The health of the people of Thailand have improved during the past two decades along with its rising economy. Infant mortality dropped from 125/1000 to 30.5/1000 live births, vaccine preventable deaths dropped by 90%, and life expectancy increased to 66.9 years for men and 71.7 for women. Despite these positive trends, the Thai health system faces formidable challenges. In rural areas, where 80% of the people live, the physician to population ratio is 1 to 29,000 versus 1 to 800 in urban area. Although total government expenditures devoted to health care increased from 5.9% to 7.7%, one quarter of the population continues to have no health insurance. Continuity of care is largely an unknown concept and few physicians assume any responsibility for addressing community health needs.

Access to care has been hindered by the increasing subspecialization of Thailand's physician workforce beginning with the accreditation and certification of specialists in 1969. Although three year rotating general practice residencies were established in 1969, few chose this route. Of 12,500 board certified physicians, only 216 (1.7%) are board certified general practitioners. Only nine of 900 medical graduates in 1999 entered these three year rotating gp programs. The remaining 3,000 practicing general practitioners were nonboard certified. As in many specialist dominated countries, more than half of specialists in urban areas maintain part-time primary care practices.

In August 1998, family practice appeared as a new specialty in Thailand. In June, 1999, nine medical student graduates began training in five newly established family practice residencies. These three year residencies differed from the rotating general practice residencies in a number of ways. They emphasize outpatient care in family practice sites and emphasize the principles of family practice, including continuity of care and the biopsychosocial model. These new family practice residencies are based in regional and provincial hospitals, rather than university teaching hospitals, to allow for their growth apart from other specialty programs.

The family practice residency graduates will be eligible for registration in the newly established Thai Board of Family Physicians. The new board was initially open for 60 days to any practicing generalist as a founding member. Since then, applicants are required to pass an examination for diplomate status in family practice. As of late 1999, there were approximately 500 diplomate members. Two medical schools in Thailand have now established departments of family practice. Reseach in family medicine has not yet developed.

Thailand is a member of Wonca through the General Practitioners/Family Physicians Association. Thailand hosted the fifth Wonca Asia Pacific Regional Conference, "Learning and Teaching Family Medicine" in Bangkok in 1998. This meeting helped advance postgraduate training in family practice.

Despite this encouraging start, many challenges exist to both the enhancement of family medicine and the improvement of health care in Thailand.

Robert Williams, M.D.
Eric Henley, MD
Somjit Prueksaritanond, MD
Apinum Aramrattana, MD

(Editor's note: Excerpted from the Journal of the American Board of Family Medicine, January-February, 2002, pp. 73-76)