Primary health care nursing in Thailand

Insights and Opportunities 

Frances Cieslak, APNA Advocacy Manager 

Source: APNA Primary Times Summer 2024-5

On a recent family trip to Thailand, I met up with my friend and nurse academic, Angun. I first met Angun, more formally known as Flight Officer Chaweewan Jitsacorn, over 15 years ago in Melbourne when I hosted her as a master’s degree student in my home for three months. She is now a nurse academic at Boromarajonani College of Nursing in Lampang in northern Thailand.  

To my surprise, Angun had arranged for me to meet with an illustrious group of nursing academics at the college, including the Head of Department for Community Health Nursing, Directors and Deputy Directors in Nursing, Policy, Training and Development, and Research and Innovation to discuss primary health care (PHC) nursing in Thailand.  

In conversation we uncovered strong similarities between the Australian and Thai PHC skillsets and in our diverse work settings. It was also noted that, like in Australia, in Thailand PHC is not always acknowledged and recognised as it should be in policy and funding models. 

The meeting was followed by an impressive tour of a nurse-led clinic run by nurse practitioners on campus at the college. The nurse-led clinics are fully funded by the government and enable advanced nurse practitioners to work to their full scope of practice, offering free health services that are embraced by local communities. 

APNA Advocacy Manager Frances Cieslak (left) with Flight Officer Chaweewan Jitsacorn, AKA Angun. 

Learnings and insights about nursing and PHC in Thailand 

Boromarajonani College of Nursing in Lampang is one of 30 colleges affiliated with Praboromarajchanok Institute. The institute has nine public health colleges, three medical centres and affiliations overseas, including with five educational institutions in Australia.  

Nurses in Thailand are well respected and supported  

Nurses are considered ‘government officers’ in Thailand allowing them access to benefits such as free government health care and education until they complete university. Wages are low compared to Australia but so is the cost of living.  

Nursing studies  

Nursing studies in Thailand involve a 4-year bachelor degree funded by the government. Graduate nurses are allocated to a hospital or PHC setting according to community need and the funding available. This means they don’t choose where they work after graduating but must take a position where it is needed. If the nurse doesn’t want to work in their allocated place, they are required to pay back the university fees incurred. 

PHC is embedded throughout the nursing curriculum and formally covered in the third and fourth years of the degree program. PHC skills are developed in later years due to the complexities and diversity of care required in the community.  

A third-year subject, ‘Community Health 1’ requires the student to undertake a clinical placement in a village near their own home where they take care of one family for a 4-week placement. In caring for the whole family, the nursing student might work in the local school, in aged care if there is an elderly family member, or work in mental health or with the family practice. They go wherever the family seeks health care.  

In the final year of their nursing degree, ‘Community Health 2’ requires students to care for the whole village. Students engage in population health activities, working together with other health students. The 4-week placement focuses on health promotion and chronic disease management, including a focus on current health issues in Thailand, such as the management of childhood obesity and mental health problems. This model is similar to the Teaching Towns concept that APNA is discussing and would like to implement across Australia, supporting clinical placements in rural and remote towns (scan the QR code below to read more). 

PHC in Thailand  

PHC in Thailand seems to be more integrated into the wider health care system. Nurses, GPs and allied health who work in the community also work in local hospitals. The single funding source for all government health services in Thailand allows practitioners to move easily from one setting to another. This is different to Australia, where hospitals are funded by the states and territories, and PHC is funded by a number of sources, including the Commonwealth (though the Medicare Benefits Schedule); the Commonwealth, states and territories for aged care; and through some Primary Health Network funding and other funding avenues. In Thailand, much like in Australia, nurses working in hospitals are paid more via penalties, which are not paid in PHC settings. This results in some reluctance to work in the community even if it is the nurse’s preference.  

PHC settings in Thailand are similar to those in Australia. Nurses work in general practice (private doctors’ clinics), in government-run nurse-led clinics, in family health care, aged care or in outreach at district hospitals. Interestingly, general practices often run after hours, usually from 5 to 8 pm as GPs and nurses work in the hospital during the day. 

Nurse-led clinics  
Nurse-led clinics are increasing across both countries due to the demand for more health care access. A shortage of doctors (like in Australia) is driving demand for nurse-led clinics in Thailand. Most clinics are located in village settings or wherever nurse care is deemed most appropriate, such as on university campuses. The clinics are run and managed by nurse practitioners who are funded according to how many patients they see, and the type and number of procedures they undertake. This can be problematic, as it encourages the throughput of patients, much like episodic Medicare billing does in general practice in Australia. Overall, however, nurse-led clinics seem to work well. In Thailand, the nurse practitioner scope of practice is similar to that in Australia, but we are yet to embrace nurse-led clinics here, or to enable nurse practitioners greater capacity to run more clinics to improve health access.  

Family health care 
Family health care is a recently introduced policy in Thailand. It has been driven by an increasing demand for chronic disease management, particularly in younger people. The Thai government aims to have four to five family health clinics in every district, where a doctor, nurse and pharmacist work together to meet local health needs. This model of government-funded, multidisciplinary care is what APNA is seeking to achieve in Australia. The Strengthening Medicare Taskforce, alongside recommendations in the Scope of Practice Review highlight the need for Australia to fund and support multidisciplinary PHC that meets the chronic and complex healthcare needs of Australian communities.  

Village volunteers  

Village volunteers who know their community well are key to supporting PHC in Thailand. Village volunteers connect community members with the health care they need. These volunteers are paid about A$90 per month by the Thai government and have some basic healthcare training. They provide support to the nurses working in the community by taking observations, monitoring sick people and providing anti-malarial medications, as well as delivering meals and communicating regularly with nurses. The volunteers often use an ‘app’ to communicate with nurses and also assist with student placements by identifying families in need of PHC services.  

Angun arranged for Frances to meet with an illustrious group of healthcare academics at the Boromarajonani College of Nursing in Lampang, Thailand. 

Opportunities  

The meeting in Lampang highlighted numerous opportunities for APNA. The lovely nurse academics I met expressed a sincere interest in working and exploring opportunities with APNA. These opportunities include:  

• continuing to build our relationship and to learn from each other, with the intention to partner on international opportunities as they arise 
• visiting Thailand/Australia to further explore and evaluate nurse-led clinic models of care  
• visiting and learning more about village clinical placements in Thailand and how we might apply lessons to the APNA Teaching Towns concept  
• implementing an international PHC clinical placement program for Australian students to experience working in a village community in Thailand  
• implementing an international aged care clinical placement for Thai students to work in Australian residential aged care facilities as this model is very different to the hospital-based care older people have in Thailand 
• identifying PHC grant and research opportunities for collaboration 
• publishing collaboratively on PHC nursing as it is represented in each country.