The prime minister chairs the CCSA, which decides national policy. While implementation is the responsibility of the Provincial Governor who chairs the multi-sectoral Provincial Communicable Disease Committee, with the Provincial Chief Medical Officer serving as secretary. This mechanism empowers governors to take action in line with the provincial context and resources.

Pandemic control was challenging in Bangkok, as it was the epicenter of waves 3 and 4. Inadequate public health capacity was complicated by complex inter-sectoral coordination across multiple government and private sectors. Of 317 private hospitals nationwide, 94 (30%) are located in Bangkok, and almost all are for-profit enterprises. The MOPH does not have direct command over the BMA. The CCSA recognized there were more problems than solutions in managing the epidemic in Bangkok.

Public communication failed when several governmental organizations conveyed contradictory and confusing messages to the public. The government’s spokesperson was replaced with healthcare professionals. A few university professors promoted exaggerated messages on Facebook, creating fear about the adverse effects of vaccines and confusing the public (7). The media spread messages about the suffering of households during the peak of daily mortality in August 2021.

Disinformation about fatal events, encouraged vaccine hesitancy, while government counter-measures were inadequate. Political conflicts also undermined vaccine rollout efforts. Statements in Parliament devalued the vaccine donated by and procured from China, despite WHO Emergency Use Listing (8) and one of the opposition leaders visited the United States asking for mRNA vaccine donations (9). Untruthful social discourse confused the public, i.e., Thai FDA is the main bottleneck of vaccine approval. However, commentators did not understand the vaccine registration process. Delayed vaccine procurement and consequently, unavailability in Thailand, due to global shortages in the second quarter of 2021 led to unfounded charges of corruption.

Lack of harmonization and inter-operability of data systems hampered effective multi-sectoral coordinated responses. Public and private RT-PCR results were not centrally pooled, leading to repetition of tests and delayed treatment.

Vaccine coverage in different population groups was reported through different unsynchronized databases. These challenges were later solved with assistance from the Government Big Data Institute (GBDI). Vaccine booking was chaotic as several organizations developed their own mobile applications and untimely reporting of vaccine coverage.

The provision and reimbursement of RT-PCR was restricted to strict case definition; this caused spread of infection among those who were not detected and isolated. The case definition became flexible and in July 2021, Antigen Test Kits were adopted and allowed flexibility in case detection.

The high numbers of cases in 2021 overwhelmed the health system especially in BMA, disrupting the provisions of non-COVID-19 services. In response, public and private hospital beds under BMA’s control were pooled and managed centrally to maximize efficiencies. Despite this measure, bed shortages remained and field hospitals with oxygen and high flow ventilators were created in Bangkok. However, these facilities were fully occupied from large surge of moderate and severe cases. Therefore, private sector, NGOs, the media, and volunteers stepped in to provide support on a voluntary basis and donation in supporting home and community isolation.

The fully occupied field hospitals pushed the government to finally adopt a home and community isolations policy for cases with mild conditions.

The Government Procurement and Inventory Management Act B.E. 2560 (2017) regulates the procurement of products available on the market. In this Act, there is no provision relating to “advance market purchasing or down payment” of COVID-19 vaccines still under research and development (R&D), which is the only mode of securing vaccines by any country. The Bureau of Budget challenged who would be responsible for the unreturned down payment if R&D failed. To overcome this, the National Vaccine Committee, [of which one of the authors (VT) is a member] endorsed the decision, which interpreted that procurement in public health emergency situations can apply “advance market purchasing.” It was then endorsed by the Cabinet, which triggered the process of bilateral negotiations with vaccine manufacturers and the COVAX facility.

Medical and nursing staff, all well-trained, were mobilized from MOPH provincial hospitals to support field hospitals in Bangkok and other hot-spot provinces on an ad hoc basis. Retired professionals and volunteers were mobilized. Extra compensation was provided to all frontline healthcare workers. BMA has limited public health capacity with only one epidemiologist, and although MOPH mobilized epidemiologists to support BMA, the number was far from sufficient. Village health volunteers played a critical role as they monitored outsiders who traveled into the community, supported home and community isolation, advocated target populations for vaccination, and supported monitoring adverse events followed immunization. It should be noted that the ratio of VHVs in Bangkok, is much lower than the country as a whole (see Table 2).

Resource scarcity, especially during the first wave in early 2020, occurred when China prohibited export of raw materials to manufacture surgical masks. Consequently, nine factories in Thailand discontinued production. In addition, half of the masks were produced for the export market. This led to introduction of export restrictions by the Ministry of Commerce (14). The situation improved during mid 2020 when China removed export restrictions. In 2021, the Government Pharmaceutical Organization ramped up local production of Favipiravir raw materials and finished products (15) licensed by Thai FDA (16).

While all ASEAN member states except Thailand participated in COVAX, Thailand continued to discuss with COVAX, and at the same time was in parallel bilateral negotiations with potential manufacturers. Advance market purchasing was signed with AstraZeneca (AZ) with a Thai manufacturer (Siam Biosciences) acting as vaccine supplier. In the second wave, no vaccine was available except Sinovac donated and purchased from China, while in the third and fourth quarter of 2021, AZ vaccines became available.

The second wave emerged when traffickers smuggled migrants across the porous border between Thailand and its neighbors. These undocumented migrants were not tested and caused virus spread in their community (17).

The Cabinet decided that all COVID-19-related services, including those used by the documented migrants, should be paid by the government, with the NHSO covering the cost for Thai citizens and the Department of Diseases Control managing payments for all non-Thai people. To facilitate undocumented migrants’ access to care, the government offered opportunities to register with the Labor Ministry before 13 February 2021, allowing migrants to remain legally in the country for another 2 years and have access to COVID services (18).

Populations from lower socioeconomic status such as those living in congested communities and slum areas, crowded households, and migrant workers were affected most by the pandemic as they were exposed to infections when earning a living and could not work from home. 26% of slum residents lost their jobs and 10% relied on donated food, the government’s rescue programs did not reach them effectively (19). Digital divides are main barriers for the vulnerable population who do not have internet literacy, such as electronic registration via mobile application, requirement of a bank account for electronic bank transfer.

Unlike in factories where an outbreak can be contained, the strategy of “localized lockdown, treatment, and isolation” of certain major areas of infection is impossible in BKK, especially in urban slums where there are no clear geographical boundaries. Further, the lockdowns faced negative reactions and resistance from local citizens who had to earn their daily living to survive.

Trust in government institutions ensures population adherence to public health and social measures. False criticisms in social media undermining the government were not rebutted by effective communication. Political conflicts created misinformation about vaccines (20, 21). A respected senior vaccine expert was falsely charged with advocating certain vaccines and being “a salesman” of inactivated vaccine. ATK, purchased by the Government Pharmaceutical Organization was accused of being of substandard quality (in terms of sensitivity and specificity) and high cost, however the subsequent anti-corruption investigation reported no evidence of corruption in the procurement procedures (22).

Private hospitals wanted to play a role and make profits from the COVID-19 vaccine when “alternative vaccines” (Moderna and Sinopharm) would be delivered by private hospitals at cost. While public vaccines (Sinovac, AstraZeneca, and Pfizer) are free. Social media deliberately devalued the public vaccines as being of low efficacy while advocating Moderna to stimulate the demand (23). The private hospitals’ criticism that the government prohibits them from directly importing vaccine, while in reality, vaccine manufactures could only sell to governments and not private entities under the WHO Emergency Use Authorization.

Political interference occurred at all levels. NHSO struggled with the procurement of ATK as, unfounded, it was accused of non-transparency on price and the technical specification, despite that the products were registered by the Thai Food and Drug Administration.

Medical experts who reviewed and issued clinical practice guidelines also faced political pressures for inclusion of certain products in the guidelines. Entertainment and hotel sectors put strong pressure on the Government to open their pubs, bars, and Karaoke despite the surge in cases. There was constant pressure, dilemmas, and political choices to be made between business and the economy and the health of the population, and decisions required evidence and building consensus.

Pool saliva tests reduced RT-PCR costs by five times as it did not affect the sensitivity with specimens that PCR cycle threshold was lower than 35 (24).

Innovative heterologous vaccination schemes were introduced prior to the confirmation by the WHO EUL COVID-19 vaccine. Five out of the 48 global references used by the WHO Strategic Advisory Group of Experts on Immunization (SAGE) in the interim recommendations on heterologous vaccine schedule are studies from Thailand (25).

A “Bubble and Seal” strategy in factories was introduced to continue manufacturing while preventing community spread; the factory and routes to and from workers’ dormitories in the factory campus were completely sealed. All symptomatic cases were treated inside the factory, while severe cases were referred to hospitals (26). Another service delivery innovations was the home isolation (HI)/community isolation (CI), which shifted patients from hospital to their own home or community with provision of food, thermometer, and pulse oximeter and monitoring using telemedicine, all reimbursed by NHSO. To increase capacity for managing cases with moderate symptoms, hotels rooms could be converted into hospitals called “Hospitel.” The hotel must affiliate with a hospital to provide clinical services. This innovation maximized the use of over 100,000 hotel rooms nationwide.

Multisectoral and inter-ministerial collaboration such as the Government Big Data Institute filled the gap of data integration. Police and armed forces monitored quarantine sites and labor trafficking. The private sector manufactured N95, and the Ministry of Commerce regulated the price and supply. The private sector supported service provision, such as pooling beds and ICU facilities, treatment of severe case, RT-PCR tests, and vaccination. Private banks, telecom companies, and technology start-ups also assisted the public sector by providing IT systems for bed management, and patient support for treatment and counseling.

A community pantry campaign run by individuals, civil society organizations, and temples aimed to ensure food was available for anyone affected by the pandemic. Food stocks were refilled regularly. Food pantries nation-wide reflected the voluntarism and social capital embedded in Thai society (27, 28).

All sub-themes emerged from participants’ views and not from literature review. However, we did not add quotes to every emerging sub-theme. Further, sub-themes 1.4 provision of service: beyond the limits and adaptation, sub-theme 1.6 public sector health workforce: professionalisms and commitment, and sub-theme 2.3 political interference delays effective responses; emerged from the analysis of interview verbatim.

Figure 1 depicts factors that contributed to and hampered effective pandemic control. The impact on the six building blocks identified in Theme 1 is thoroughly described, taking into account that the Thai health system can provide universal health coverage in a stable situation. Theme 2 is concerned with external factors beyond health that complicated the effective pandemic control such as politics and inequity. Innovative technology and social solutions identified in Theme 3 are mitigating factors, which minimized the direct and indirect consequences of pandemic.