Improving Thailand Public Emergency Medical Service System through Meaningful Participatory Networks
Emergency Medical Institute of Thailand

The Problem

The Emergency medical services (EMS) in Thailand was initiated in 1970, firstly in the capital Bangkok, by a non-profit foundation, in response to the needs of medical care for emergency and critically ill patients before accessing to a health care facility. In 1989, the first government Bureau of Emergency Medical Service under the Ministry of Public Health was set up to manage ambulance services. Gradual development of medical ambulance services by several agencies such as army and police forces has been observed with different pace and scale.
The Emergency Call Number 1669 was the first number set up for nationwide EMS use with 24 hour standby. Each province has a Call and Dispatch Center (CDC) operated as a gate keeper for access to emergency medical care, especially pre-hospital care. Other health services such as mental health consultations, violence, and unwanted pregnancies were later integrated into this emergency call service.
Multiple emergency medical service guidelines were performed with disparities in quality especially patients’ triage protocols, initial treatment protocols, and certification of personnel and medical vehicles according to provincial management capacity.
Areas covered by EMS were limited as most urban areas had the services in placed while others were receiving inadequate services. None of the local administrations were providing First Responder Service in its responsible areas.
Only land emergency medical transportations were available in the country, occasionally, critically ill patients needed to seek medical attention in facilities by themselves or by their relatives. Before the initiative, the national budget for EMS was assigned for the Universal Healthcare Coverage scheme only. The other healthcare insurance schemes, which consisted of the Civil Servant Medical Benefit Scheme and Social Security Healthcare Scheme did not received financial support for EMS. Foreigners and legal migrants were not eligible for the services.
There was no air medical transport to serve emergency medical patients who were in need of timely –medical intervention in mountainous areas such as Mae Hong Son province or outreach areas such as the three Southern provinces (Narathiwat, Yala, and Pattani).
Even though tourism promotion played a crucial part of Thailand’s economic growth, especially Thailand’s islands and beaches and marine medical transport for foreign tourists and Thai citizens in islands and bay area was not available.
While unmet needs were in evidence, there were unused capacities of various resources such as rotorcrafts, fixed- wing aircrafts, boats, and vans located around country, even in remote and hard to reach areas.
Emergency medical data collection from providing agencies was unsystematic. Essential information and experience exchanges among key stakeholders had been insufficient throughout the pre-initiative period.
External causes and cardiovascular disease were leading causes of death of Thai citizens in 2005 as reported in the Thailand health Profile Report 2005.

Solution and Key Benefits

 What is the initiative about? (the solution)
The initiative started when the Bureau of Emergency Medical Services handed over authority to the Emergency Medical Services Institute of Thailand (EMIT) in early 2008. The philosophy of the initiative is to make the ownership and collective leadership of stakeholders sustainable. National Strategies for these service systems have been mapped out to improve large scale services through Emergency Call 1669 networks.
The initiative aims at improving the equality, equity and quality of the EMS system nationwide especially ambulance service of pre-hospital care delivered to all citizens residing in Thailand’s territory by promotion of multi-sectoral participation. A holistic approach was used for the initiative.
The efforts were focused on gathering key stakeholders, brainstorming, setting up projects to fill in gaps, setting up of relevant protocols, remobilizing resources, training activity-related personnel, and the scaling up of services to national level.
Two service innovations and two leveragable existing developments were identified by the process of participation to achieve the aims.
The establishment of air medical transport innovation was targeted to serve patients in need of timely-response intervention or to provide the service in hard to reach areas. Innovation of setting up marine medical transport was a key project to serve tourists and frequent flood disasters. To standardize the patients’ triage systems and service protocols at the national level, the project of further leveraging Information Technology for Emergency Medical Services (ITEMS) was set up.
The enhanced provision of EMS by local administration projects was aimed at increasing the EMS land area coverage to 100 percent and sustaining the services.

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
EMIT had gathered key stakeholders to brainstorm on how to improve national scale service systems in a more customer-oriented manner. Meetings with various policy makers, professionals, EMS frontiers and groups was been performed. The possibility of setting up innovations for EMS such as air medical transfers, marine medical transfers, computerized patient’s triage system, and the provision of EMS by local administrations was identified.
EMIT has played coordinated roles for the initiative as a member of collective leaderships in the execution process; technical support and quality control to the initiative process have been offered to members. Key stakeholders have been holding a leading responsibility for their activities.
Hospitals under various agencies such as the Ministry of Public Health, Ministry of Education, Ministry of Defense, and the private sector are the service providers of the Basic Life Support Ambulance and Advance Life Support Ambulance. Provincial Health Offices and Bangkok Metropolitan Administration (BMA) are a coordinating body within their provinces.
Local Administrations are managerial bodies for the Basic Life Support Ambulance, and First Responder Service in their areas. Most providers of First Responder Services are non-profit foundations; small numbers of local administrations are providing First Responder Services and Basic Life Support Ambulances by themselves.
Resources for medical transportation such as helicopters, airplanes, and boats are supported by the Ministry of Defense, National Police Office, Department of Agriculture and Cooperatives, and Department of Natural Resources and Environment, non-profit foundations, associations, and NGOs. Medical equipment required for transportations is normally supplied by hospitals within the provincial network.

(a) Strategies

 Describe how and when the initiative was implemented by answering these questions
 a.      What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
To carry out the initiative, the following three strategies were implemented. The first strategy was to seek major strategic partnerships from diverse disciplines then reach out to wider target audiences. There were five strategic partners at the initiation in which consisted of the Ministry of Public Health, Department of Disaster Prevention and Mitigation, Department of Local Administration Promotion, Khon kaen Provincial Hospital, and Rajvithee Hospital.
The second strategy was to assure the long term synergic alliances and resources mobilization by using constructive relationships; for example, Memorandums of Understandings (MOUs), associations, committees, and working groups. As of 2011, there were twenty-two MOUs with fifty-two organizations signed up throughout the initiative.
The third strategy was to direct the initiative by the operational research nature. Analysis of service gaps and the execution process’s pitfalls were based on input from policy makers, service providers, system regulators, and clients. Different delivery methods of water and marine medical services in Chonburi province, Krabi province and BMA were the result of operational research process.

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
The process of the establishment of air medical transfer started in early 2009. Several informal meetings were convened before official meetings with stakeholders. Committees on the Thailand Aero Medical EMS Protocol were set up. The Institute of Aviation Medicine played a major role in the provision of training of EMS personnel. A pilot protocol was deployed to outreach areas in the Northeastern, Upper-Northern, and Southern regions. Memorandums of Understandings (MOUs) were signed among ten stakeholders such as the Royal Thai Army, Royal Thai Navy, Royal Thai Air Force, Ministry of Agriculture and Cooperatives, Ministry of Natural Resources and Environment, and Ministry of Public Health. Nine patients benefited from the transfer in the same year. In 2010, the Skydoctor Operation was designated to standby in five strategic geographical locations. Moreover, five hundred and thirty four patients were transferred by the protocol through end of 2011.
Marine medical transfer was initiated in the tourist city of Pattaya in early 2009. Twelve stakeholders gathered for the signing of an MOU of “the Holistic Provision of Marine Emergency Medical Life Support Project”. Marine EMS protocol was developed and taught to relevant health and non-health personnel. The service was expanded to cover wider areas such as river areas of Bangkok and Krabi province’s marine areas. One hundred and seven patients received medical transportation in 2009 and 2,767 patients in 2011.
In 2008, key players in the EMS data information teamed up to further develop a computerized information technology for EMS entitled “Information Technology for Emergency Medical Service (ITEMS)” in the light of improving standards of service protocols, budget disbursement and national data collection. It was designed to support day-to-day operations of CDCs. ITEMS characterized emergency medical patients according to timely-response interventions into five categories comprised of Red, Yellow, Green, White, and Black. An Advance Life Support Operational Team (ALS) was assigned to be dispatched for the Red category. A Basic Life Support Operational Team (BLS) was responsible for the Yellow category and a First Responder Operational Team (FR) was answerable to the Green category. A pilot implementation was undertaken in seven provinces in 2008 with major changes in its triage system. Large scale training to all CDCs was conducted in 2009. Later in 2010, every province used ITEMS as a prime tool in supporting its day-to-day operation. Previous, manually recorded EMS data nationwide was migrated into ITEMS. To encourage data utilization and further development of ITEMS at provincial level, an Award of ITEMS STAR Quality Assurance was given to provinces that showed EMS improvement by using ITEMS quality improvement process.
No local administrations steered the provision of EMS in its responsible area before 2008. After stakeholders and beneficiaries had met and formed working groups, the activities to integrate the existing First Responder Services provided by non- profit foundations into routine works for local administrations were executed. In 2011, of 7,853 local administrations, 7,150 (91%) were offered the services in harmony with community and provincial hospitals.

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
The shortage of EMS health personnel was the primary and it concern determined the development pace and scale of the initiative. Health personnel shortage was universal in the country. Distribution of health workforces to non-urban areas was poor. Certain health professions were unpopular with prospective students.
Emergency physicians, emergency nurses, and Para-medics were not well recognized. Incentives for these groups of profession were less than the others taking into account the possibility of having sideline work and unclear opportunities in the career path. In addition, standard training curriculum, training facilities and certifications for these groups were insufficient compared to the need for the initiatives’ scale up.
To overcome this obstacle, three strategic approaches were drawn out from key stakeholders and beneficiaries through several meetings.
A first approach was to expand the availability of training sites for different levels of EMS operational teams. All provincial hospitals were made ready and utilized for the training of First Responders (FR). In 2007, there were 3,409 FR teams and in 2011 there were 7,771 teams. With this approach, the number of Advanced Life Support teams rose from 979 in 2007 to 1,796 in 2011.
The production of EMS personnel equivalence was another approach. Community volunteers, fire fighters, and health volunteers were recruited and trained to become a member of the First Responder Operational Team in their areas.
The desire to increase the profession’s incentives was the third approach. Honor medals, certifications of accomplishment, awards of best practice, the opportunity to participate in academic conferences and study visits overseas, and life insurance were given year round as incentive tools. Setting up an EMS personnel network in each province was encouraged in order to receive better communication and fellowships among these frontiers.

(d) Use of Resources

 d.      What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
To follow the philosophy of the initiative, resource mobilization and cost sharing are key concepts in utilizing national scale resources.
Each CDC has had ten to fifteen staff, computer hardware, telecommunication equipment, and accessories. Of a total of seventy-eight CDCs, seventy-three CDCs are owned and operated by provincial hospitals, two CDCs are owned and operated by the Provincial Health Office, two CDCs are owned and operated by local administrations, and the last one, Narenthorn Call and Command Center, which is a central coordinating center , is run by EMIT . Investment costs have been input by each owner while operational costs have been shared by the owners and EMIT.
The financial sharing for operational costs of each province is disbursed to Provincial Health Offices and BMA then local administrations other than BMA will received financial subsidies through this gateway.
All medical vehicles such as vans, trucks, boats, and helicopters have been invested for and maintained by operational partners; for instance, community and provincial hospitals, non-profit foundations, Armed Forces, Ministry of Agriculture and Cooperatives, and Ministry of Natural Resources and Environment, none of which was invested by EMIT.
As of June 2011, there were one hundred and one helicopters and an airplane available for air medical transportation. 1,128 boats were ready for water and marine medical transportation. 4,814 car ambulances were located nationwide along with 9,375 First Responders’ cars. No EMS personnel assembled as life support operational teams or First Responder teams were under direct command lines or employees of EMIT; there was a total of 14,189 life support operational teams. Of 122,945 EMS personnel registered, 101,690 were volunteers from non-profit foundations and NGOs.
Every operation dispatched by a CDC in response to requests for EMS will be subject to financial compensation according to the cost sharing basis. In 2007, financial subsidies for operations dispatched according to routine services and disaster response was 460 million Baht and in 2011 it had raised to 806 million Baht.

Sustainability and Transferability

  Is the initiative sustainable and transferable?
Sustainability of this initiative lays upon four fundamental elements.
First, the need for coordination of EMS at national level remained a pivotal part of healthcare. New services and resource mobilization will be required for future disaster responses and advanced technology. Integration of EMS provision from various sectors is necessary in order to reduce redundancy and overall expenditures.
Second, the capacity building systems for emergency medical personnel were established in terms of standard curriculums, certified training sites, and laws pertaining to emergency medical education.
Third, the government’s Emergency Medical Fund, which provides supports to most activities, has had its permanent line in the government budgetary system since 2008. More significantly, the Emergency Medical Act 2008 has endorsed the establishment of the fund.
The last essential element is the growing ownership and collective leadership in delivery of emergency medical tasks of local administrations and communities.
Core components of the fostering of multi-sectoral participation, creation of new services, enabling legal supports, standardizing emergency medical education, and earmarking financial structures can be transferrable to other organizations domestically and regionally. Participations from various sectors were the first and most important component to be started with. There are a number of public services domestically that can benefit from adapting and undertaking the core components of the initiative into practice.
The similarity of geographic structures, cultures, lifestyles and burdens of disease in ASEAN countries has been well recognized. With this association, the sharing and transferring of experience, technology, know- how and pitfalls can be performed with others in a less restrictive manner.

Lessons Learned

 What are the impact of your initiative and the lessons learned?
Reduction in morbidity and mortality of emergency medical patients was prevailed as the death percentage during transportations from scenes to hospitals was declined from 5.7 percent in 2008 to 2.0 percent in 2011 in the New Year Festivals. The number of emergency medical life support operations was increased from 410,834 dispatches in 2007 to 1,473,877 dispatches in 2011. In addition, the ratio of number 1669 called to total dispatches continually increased from 37 percent to 74 percent, respectively.
A service satisfaction survey of patients and relatives receiving routine services of Emergency Call 1669 was conducted annually by EMIT as its internal quality improvement tool. Eighty six percent of respondents were satisfied with the services in 2010. In 2011, the Office of Public Sector Development Commission Thailand awarded its “Public Service Awards 2011” to EMIT for its innovations and promotion of multi-sectors participation in improving the public service system through Emergency Call 1669.
The initiative has been coherent with the direction of the Thailand Public Health Development Plan. Its streamlining process of development has enabled a positive environment for other developing public health programs such as the promotion of healthy tourism, the reduction of morbidity and mortality from accidents, and from cardiovascular accidents.
The readiness of the Thai public health system for disaster response has been one of the crucial impacts derived from the initiative’s nature. As shown in 2010 and 2011, the emergency medical response to hard hit floods and landslides was applauded by the media and agencies as nearly four thousands patients were evacuated from inundated areas to safer hospitals. A survey conducted by Academic Network for Community Happiness Observation and Research found that Emergency Call 1669 was listed as the most satisfaction emergency service during the late-2011 massive flood response.
Local administrations and inhabitants were sensitized to their duly roles. As designs and evaluation of their services were encouraged in harmony with the decentralization of administrative power principles, increasing ownership of emergency medical tasks at local levels has been recognized recently, especially local administration’s roles in responding to historic floods in late 2011.
The initiative process provides public system development insights on how to further strengthen partnership and ownership of EMS provision.
First, the conceal willing of non-health sectors to meaningfully participate and share resources in the delivery of public services can be revealed if an appropriate opportunity arises.
Second, ideas, inputs, resources, and solutions that are proposed by partners even in an ordinary position, sometimes can be invaluable and exceed expectations.
Third, in responding to disaster, local inhabitants are the key guidance in the execution of emergency medical management. The forth, positive reward system to EMS personnel especially those who work at frontlines is one of stimulating factors to drive the initiative.
Finally, the most important is that budget limitation in the implementation of public services can be overcome by reallocation and sharing the resources of stakeholders.

Contact Information

Institution Name:   Emergency Medical Institute of Thailand
Institution Type:   Public Organization  
Contact Person:   Dr. Sanchai Chasombat
Title:   Acting Director  
Telephone/ Fax:   +6628721669/+6628721660-6
Institution's / Project's Website:
Address:   88/40, Moo 4, Tiwanon Road, Muang District
Postal Code:   11000
State/Province:   Nonthaburi
Country:   Thailand

          Go Back

Print friendly Page