks of follow-up, 4 of 5 cases had a total of 10 recurrent OIs of which Mycobacterium abscessus was the most common. Infection with Talaromyces marneffei was observed in 3 patients at approximately 1 year after bortezomib administration. Conclusions: Bortezomib appears unable to reduce autoantibody in patients with anti-IFN-ϒ auto-Abs. Although no recurrent infection was observed within the first 6 months during the study medication, recurrent OIs were observed thereafter. Bortezomib seems to increase risk of infection with T. marneffei. Long term follow-up should be considered in patients with anti-IFN-ϒ auto-Abs who received immunosuppressive agents.


The problem of shortage of human resource for health (HRH) in remote areas has been concerned for decades. Providing financial and non-financial incentives is one of the effective solutions. The objectives of this study include (1) to indicate incentives and quality of life of HRH working on remote areas and (2) to develop policies for motivating HRH to be willing to working in remote areas. The quantitative and qualitative research has been used. We used qualitative method for development of attributes and response level for an analysis of Discrete Choice Experiment (DCE). The DCE was conducted into two groups: group 1 - physicians, dentists and pharmacists; and group 2 - nurses and multidisciplinary team. The thematic analysis and conditional logit regression model were used for qualitative research and DCE, respectively. Regarding results from qualitative analysis, the attributes influencing decision making of HRH working in remote areas include income, workload, self development, working in hometown, horizontal relationship, good facilities (e.g. electricity, water supply, especially the internet that is important for work and recreational activities), having a safe and convenient house, being instilled as government official, clean environment and family issues. The results from conditional logit regression model determine that workload, convenient stores, and private accommodation are important incentives, however, the most important attribute was income. It was found that if they got income a 40% higher than friends working in urban areas, they had 4.2 times more chance to work in remote areas; If a 60% higher, 8.3 times more chance to work in remote areas. For Nurses and multidisciplinary team, workload, self development, working in hometown, living in private accommodation, being instilled as government official, especially income are important incentives. It was confirmed that income is the most important incentive to motivate HRH working in remote areas. The current incentive policy of providing subsidy for HRH working remote areas should be remained. Another policy to be considered is providing scholarship to local students to work in their hometown as well as providing private accommodation to meet requirement of workers. This policy can be managed at the level of provinces and regions.


Information tools are the tools for transforming collected data into meaningful and useful information which is important for district health system management and health service quality improvement. Objective of this study is development or adoption of appropriate information tools for analyzing or displaying information for district health system management and health service quality improvement. Three types of information tools were developed or adopted including Business Intelligence, Geographical Information System (GIS) and Data mining by applying in 3 districts. The results revealed that Business Intelligence tool for visualizing mortality data, disease surveillance data, health status and health service data was appropriate because of easiness and adequacy for use. It can compare data across sub-districts and across health facilities within each particular district. Trend over time is also provided together with map across sub-districts. Business Intelligence tool should be, therefore, the main tool for further expansion and improvement for covering all districts as it uses mainly national databases. For GIS tool, which is open source software, it can be the additional tool for interested districts as well as Data mining tool which can produce various models from service data such as Decision Tree, Neural Network, Logistic Regression and Clustering. Data mining can be used for knowledge generation by interested organizations and requires specific training for applying software and learning related fundamental knowledge.


This research aims to 1) attain a better understanding in the nature of the situation related to the safety of daily commute via public passenger vans through the perception of commuters and van drivers 2) explore possible measures to prevent the danger of the daily commute via public passenger vans through the perception of the involved parties, and 3) study past policies and outcomes of the implemented policies by different working bodies related to the safety of daily commute via public passenger vans and analyze the factors affecting both the success and failure. The research procedure is divided into two phases. The first phase utilizes qualitative and quantitative research methods to achieve the first and third objective. Data collection is conducted in 3 van stations (Bangkok-Chonburi route, Chonburi – Bangkok route and Bangkok-Nakhonnayok route) with the subjects being 45 van drivers and 210 passengers, 6 business operators, 3 officers from the Land Transport Department, 6 traffic polices. The data analysis is done using content analysis and Multiple Recession method. The second phase employs the participative action research to help develop for the most effective measures to prevent the danger caused by daily commute via public passenger vans. The analyzed data from phase one is provided back to the research participants (3 officers from the Land Transport Department, police officers and representatives from Road Safety Group Thailand (RSG), 30 van drivers, and 2 operators of public passenger van business). The findings reveal the following: 1. The factors affecting the behaviors and safety of the commute via public passenger vans in Bangkok Metropolitan Region are people’s knowledge and attitudes towards safety. Such factors have significant statistical impact on the safety behaviors of the commuters at .001 with the predictable rate of 29%. 2. The driver’s perceptions towards situations related to the safety of daily commute via public passenger vans reveal that the drivers are aware of the risks of driving public vans caused by other road users. They are also aware that accidents can cost them not only, their time and income, but also their lives. Other risks include poor conditions of the roads and operating vans, drivers’ insufficient sleep and excessive passenger capacity. The risk factors are derived from families and business operators competing for clients. From the passengers’ point of view, the finding discloses the passengers’ realization in the risks of commuting via public passenger vans, which are still ongoing and somewhat normalized. 3.Compliance with implemented policies and factors affecting the success of the developing greater safety for public passenger vans encompass the understanding in the problems of the service, strict enforcement of the laws, collaborations between government agencies and understanding in the implementation of policies as well as the use of technology, social media platforms and applications to make opinions heard and complaints resolved. The problems include expired Compulsory Motor Insurance, relatively small fines, inconsistent/only occasional inspection, and problematic mindset/conflicted benefits of illegally operated vans. The solutions include the revision of Government Gazette to appropriately enable a system where safety measures can be continually and effectively monitored, as well as creating a greater acknowledgement in the passengers’ benefits and safety. 4. Conceived is a participative action approach adopted among public van drivers, which aims to develop greater knowledge in the prevention of risky behaviors, proper training that follows anger management principles, and positive communication skills. The passengers must also be properly educated about appropriate commuting behaviors and skills to ensure their own safety as well as the public’s, while the development of positive communication skills should also be encouraged.


An Implementation research program on development of Integrated People-centered Primary Care System (IPCPCS) in Thailand aims to redesign health services at primary care level to be an integrated-people centered health care and develop tools to support the implement in addition to evaluation on implementation outcomes. The program has been implementing in 20 piloted primary care clusters (PCC) and started to implement the new model since August 2019. The program employed mixed research methods including literature review, in-depth interview, focus group discussion, and a survey of 200 patients with diabetes and hypertension from each PCC on chronic care experiences. Initial assessment found that PCC under the research program performed better than other health facilities in the same areas in all components of integrated people-centered care (patient and family health team relationship, shared individual care plan, personal health record, health literacy and self-management support, and continuity and coordination). However, there is room needed for further improvement especially on patient and family care team relationship and health literacy and self-management support. Further implementation research is needed for further development and evaluation of service outcomes.


The Thai Health Literacy Survey (THL-S) of Thais aged 15 years and above has four objectives as follows: 1. to study the current situation of health literacy among Thais aged 15 years and above at the health regional and national level across health literacy competences and health domains. 2. to explore relationships between relevant factors and health literacy for identifying populations at risk. 3. to raise awareness among health professionals and relevant professionals on the impact of limited health literacy on national public health. 4. to produce evidence – based knowledge for better policy making, planning and implementation. The survey took place between March – August 2019. The Office of DoH 4.0 and Health Literacy led the project in collaborations with the 12 health promoting centers and Metropolitan Health and Wellness Institute. The project was financially supported by the Health System Research Institute. The valid sample size was 17,530 people. 38.67 percent were male and 61.33 percent were female. Key Recommendations Relevant organizations in health, educational, and social sectors should raise awareness and improve understanding among their personnel about the impact of limited health literacy on access to and utilization of their services. Effective health literacy related interventions should emphasize two approaches; one is to motivate and build individual capacity needed for finding, understanding, communicating and making health related decisions. The other one is to reduce the system demand and complexity and empower the people to become self-reliant so that the systems and services are health literacy friendly for all. Relevant educational organizations should build a strong literacy among students for finding, understanding, communicating about health information and making health related decisions. They might emphasize e-health literacy skills. The people in communities should be encouraged to take part in community based activities and assigned a role. All organizations should develop reliable and accessible channels for disseminating and searching for information. They also should announce and explain how to make use of the channels in appropriate manners. Curricula for health professionals, educators and social workers should address knowledge, skills, and technologies that can be used to facilitate and assist those who have limited health literacy.


Accumulating data indicate that obstructive sleep apnea is an independent risk for gestational hypertension, preeclampsia, gestational diabetes, and preterm delivery. Preliminary studies demonstrated the benefits of early nasal continuous positive airway pressure (CPAP) treatment in high risk pregnant women to prevent adverse maternal and fetal outcomes. Highrisk pregnant women such as those with obesity, chronic hypertension and prior history of preeclamsia should be evaluated for diagnosis and treatment of sleep-disordered breathing given the potential benefit of early CPAP treatment. The pathophysiological evidence linking preeclampsia and sleep-disordered breathing supported the rationale for CPAP treatment in addition to conventional antenatal care. However, currently there is no standard guideline that systematically screens and treats for sleep-disordered breathing during pregnancy. The situation of sleep-disordered breathing is in the state of “clinical equipoise”, where strong evidence is needed to make any treatment recommendation during pregnancy. It is an urgent need to conduct a randomized controlled trial that can demonstrate the efficacy of CPAP treatment.


Diabetic Retinopathy (DR) and Age-related Macular Degeneration (AMD) can prevent or reduce the severity of the disease if the diseases are found early.  This can lead to a treatment to reduce loss, reduce medical expenses, and increase the quality of life for the elderly.  Diagnosis of DR and AMD must be examined by an ophthalmologist by retinal examination. However, ophthalmologists in Thailand are still inadequate for their needs, especially in remote areas. With such restrictions, patients do not receive proper treatment on time and that can cause vision loss. Therefore, our research team developed DeepEye using deep learning, a technique in artificial intelligence that is very accurate. By developing it to be easy to use in the form of application on smartphone that can connect to any portable fundus cameras, can be screened quickly, and provide very high accuracy equivalent to an ophthalmologist.  Specifically, it can be used to screen DR and classified into three types of retinal images that are normal, DR, and other diseases. If detecting a diabetic retinopathy, DeepEye can also accurately identify the severity of DR into 4 levels, i.e., mild, moderate non-proliferative DR (moderate NPDR), severe (severe non-proliferative DR: severe NPDR), and severe with new blood vessels (proliferative diabetic retinopathy: PDR) which is a very dangerous stage of DR.  Moreover, DeepEye can be used to screen AMD, which can be classified into dry age-related macular degeneration (dry AMD) and wet age-related macular degeneration (wet AMD).


Coronary artery disease (CAD) is the leading cause of death and disability in Thailand. The incidence of CAD has constantly been increasing. Percutaneous coronary intervention (PCI) is the standard and mainstay of CAD treatment. In Thailand, PCI has been performed for more than 20 years. Because of the benefit of PCI in reducing mortality, morbidity and symptom, it is recommended by many clinical practice guideline as a standard treatment of CAD. Since the Ministry of Health realized the benefit of PCI and support the opening of new catheterization laboratories (cath lab) in all parts of the country, the number of cath lab and the number of PCI cases in Thailand has rapidly increasing for the last ten years. PCI registry is very important, as it provides many useful information (e.g. baseline demographic data of the patients, practice pattern, device and equipment use, outcome of treatment, complications, success rate, emergency CABG rate), as well as information regarding health care system (e.g. prevalence of referral cases, waiting time of the system, appropriateness of PCI, cost of PCI, cost-effectiveness/cost-utility which could be compared to treatment of other diseases (such as cancer, etc.). The information is essential in improving the outcomes of PCI, in preventing complications, in increasing the efficacy and safety of PCI, which may lead to more effective national resource allocation and proper reimbursement. With the reasons given, many countries have conducted their own data collection and PCI registry. The good examples include SCARR registry of Sweden, NCDR of USA and NCVD PCI registry of the National Heart Association of Malaysia. Cardiovascular Intervention Association of Thailand (CIAT) realized the importance of having our own data, therefore initiating the project “Thai PCI Registry” in order to collect the data of patients undergoing PCI in current clinical practice in our country. The project received financial support from Health System Research Institute (HSRI). The project was planned for 4 years with summary of the project as follow: The first year is the preparation year. The plan was to generate CRF, get approval from CREC and local EC/IRB, create definition brochure/operator manual, invite every cath lab all over the countries to participate, set up the online data entry system, set up and maintain database and server, establish national network for cath lab personnel, test the data entry system and arrange for workshop and training of research personnel/cath lab staff from every participated site. The second year would focus mainly on data entry. The plan was to maintain uneventful data registry, improve and evolve the online data entry system, maintenance of database, communicate within the network and perform site audit of all 39 participating hospital all over the countries. The third year is to close the recruitment of new cases, clean and check of the data obtained as well as perform data query. When the data quality is confirmed, the data lockdown of the baseline (in-hospital) data would be conducted. During this year, there will be initial data analysis, some manuscript writing and submission for publication. Furthermore, the follow data at 6 and 12 months will be gather as well as outcome verification and ascertainment. The final year we plan to perform data query of follow up data before the final and complete data lockdown as well as data analysis, manuscript writing and submission for publication. The main activity of this year will also focus on distribute all important results to the public and all stakeholders. This report is the full report of the Phase 1 of Thai PCI registry project (year 1-2) which received financial support from HSRI. The final Phase 2 of the Thai PCI registry project (year 3-4) will be conducted immediately after receiving approval and grant support from HSRI. There were 22,741 patients participating in Thai PCI registry. Approximately 70% were male with the mean age of 64 years. Two third of all patients use Universal Coverage (UC) scheme. Most common presentation was stable CAD (37.6%) and most common procedures were performed electively (61.2%). More than half of all patients were referral cases. In terms of coronary anatomy, most patients were classified as triple vessel disease (32.9%) follow by double vessel disease (28.7%) and single vessel disease (26.4%), respectively. Ten percent of all patients had left main stenosis. The main vascular access was femoral approach (12,568 cases; 54.4%). When we categorized the patients into their presentation of acute coronary syndrome and stable coronary disease, we found that 27.6% was STEMI, 29.8% was Non STEMI, 37.6% was Stable CAD, and others was 5.1%. The In-hospital mortality rate was 6.7%, 2.1%, 0.3%, and 3.3%, respectively. with overall in-hospital mortality was 2.8%. The overall success rate of PCI in this registry was 96% which was very good and comparable to data from other countries. The factors that were independently associated with procedural failure included older age, referral cases, hypertension, history of heart disease, complex lesion, long lesion, and poor TIMI flow. The incidence of procedural complications was approximately 5%. The common complications reported included coronary dissection, side branch occlusion, no reflow, coronary perforation, device dislodge, acute stent thrombosis. The factors that were independently associated with procedural complications included older age, female, health care coverage, hypertension, history of heart disease, cardiogenic shock, requirement of IABP/mechanical support, unsuccessful vascular access, long lesion, thrombotic lesion, complex lesion, bifurcation and abnormal TIMI flow. The common clinical complications included post-PCI MI (1,374 cases, 6.0%), bleeding within 72 hours (1,102 cases, 4.9%), stroke (85 cases, 0.4%) and emergency CABG (0.3%). In term of mortality, the in-hospital mortality rate was 2.8%. The independent factors associated with incidence of clinical complications included older age, female, referral cases, peripheral vascular disease, requirement of dialysis, emergency PCI, ACS, cardiogenic shock, requirement of IABP/mechanical support, left main stenosis, unsuccessful PCI, and procedural complication. In summary, the first phase (year 1-2) of Thai PCI registry was completed with great success. Many goals and objectives were achieved which included 1) establishing national network which can be a platform of nation-wide collaboration of other registry in the future, 2) creating CRF in PCI cases which can be used by any participating sites even after completion of the registry or can also be used by general public by request, 3) Training the new researchers from all area of the country, 4) obtaining crucial data which will lead to improvement of PCI outcomes, prevention of complications and improvement of health care system resulting in better care of patients with cardiovascular diseases in the future.


Background: The deep southern border provinces consist of Pattani, Yala, Narathiwat and 4 districts of Songkhla province--Nathawi, Chana Thepha and Sabayoi, which are the diverse areas of life under the framework of beliefs, religions, cultures, and other traditional ethnic groups. Besides, there has been a situation of unrest and violence for more than 15 years, affecting health service systems, quality and accessibility. This research is a descriptive study aimed to explore the feasibility of applying the multicultural health service standards for the three levels of health services in those areas to meet the spiritual needs, religions, cultures and customs of each ethnic group or focus on the culture of the sub-groups, contributing to health equity. Methods: The study consisted of 2 phases between June 2018 - November 2019: phase 1, the draft criteria were developed in 5 steps. First, documentary research was reviewed and synthesized to provide a general understanding of the multicultural health service standards in other countries. Second, the survey was conducted to draw the opinions of people in the area by using questionnaires. Third, the focus group discussion was performed between the recipients and health service providers. Fourth, in-depth interviewing was a loosely structured interview among the service management team such as the hospital director, head of district public health, and the local government organizations. Fifth, the content of the standards was screened and standardized by experts such as provincial public health doctors in Delphi techniques. A total number of 5,555 people were given information in these processes. Phase 2, a feasibility study of using standards was launched in the pilot areas with 3 steps: (1) the standards were approved by policymakers to consider into action, (2) the standards were implemented in pilot hospitals, and (3) an evaluation and monitoring was then proceeded to announce as a policy. Results: The multicultural health service standards were finally drafted and organized into 7 main criteria and 47 sub-criteria. The standards were then implemented in 4 hospitals in study areas and 1 hospital in the other area that has a similar context. The parallel evaluation during the trial period revealed that the customers’ opinions for the service quality were 88.6-99.4%. They knew, needed and satisfied this service that was 34.3%, 99.2%, and 97.1% respectively. While the health care providers know about this service 100% and need it 85.0%. The outcomes also provided 97.9% of the concrete model and 98.6% having good management for customer complaints. Suggestion and conclusion: The feasibility study of the multicultural health service standards utilization in the Southern border provinces has contributed to familiar and acceptance among recipients and health service providers. Therefore, this is an opportunity for the Ministry of public health and local administrative organizations to promoting as a policy to apply in all health services and in communities for better service accessibility in the long run.


This study aims to develop a policy on employment of retiring nurses in health services under the government sector. The mixed-methods, qualitative data and quantitative data, was used to conduct in this study. The research procedures are as follows: 1) Reviewing literature on employment and employment situation for retirement proposals in various health care facilities in Thailand. 2) surveying information on employment of retiring nurses in health care centers by phone and 3) interviewing the executive representatives such as human resources director, director of nursing division, inspector of public health supervision area under the Ministry of Public Health about the opinions on the retirement nursing employment policy. The analysis of quantitative data from survey was frequency and percentage. The information from interviewing was analyzed by content analysis. The results of the content analysis from the interviews of the high level executives revealed that most of the senior executives had good attitudes towards hiring retirement nurses because it is a support to the policy to expand working opportunities for the elderly in accordance with the government policy, and also using the knowledge experience of retirement nurses. The situation regarding the necessity of hiring a nursing nurse due to 1) the shortage due to the distribution of nursing personnel is not good. Causing a lack of balance between the workload and the workforce in the health service 2) The system to maintain nursing personnel to remain in an ineffective profession Resulting in nurses in the service system lacking work motivation and resigning, and 3) shortage due to increased workload. The management has made recommendations regarding the objectives of hiring retired nurses as follows: 1) having need for employment in some positions where retirees have specialized knowledge And currently cannot find replacement personnel. 2) Hiring only department having insufficient staffs. 3) Primary care services in the community should be implemented especially to the family doctor team. 4) Social medicine work because they have the right skills. 5) Intermediate care services, with training to increase knowledge and skills in operations, 6) care manager jobs, and 7) design new jobs by studying the need of patients, and design new work services that are appropriate for the modern world by focusing on health promotion. The most work is to provide service in the community, suitable services for all age group by using the local government organization mechanism, Health promotion educational system, and health promotion operations Solving health problems in schools, etc. The policy recommendations on hiring retirement nurses were 1) the extending the retirement period according to government policy. 2) Hiring retirement nurses for services such as community service in the roles of community nurse at health services center by yearly contract and use universal coverage budget (UC). 3) Hiring retirement nurses for new services that having value and income by yearly contract and use the budget from organization in community such as education organization, local government organization or private sectors. The examples of new service are counsellor at chronic disease clinic, caregiver in community, nurse in child development center, school nurse, and etc. 4) Part time or Full time hiring depending on the need of organization to prevent insufficient human resource. The duties are almost same as before retirement. The pattern of hiring is freelance with flexible hours, and use the budget of service center services.


This study aimed to explore process for the selection of global health issues, frameworks for
monitoring and evaluation (M&E) activities, and the management of global health strategies internationally,
and to provide recommendations on future development process of Thailand’s global health
strategy. This study collected data through descriptive literature search and document reviews. Literature
search was conducted from July to August 2017 and was updated in August 2019. Global health
strategies of eight countries were selected as case studies, namely Canada, Japan, Norway, the USA,
Switzerland, England, Australia, and Thailand.
This study found that in most countries, the ministries of foreign affairs were responsible for the
development and the monitoring and evaluation (M&E) of global health strategy. The widely used
principles for the selection of global health issues comprised: (1) the globally threathening health
problems which also threatened own country, and (2) the country’s public health and foreign policies.
Deliberative discussion and consultation with stakeholders were the methods that all eight countries
employed to select global health issues for the development of their global health strategic framework.
There was no evidence of using quantitative methods or weighting methods for selection of global health
issues. The main principles underpinning the M&E activities focused on: (1) incorporating the M&E
activities as an integral part of the global health strategic framework at the beginning of the process;
(2) evaluating both outcomes and impacts (if possible) and (3) appropriately designing the M&E process
that fits with the implementation of the strategic framework.


The Ministry of Public Health issued the Health Insurance Card Scheme (HICS) for migrants who
were not covered by any health insurance schemes; however, the benefit package under the HICS has
not been significantly revised for the last 10 years. This study aimed to review and develop a proposal
to revise the benefit package of the HICS for migrants. The study was conducted by reviewing documents,
including clinical practice guidelines and cost-effectiveness studies of health interventions of the first 20
important health problems among migrants in Thailand, 10 communicable and 10 non-communicable
diseases. The benefit packages of the HICS and the universal health scheme were also compared. A
focus group discussion was arranged with 13 representatives from relevant agencies and healthcare
providers, and in-depth interviews were conducted with 33 key informants comprising decision-makers/
government officers, healthcare providers, non-governmental organizations and 15 migrants. The study
showed that the HICS covered diagnosis and treatment of almost all (90%) of the prioritized health
problems. About 80% of the non-listed or unclear health services in the current benefit package were
related to health promotion and disease prevention activities. Those unclear benefits led to disparities
in services availability and user charge for access to service. The analysis of qualitative data suggested
that health interventions that should be included in the benefit package and provided in all hospitals
consisted of the maternal and child health diary (in translated version), the screening and treatment for
common mental disorders, and breast self-examination advice.


An implementation research on the development of integrated-people centered care started a
pilot reform of service delivery system in 20 primary care clusters (PCCs). Patients with diabetes and/or
hypertension were employed in this pilot test model. An initial assessment was taken after a 4-months
implemention on patient’s experiences on receiving integrated people-centered care comparing between
PCC under the project with other primary and ambulatory care facilities in the same district. A community
survey of 200 samples was conducted from each district. There were totally 4,071 samples, 1,311
samples from hospital DM/HT clinics, 1,721 from PCCs in the project, 823 from other PCCs, and 216
samples from health centers.
Results showed that PCCs in the project had significantly better patient-family care team relationship
compared with other types of health facilities, a greater proportion of patients knew the name of family
physician, family care team, and had more convenient communication channel. However, the target of
receiving care from the same family doctor and team needed further improvement. The PCCs in the
project achieved significantly greater proportions of patients receiving care according to the guideline for
chronic illness care in most of the 5 dimensions (knowing health determinant factor, care plan, goal
setting, health behavior, and care result) compared with other types of facilities. However, the dimension
on health behavior modification got relatively low score compared with other dimensions. It is noticeable
that the other PCCs did not perform any better than hospital DM/HT clinics either in terms of patient-doctor/
family care team relationship or care for chronic illness. Further implementation research is needed
to evaluate implementation outcomes and service outcomes of the model.


This report presents a brief technical methodology on unit cost per disease and cost per diagnosis
related group (DRG) for Thailand. Cost analysis was on provider perspective. Standard costing method
and micro-costing or bottom-up approach were employed. The process started with cost per activity
estimation, patient-level costing, disease costing, and DRG costing. Cost data were voluntarily collected
from 13 hospitals. They were 4 regional hospitals, 1 general hospital, 7 community hospitals, and 1
specialty hospital. All data were for the fiscal year 2018 (October 2017 to September 2018). Results were
presented into two parts, cost methodology prototype and cost per disease and cost per DRG. Cost
analyses consisted of 2 major processes. They were hospital cost and cost center analysis using top-down
costing method, and cost per disease using bottom-up method. Top-down costing included 4 steps
1) cost center identification, 2) direct cost determination, 3) indirect cost determination, and 4) total cost
determination. The bottom-up costing was composed of 1) unit cost per service activity, 2) patient level
costing, and finally, costs of each patient were summed up as cost per disease of outpatient visit and
cost by Thai DRG version 6.2. The study also demonstrated that cost per activity such as an average
bed-day (room and board) cost for common ward was 377 baht, for intensive care unit was 930 baht.
An average outpatient nursing service cost was 252 baht per visit, inpatient nursing service cost was 1,055
baht per bed-day, ICU nursing service was 4,245 baht per bed-day. Metformin drug was 0.35 baht per
tablet, and HbA1C was 126 baht per test. Average cost of outpatient treatment for diabetes mellitus was
1,676 baht per visit: 1,951 baht per visit for regional hospital, 1,114 baht for big community hospital, and
929 baht for small community hospital. The total cost per admission was 3,847 baht for DRG 15540
newborn admission weight >2499 gm, 18,478 baht for DRG 14010 cesarean delivery. Costs of admission
among hospital levels were still different even for common DRG 06570 infectious gastroenteritis age >
9: 9,601 baht per admission for regional hospital, 7,772 baht for big community hospital, and 8,176 baht
for small community hospital. This paper demonstrated that the expanded standard cost methodology
development on cost per activity estimation at patient level would be useful for studying costs of service
provision of all health insurance systems in Thailand.


The objective of this study was to estimate unit cost of Thasongyang Hospital, Tak province from
provider perspective. Retrospective study was conducted in fiscal year 2018 and cost was obtained during
1 October 2017 and 30 September 2018. The hospital cost and service cost were analyzed using standard
top-down method and cost-per-patient was analyzed using bottom-up method. Cost centers were divided
by department types into two main groups: absorbing cost center and transient cost center. Costs
were distributed from transient cost centers to absorbing cost centers using simultaneous equation
method. The allocation criteria used data from absorbing cost centers together with information from
hospital database, and data were processed by (Hospital Service Cost Estimate: HSCE) computer program.
The study found that in fiscal year 2018, total service cost of Thasongyang Hospital was 159,909,496
baht. The proportion of labor cost, material cost and capital cost was 56.7:32.4:10.9 respectively. An
average outpatient cost per visit was 615 baht. An average outpatient cost per visit of each scheme including
the civil servant medical benefit scheme, social security scheme, universal coverage scheme,
stateless people, non-Thai resident with health insurance, non-Thai resident, road accident victims and
other was 747, 613, 599, 629, 617, 581, 1,175 and 459 baht, respectively. An average inpatient cost per
adjusted relative weight was 13,945 baht. An average inpatient cost per adjusted relative weight of each
scheme including the civil servant medical benefit scheme, social security scheme, universal coverage
scheme, stateless people, non-Thai resident with health insurance, non-Thai resident, road accident
victims and other was 15,330, 12,888, 13,792, 13,263, 14,429, 14,488, 10,840 and 22,967 baht, respectively.
Service cost of Thasongyang Hospital was higher than the service charge and labor cost was the
highest cost. Hospital administrators, therefore, should apply the results from this study for better management.
Further studies should examine cost recovery in each scheme.


Background and Rationale: Previous studies showed that emergency medical dispatcher (EMD)
infrequently made a correct diagnosis. We found no similar study in Thailand. This study aimed to evaluate
the accuracy of out-of-hospital cardiac arrest (OHCA) diagnosis made by EMD. Methodology: This
was a retrospective study. We reviewed emergency response record from Maharaj Nakorn Chiang Mai
Hospital EMS unit and all records with the diagnosis of OHCA made by EMD at Chiang Mai Province EMS
center from 2011 through 2018. Results: In total, 276 medical records were reviewed. The mean age was
55.3+20.5 years, 72.1% were male, 272 patients had cardiac arrest upon arrival of the EMS team, whereas
4 patients had other conditions. Among these 272 patients, 116 patients (42.6%) were diagnosed with
OHCA by EMD; whereas 86 patients (31.6%) were diagnosed with unconsciousness, 22 (8.1%) with traffic
accident, and 48 (17.6%) with other conditions. The EMD made a diagnosis of OHCA in 120 out of 272
patients, with the sensitivity of 42.6%, and positive predictive value 96.7%. Conclusion: EMD’s diagnosis
of OHCA was inaccurate. However, the diagnosis of OHCA made by EMD had high probability.


Objectives: To evaluate people’s understanding on prehospital triage for the level of severity of
emergency illness in terms of interrater agreement compared with the Thai criteria-based dispatch, and
to assess the factors associated with people’s understanding. Study design: A cross-sectional survey of
Chiang Mai people’s perception on responses and management by call takers and dispatchers at the
call center of the emergency medical service. Methods: The survey asked people’s perceived priorities
by randomly selecting 4 out of 24 pre-set emergency scenarios of the Thai criteria-based dispatch triage
cases. The questionnaire also asked respondent’s characteristics, such as, education, previous experience
on emergency medical care, and related perceptional factors. Apart from descriptive statistics, Cohen’s
kappa coefficient to compare the agreement and logistic regression to explore associated factors with
agreement were analyzed. Results: A total of 102 participants responded to the survey, 62.7% were
female, median age was 25 years old (IQR = 21-37). Most of them were bachelor’s degree holders, a
38.2% agreement between people’s perceived priority and the Thai criteria-based dispatch was found
(k = 0.175, p < 0.005), with 42.9% under triage and 18.9% over triage. The percentage of agreement was
higher for non-urgency (49.5%), and semi urgency (40.8%), but lower for urgency (33.0%) and emergency
scenarios (29.0%). No factors associated with the agreement of people’s perceived priority and the prehospital
triage were found. Conclusions: People’s perceived priority did not match with the actual triage
category, and no people’s characteristics associated with prehospital triage agreement were established.


Physical activity (PA) for the active aging becomes essential policy for health among the global
countries, as well as Thailand. Thus, the database of PA policy is essential to accurately identify direction
of formulating master plan to promote physical activity for active aging. The aims of this study were to:
1) systematic review the physical activity policy for active aging, and 2) recommend physical activity
policy to promote active aging. A systematic review was conducted on PA research articles through 12
bibliographic international electronic databases and Thai articles were identified through 5 reference lists
published during 2008-2018. Experts and researchers screened the selected papers independently.
The result showed that out of 3,239 screened articles, a total of 315 studies were included in the
review. Most studies (35.2%) were for the built environment (BE), 34.3% for the PA intervention, 20.0%
for the active transportation (AT), and 10.5% the accessibility towards PA resources. According to the
systematic review, recommendations were as follows. 1) The government and business organizations as
well as older adults’ club and school should develop 6 PA intervention programs, namely, home-based,
community-based, group-based, sedentary-based, noncommunicable disease-based, and smart phone
application-based PA programs engaging in at least 150 minutes per week of moderate to vigorous PA.
2) The Ministry of Transportation should arrange AT to support independent mobility for active aging
under the safe and flexible circumstances relevant to their needs. 3) The government and business
sectors should develop built-environment policy to promote PA for older adults’ better lifestyle in all
levels of social status with safety. 4) The Ministry of Digital Economy and Society, the Ministry of Social
Development and Human Security as well as academic institutions should provide an opportunity and
capability to older adults to access PA knowledge and information via smartphone and applications.
Moreover, due to the lack of study regarding the impact of the 4 PA policies, further studies should focus
more on the impact of PA policy, particularly on AT system and BE, as well as health outcome in active
aging. The evidence from this study should be a basis for reformulation of future national elderly policy
directions.


This research aims to evaluate the compliance level of Health Measure and its constraints to prevent and control COVID-19 pandemic of several population groups in Thailand; general urban people, urban poor, rural people and people in Southern border. This research uses questionnaire survey via google form and telephone with 7,569 samples and then repeats two more times with different but continuous surveys. The Behavioral Insights concept is applied. Results find that each population group can comply with Health Measure in public area indifferently, but each one has different capacity to comply in house due to physical constraint such as limited space, which is from limited wealth and income before. Moreover, repeated survey finds that low-income people have to face with higher risk because of insufficient income to survive for their family. So fiscal measure for the poor such as subsidy is necessary and important to capacity to comply Health Measure and then to prevent and control COVID-19 pandemic.


This research was a qualitative research with the purposes to monitor and evaluate the policy implementation, and to review the policy recommendation of the Participatory Health Region 3. Data sources were documents related to the Participatory Health Region 3, and informants which consist of 24 committees of the Participatory Health Region 3, and 50 stakeholders of the Participatory Heath Region 3. Research tools composed of the in-depth interview question, focus group interview question, field record form, and data record forms. Data were analyzed as a descriptive statistic: frequency distribution, percent, mean, and standard deviation. Thematic analysis was used to analyze a qualitative data. Research results showed that: 1. Monitoring and evaluation of the policy implementation for the Participatory Health Region 3 1.1 Personnel: qualification and experience of the committees played a major role in the operation of the Participatory Health Region. Stakeholders were involved in effectively as a role in national. 1.2 Working process composed of though adjustment and cooperation noticeable in the starting phase, network cooperative system, conferences, and cross-organizational collaboration. 1.3 Policy of the Participatory Health Region 3 operation consisted of five topics: resources and environment system, nutritional stabilization system, ecological and cultural traveling system, local health service system, and public health system. The policy in this level implementation for Participatory Health Region 3 was successful in a policy level. The operation was done by network cooperation and designation of the Level point "Agroforestry". On the other hand, monitoring and evaluation remained unclear for most part, and the results of the performances indices (minus 9 plus 5) remain unclear for evaluation. However, the committees were maintained that the operation was on the right track.  1.4 Keys to success were commitment of the leader, teamwork, expertise of the key persons, common ground/objectives, and network cooperation. Weaknesses composed of lack of understanding in one's role for many departments, discontinuity in the committees and time for activities, and restriction on news and information. 2. Review of policy recommendation for the operation of Participatory Health Region 3 2.1 National policy recommendation: creation of information sources related to the Participatory Health Region, electing committee by considering the experience and determination to operate the policy, preparation of the teamwork for the committee of Health Region, seminars for all Participatory Health Regions, forming a central academic team to support the regions, and appointing a secretary of the committee of the Participatory Health Region who should be a full-time employee. 2.2 Regional policy recommendation: public relation on the operation of the Participatory Health Region, database of each region and/or information for decision, permission for the stakeholders to formulate the operating policy from the beginning, encouragement of collaboration between organizations in order to operate each topic effectively, designation of the leverage point, review of the performance indices in the event of the change in working process and topics, and academic conference by the Participatory Health Region 3. 2.3 Local policy recommendation: policy enforcement according to the capability of each area, database of each province and/or information for decision, teamwork encouragement, common objective, and network cooperative working.


The conceptual framework that policymakers in Thailand can use to deal with the pandemic of the novel coronavirus SARS-CoV-2 (the COVID-19 pandemic) under the contexts of Thailand‖s health systems might be driven from compartmentalized thinking or decision supports from experts in health disciplines. But the COVID-19 pandemic is a complex problem, with interconnected causes of the health, social and economic problems, and uncertainties of how to solve such problems as only limited knowledge exists due to its nature of an emerging disease. With compartmentalized thinking, any decision-making could create unintended adverse consequences. However, epidemiologists and health systems researchers can apply concepts and tools of systems thinking to create well-rounded policy options to address the COVID-19 pandemic by investigating all interconnected relationship among factors that can influence the outcome of the disease epidemic, and considering the society as a complex adaptive system that will adapt to both the disease and the disease control policies. Literature suggests that behavioral change of stakeholders can lead to many avoidable problems of COVID-19 in Thai health systems contexts. By the nature of infectious disease, the number of infected people has not increased linearly, but non-linearly. The speed that the disease spreading out depends on the basic reproduction number (R0) that represents an average number of susceptible people who get infected from one infected person, and the effective reproduction number (Rt) that represents an average number of susceptible people who get infected from one infected person taking into the accent of the effectiveness of policies and measures in disease control, where Rt < 1 indicates an effective disease control. A causal loop diagram (CLD) was constructed from qualitative data analyses to demonstrate the relationships among all factors relevant to the epidemic. The CLD points out that many epidemic problems can be a result of adaptations of stakeholders. For instance, the number of infected people in Thailand were minimum and only gradually increased in the early phase of the epidemic, thanks to effective quarantine and isolation measures of those who came back from an international trip, as well as personal hygiene and physical distancing behaviors of the population. But the clustered epidemics at pubs, bars, and a boxing stadium in Bangkok increased the number of newly infected each day in late March led to policy-decision to use the “hammer” measures (closing workplace, stay-at-home policy, work-from-home policy, and travel bans). However, such the policies also created adverse consequences as the workers in Bangkok who lost their jobs due to the workplace close needed to travel back to their hometown, spreading the disease to all over the country. The understanding of epidemic systems from CLD led to the development of system dynamics simulation models (SD), which can be used as an integrated systems tool for addressing the COVID-19 problems by adding policies and measures upon the epidemic model, such as increasing personal hygiene and physical distancing, and enhancing the capacity of outbreak investigators and healthcare facilities. Experimenting each policy option on the simulation modeling can help policymakers decide which policy potentially results into the most effectiveness and the least unintended consequences. In the long-run, it can also be used for synthesizing healthcare reforms strategies on how to mitigate the future epidemics, reduce consequences of epidemics on the vulnerable populations and health inequity, and improve the health systems resilience and be more ready for any future crises.