INTRODUCTION
Emergency medical services (EMS) that provide pre-hospital care have the potential to reduce deaths and long-term sequelae from time-critical trauma and acute illness through timely intervention. Because emergencies can affect any individual, healthcare systems should ensure equitable access to emergency care alongside routine health services [1]. Accordingly, EMS contributes to population health as a core component of secondary prevention, complementing primary prevention strategies that aim to reduce the incidence of injuries and acute illnesses.
Despite their importance, emergency medicine and EMS have long been overlooked and underfunded in low- and middle-income countries (LMICs), resulting in fragmented systems and persistent regional disparities [2-4]. Even in settings where formal EMS systems exist, they frequently fail to meet population needs. As a result, auxiliary systems such as taxi ambulances, bicycle ambulances, or volunteer services often emerge to fill service gaps [5-9]. In addition, private ambulance services commonly compete with public EMS systems rather than complementing them, and they frequently deliver care of substandard quality [10-12].
The resource-intensive EMS models used in high-income countries are often impractical for LMICs. For instance, Vietnam’s physician-staffed ambulance system, which was modeled after the French system, has struggled to achieve adequate population coverage because of persistent resource constraints [8]. Instead, LMICs may benefit more from EMS models centered on basic-level units staffed by personnel with short-term training and coordinated through multi-sector collaboration. Thailand exemplifies this adaptable and context-sensitive approach [13,14].
Thailand’s EMS model provides important lessons for other LMICs seeking to develop effective emergency care systems under resource constraints. In particular, the Khon Kaen Model, one of the country’s most successful EMS systems, illustrates how locally driven innovations can be leveraged to build a nationwide system [15]. This paper reviews Thailand’s EMS system, including its development history, key policies, and the Khon Kaen Model, to identify lessons that may be generalizable to other settings.
THAI EMS SYSTEM: STRUCTURE AND OPERATION
The National Institute of Emergency Medicine (NIEM) serves as the national lead agency for EMS in Thailand, while provincial governments are legally responsible for managing local EMS systems [16,17]. Each province typically operates one command-and-control center, although a few provinces maintain multiple centers to accommodate geographic needs. In total, 80 command-and-control centers operate across 77 provinces: 60 provinces locate their centers in provincial hospitals, whereas 16 provinces and Bangkok house their centers within provincial (local) administrative organizations.
The EMS system comprises multi-level units operated by organizations from multiple sectors (Fig. 1). These units fall into two main categories: advanced-level units based in hospitals (both public and private) and basic-level units operated by subdistrict offices (local governments) and charity foundations. The majority of EMS services are delivered by basic-level units, which are staffed by personnel who receive short-term training [14,18]. Zoning assigns specific service areas separately to advanced- and basic-level units, ensuring that every area is covered by both levels without overlap or service gaps within each level. Rural areas that are beyond the reach of city-centered hospital-based and charity units depend primarily on subdistrict units.
Command-and-control centers coordinate these diverse EMS units and are accessible through the national EMS hotline, 1-6-6-9. Center personnel assess patient urgency based on information obtained during calls and dispatch the nearest appropriate unit [15]. For critical cases, the centers may coordinate dual dispatch, in which a nearby basic-level unit provides initial care and transport while an advanced-level unit follows to deliver higher-level interventions.
The NIEM allocates stable budgets from the tax-based Emergency Medical Fund to support nationwide EMS development and provide services free of charge. In 2024, the annual per capita budget amounted to 17 THB (US$0.52), with 79% allocated to service reimbursement; reimbursement rates vary according to service level and urgency (Fig. 1) [19]. The Universal Coverage for Emergency Patients Scheme further promotes equitable access by covering the first 72 hours of emergency care, including care provided by private services, for six life-threatening conditions (e.g., severe chest pain and shock) without copayment [20,21].
HISTORY OF EMS DEVELOPMENT IN THAILAND
Early Thai EMS
Until the 1970s, no formal EMS system existed in Thailand, and patient transport relied primarily on volunteer groups and the Siam Red Cross Society (Table 1). In the 1980s, the Police, the Army, and the Ministry of Public Health (MOPH) initiated EMS services in Bangkok [22]. However, these efforts were isolated initiatives rather than components of a coordinated regional system and faced persistent challenges related to limited resources and insufficient political support [14,22,23].
National EMS development and creation of the Khon Kaen Model
In the early 1990s, the MOPH initiated EMS development efforts that resulted in the establishment of local EMS systems as demonstration projects [22]. In 1994, Khon Kaen Hospital launched an EMS system with support from the Japan International Cooperation Agency as a secondary prevention initiative under the Injury Control and Prevention Project, which had begun in 1989 [24]. This system integrated EMS units from Khon Kaen Hospital and charity foundations, both of which had been established in the preceding few years, and coordinated their operations through a command-and-control center located at Khon Kaen Hospital [22]. This arrangement covered the central area of the province and represented the initial form of what later became known as the Khon Kaen Model [25].
In the same year, the Bangkok Metropolitan Government established its own EMS system, the Surgico Medical Ambulance and Rescue Team, centered at Vajira Hospital and jointly operated with its affiliated hospitals. This system provided EMS throughout the Bangkok metropolitan area and was accessible via a dedicated hotline number, 1-5-5-4.
In 1995, the MOPH introduced the “Narenthorn EMS” policy to establish EMS systems in all provincial hospitals, using the newly designated emergency hotline, 1-6-6-9. However, this objective was not fully realized until the mid-2000s. The MOPH’s EMS unit at Rajavithi Hospital in Bangkok was upgraded to serve as the national lead agency, the Narenthorn EMS Center, which was tasked with overseeing EMS nationwide while continuing to provide EMS in Bangkok in collaboration with several other MOPH hospitals. Under the 8th National Economic and Social Development Plan (1997–2001), which emphasized strengthening the healthcare system [26], EMS units were deployed in all 90 provincial hospitals with the goal of achieving nationwide coverage. Nevertheless, insufficient legislative and budgetary support constrained implementation, leaving EMS development fragmented, emergency departments underdeveloped, and the emergency hotline used only in Bangkok on a limited basis [14].
Meanwhile, the Khon Kaen Model continued to develop independently. In 1998, district hospitals and a university hospital joined the provincial EMS system, expanding coverage from the city center to the entire province. To strengthen EMS human resources, Khon Kaen Hospital established EMS training courses at multiple levels, which were open to personnel from other organizations.
National EMS reform and evolution of the Khon Kaen Model
Until the early 2000s, most critically ill or injured patients across Thailand still arrived at hospitals without EMS support. Public awareness of EMS remained low, and service coverage was insufficient. The Khon Kaen EMS system faced similar challenges, including uneven service coverage, limited coordination, low public awareness, and technical problems with hotline connectivity [11].
The MOPH launched the National EMS Reform Policy under the 9th National Economic and Social Development Plan (2002–2006), which prioritized equitable access to healthcare by expanding public health insurance [27]. This policy revived a long-standing but previously unmet objective of establishing functional EMS systems in all provinces. In 2001, the Office of EMS System, also known as the “Narenthorn Center,” was established within the MOPH as a strengthened national EMS lead agency, assuming leadership roles previously held by Rajavithi Hospital [14]. In 2003, pilot projects were initiated in seven provinces, including Bangkok and Khon Kaen [14], with funding from the National Health Security Office, which had been established in 2002 to manage the expanded health insurance system. This funding covered reimbursement for EMS operations to promote financial sustainability and system development. An initial per capita budget of 10 THB (US$0.31) was allocated by the Office. Nationwide establishment of EMS systems was completed in 2005 [14].
Under the reform policy, the Khon Kaen Model continued to evolve, with further expansion of EMS coverage. In 2003, the deployment of subdistrict EMS units and the formal integration of private hospitals began, creating a system that combined hospital-based services (both public and private), volunteer organizations, and local governments [11,13,18]. Public awareness campaigns, workforce training, and improvements in communication networks linking providers with the command-and-control center contributed to increased EMS utilization. In addition, the Japan International Cooperation Agency provided technical and financial support for the Trauma Center Project at Khon Kaen Hospital from 2001 to 2005, which further strengthened EMS development.
During this period, EMS coverage in Khon Kaen expanded substantially, with basic-level units comprising the majority of services: they accounted for approximately half of all units in 2003 and increased to 85% by 2008, although the number of advanced-level units has risen in more recent years [15]. EMS accessibility also improved, with 70% of missions reaching the scene within 10 minutes in 2007 [14]. The proportion of severely injured patients transported to Khon Kaen Hospital by EMS increased from 42% in 2000 to 62% in 2003, 87% in 2008, and now exceeds 95% [28].
In the late 2000s, EMS reform was further strengthened through the launch of the first 5-year National EMS Development Plan (2006–2010), which incorporated key elements of the Khon Kaen Model, particularly its multi-sectoral structure. This plan expanded the deployment of subdistrict units staffed by First Responders who received 16 hours of training, thereby accelerating nationwide EMS expansion. In 2008, the NIEM was established as the national EMS lead agency and assumed responsibility for the 5-year development plans, with mandates to oversee, standardize, and evaluate EMS operations through legislation, standardized training, personnel certification, protocol development, and funding mechanisms. Its initial per capita budget was 12 THB (US$0.37), which gradually increased to 17 THB by 2024 [14,19]. The Institute clarified provincial responsibilities in EMS management [17], and accelerated nationwide scale-up of previously informal local innovations by formalizing, legalizing, and standardizing them. This process included certification and registration of charity foundation EMS units that had previously operated without official recognition.
The 2010s marked a period of EMS system maturation. First, efforts focused on strengthening service capacity through training, standardization, and technological advancement. In 2011, the National EMS Rally, modeled after the successful Khon Kaen EMS Rally launched in 2006, was introduced to enhance EMS personnel skills through competitive exercises. Training programs were progressively upgraded and standardized: the 40-hour pre-hospital nurse courses evolved into 4-month Emergency Nurse Practitioner programs in 2013; 4-year paramedic degree programs were initiated in 2014; and the 16-hour First Responder courses were expanded to 40-hour Emergency Medical Responder courses in 2018 and subsequently to 50-hour courses in 2022. In 2013, a criteria-based dispatch tool was introduced to guide command-and-control center decision-making and was later digitized in Khon Kaen. The NIEM is currently developing a national computer-based version, which is being piloted in several provinces.
Second, policy measures were implemented to improve responsiveness to population needs. In 2017, the Universal Coverage for Emergency Patients Scheme was introduced to cover the first 72 hours of emergency services. In parallel, beginning in 2016, the NIEM initiated decentralization of the EMS governance structure to better align services with local needs, including relocating hospital-based command-and-control centers to provincial administrative offices.
NATIONAL POLICIES
Early policies in the 1990s prompted the emergence of several small-scale local initiatives but lacked a sufficient combination of comprehensive legal frameworks, clearly defined stakeholder responsibilities, detailed documentation, and adequate budgets. Initiatives such as EMS development in Bangkok and Khon Kaen were sustained as pilot projects or relied on external support [24]; however, they remained fragmented efforts rather than components of a coordinated nationwide system.
In contrast, the National EMS Reform Policy in the 2000s integrated health financing reform to promote system development and improve service provision. The Health Security Act of 2002 established the National Health Security Office to manage the Universal Coverage Scheme, thereby extending healthcare access to previously uninsured populations [29]. This scheme provided a stable budget for EMS, enabling systematic expansion and the provision of free EMS services during the early and mid-2000s, prior to the establishment of the NIEM.
The NIEM was established under the Emergency Medical Act, which consolidated responsibilities for policy-making and technical support from the MOPH, including its Narenthorn Center, and centralized budget allocation from the National Health Security Office [16]. The Act defines the roles of government organizations at both national and provincial levels, outlines the structure and responsibilities of the NIEM, and establishes core operational principles for EMS. Notably, it formalized provincial responsibilities and mandated the creation of provincial EMS steering committees, which substantially advanced EMS development [17].
Structured plans and clear targets were developed based on well-defined policy directions. Although the National Economic and Social Development Plans did not explicitly reference EMS, they provided overarching policy priorities, such as strengthening the health system and achieving universal health coverage, which legitimized EMS as a national development priority. Building on this foundation, the first National EMS Development Plan (2006–2010) established specific targets, including ensuring EMS transport for at least half of critical patients and extending service coverage to all villages by 2010. The plan also incorporated local innovations, particularly the Khon Kaen Model, which accelerated nationwide EMS expansion [14].
KHON KAEN MODEL
Innovations within the Khon Kaen EMS system have influenced national policies and driven broader reforms, with a key distinguishing feature being its multi-sector structure (Table 2) [15]. The initial model integrated hospital-based and voluntary services; however, their concentration in urban areas limited coverage in rural regions [14,22]. To address this limitation, subdistrict governments were subsequently incorporated. In addition, private hospitals were included, and zoning mechanisms were introduced to prevent service gaps and duplication among diverse providers.
This multi-sector structure evolved into a multi-level EMS system that reflects the differing capacities of service providers. Each geographic area is served by both basic- and advanced-level units, which are coordinated through the command-and-control center. Dual-dispatch operations are implemented when necessary. Basic-level units, which require short-term training and relatively low-cost equipment and vehicles, have played a central role in expanding EMS coverage.
Provincial EMS steering committees, operating at both executive and operational levels, effectively guide system development and coordination among diverse providers. Chaired by the provincial governor, these committees demonstrate strong political commitment, thereby enhancing the legitimacy and credibility of EMS initiatives. Regular monthly meetings of the operational committees bring together all stakeholders to promote collaboration, share experiences, address operational challenges, and guide system development, standardization, and expansion.
Hospital staff, particularly those at Khon Kaen Hospital, are deeply committed to EMS development and operations. They host and facilitate the monthly committee meetings, contribute to the formulation of policies, plans, and regulations, and support command-and-control center operations. In addition, they participate in the design and delivery of training programs for EMS personnel at multiple levels as well as for the general public [30,31].
The hospital-based command-and-control center manages dispatch operations, including assessment of patient conditions and selection of appropriate EMS units. Its location within the hospital provides several advantages. Emergency physicians on duty in the emergency department can directly supervise field procedures by providing real-time online medical direction (emergency medicine residents may be stationed at the command-and-control center, though not on a 24-hour basis, under the supervision of on-duty emergency physicians). Coordination between pre-hospital and in-hospital care is thereby strengthened. In addition, the center’s steering committee includes emergency physicians and nurses and is chaired by the head of the hospital’s emergency department, further integrating hospital expertise into EMS operations.
Since the late 1980s, staff at Khon Kaen Hospital have systematically collected and analyzed data on patient referrals and injuries [24,32]. These analyses identified deficiencies in the referral system as well as in pre-hospital and in-hospital care for injured patients, which prompted the initiation of the Injury Control and Prevention Project in 1989 and subsequent EMS development. The data continue to inform quality management, injury surveillance, and the planning and evaluation of injury prevention initiatives [13].
In addition, Khon Kaen has continued to introduce innovations over time. The Khon Kaen EMS Rally was launched in 2006; the Khon Kaen EMS Foundation was established in 2013 to generate supplementary funding; a computer-assisted dispatch system was introduced in 2018; and a fully digitalized command-and-control center became operational in 2021.
DISCUSSION
Thailand’s EMS development offers valuable lessons, particularly through its distinctive policy framework and local innovations, such as the Khon Kaen Model. These experiences provide important guidance for resource-limited settings with underdeveloped EMS systems, demonstrating how systems can be tailored to local conditions rather than simply replicating models from high-income countries.
Consistent national policies, stable funding, and effective leadership are well-recognized drivers of EMS development and have contributed substantially to Thailand’s achievements [3,33-36]. Financing EMS through the tax-funded Universal Coverage Scheme was a deliberate political decision aligned with the national commitment to equitable healthcare access, as articulated in successive National Economic and Social Development Plans. This approach stabilized service provision, enabled free EMS delivery, and facilitated the integration of economically unstable private organizations, benefiting even relatively advanced regions such as Khon Kaen [11]. In many LMICs, economic barriers remain pervasive, with EMS fees often distance-based and private services requiring direct payment [3]. Embedding equity in emergency care within national health strategies and aligning financing policies accordingly may help replicate Thailand’s success.
Flexible policy environments can encourage local innovation. In Thailand, the MOPH initially permitted non-standard strategies and later formalized and scaled them, including the integration of volunteer EMS units that initially lacked legal recognition or standardized qualifications. Many LMICs rely on community-first-responder models, in which lay volunteers, such as commercial drivers or shop owners, provide basic EMS with minimal training or incentives as auxiliary systems [5-7,9]. Regardless of responder type, incorporating these actors into formal EMS structures with adequate training and reimbursement mechanisms would help sustain motivation and mitigate commonly observed problems, including competition with public services and suboptimal care quality [10-12]. Such flexibility may also allow extensive legal reforms to be deferred while systems mature.
Thailand’s multi-sector, multi-level EMS model offers practical solutions for resource-limited settings. Collaboration across sectors expands the EMS workforce and service coverage by leveraging the comparative strengths of different providers: village-based subdistrict units can reach areas that city-centered hospital-based units cannot. Basic-level units have enabled rapid system expansion at relatively low cost. Aligning response levels with patient severity further improves efficiency, given that most EMS users present with mild to moderate conditions.
Effective coordination is essential to ensure coherent planning and operations within an EMS system that involves multiple organizations. A key mechanism for achieving such coordination is the establishment of steering committees that include all relevant stakeholders. Regular meetings facilitate alignment among diverse provider perspectives and contribute to improved service consistency [11]. Securing support from local authorities enhances institutional legitimacy, while the involvement of educational institutions strengthens future workforce development. In settings where such committees have not yet been established, beginning with a small group of motivated individuals and a limited number of EMS providers—as occurred during the early stages of the Khon Kaen EMS—can serve as an effective initial step. In addition, effective dispatch coordination through command-and-control centers is critical, with their organizational structure and physical placement adapted to local contexts.
The commitment of hospital staff was a key driving force in Khon Kaen, where motivated individuals initiated the EMS project and sustained its activities [24]. Although replicating such a highly dedicated team may be challenging, individuals engaged in international EMS research networks are likely to share similar levels of commitment and may be well positioned to lead comparable initiatives in their local contexts [3,33,37].
Long-standing data-driven strategies have guided innovations in injury prevention and EMS development in Khon Kaen, and these efforts have influenced national policies. Analyses of collected data effectively informed stakeholders and policymakers about key problems and appropriate solutions. This success led to a nationwide expansion of data collection activities, including the establishment of a national injury surveillance system in 2001 [32,38].
Despite these achievements, several challenges remain. EMS capacity and quality require further improvement, particularly with respect to services delivered by basic-level units, access in remote islands and mountainous areas, and care for older adults and infants. Weak inter-provincial coordination and communication also pose challenges for disaster response. Decentralization efforts are currently underway, including the relocation of hospital-based command-and-control centers to provincial administrative offices to improve EMS responsiveness; however, the effects of these changes remain a matter of debate [39]. These issues are being addressed through upgraded and standardized training, the introduction of modern technologies and transportation resources, and continued data-driven assessments.
CONCLUSION
Thailand’s experience with EMS development offers lessons applicable to other resource-limited settings seeking to establish context-specific systems. Flexible policies can foster local innovation, while stable funding and effective leadership facilitate the rapid nationwide expansion of services. Well-coordinated multi-sectoral and multi-level systems enable broad service coverage even under resource constraints. At the same time, system standardization remains essential to ensure consistent service quality.
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