Health impact assessment of decentralization of Emergency Medical Services: a case study in Chonburi Province, Thailand

Abstract

The decentralization of Emergency Medical Services (EMS) to local administrative organizations is a critical policy initiative in Thailand aimed at enhancing service responsiveness and community participation. This study applied a prospective Health Impact Assessment (HIA) to identify positive and negative health impacts of EMS decentralization in Chonburi Province and develop evidence-based policy recommendations to guide the transition from the Ministry of Public Health to local governance. A mixed-methods approach was designed based on the six-step HIA framework. The study involved 562 participants, including EMS providers, recipients, and policymakers. Qualitative participants were selected through purposive sampling for interviews and focus groups, and quantitative participants through stratified random sampling for surveys. Qualitative data were thematically analyzed, and quantitative data were analyzed descriptively. Findings revealed both positive and negative impacts across four pre-hospital care activity domains (dispatch, incident response, referral, and administrative management) and four dimensions of well-being (physical, mental, social, and spiritual). Positive impacts included improved responsiveness, collaboration, and staff motivation, while negative impacts involved personnel shortages, communication gaps, and limited budgets. The derived policy recommendations emphasize structured workforce planning, upgraded communication systems, sustainable financing, and participatory monitoring to strengthen decentralized EMS. The use of HIA provided a systematic and participatory process that translated empirical evidence into actionable policy guidance for health service decentralization in Thailand and similar contexts.

Supplementary Information

The online version contains supplementary material available at 10.1038/s41598-025-27900-2.

Introduction

Decentralization is a widely adopted approach to health system reform, particularly in low- and middle-income countries¹. It seeks to improve responsiveness, efficiency, and equity in healthcare delivery. Nevertheless, decentralization presents inherent complexities and, when inadequately planned or implemented, may result in fragmented services, inequitable resource allocation, and disparities in access^2,3. The effectiveness of decentralization depends on the administrative capacity, financial autonomy, and coordination frameworks within local governance structures^4,5. In Thailand, the government has undertaken reforms to transfer responsibility for healthcare services to Local Administrative Organizations (LAOs). This transition has been underway since 1999, under the legal framework established by the Determining Plans and Process of Decentralization to Local Government Organization Act B.E. 2542 (1999) and the Second Decentralization Plan B.E. 2551 (2008). The primary objectives of these reforms are to enhance local responsiveness, improve service efficiency, and promote equity in healthcare access^6,7.

Emergency Medical Services (EMS) are a vital component of the health system, providing pre-hospital care and rapid medical intervention to reduce mortality and morbidity, particularly in trauma and critical illness cases⁸. In Thailand, the EMS has previously centralized at the Ministry of Public Health, operating through a hierarchical structure led by the National Institute for Emergency Medicine (NIEM)⁹. In recent years, the EMS responsibilities have been gradually decentralized to LAOs, though the pace and scope of implementation have varied across provinces due to differences in readiness, capacity, and contextual factors¹⁰.

An excellent illustration of decentralization is being implemented in practice is Chonburi Province, a heavily urbanized and economically active area. This province has increasingly trended of traffic-related injuries and fatalities¹¹, underscoring the need for timely and effective EMS delivery.

Several tools can be used to assess the impacts of major policy reforms, such as Strategic Environmental Assessment (SEA), Environmental Impact Assessment (EIA), Environmental and Health Impact Assessment (EHIA), and Social Impact Assessment (SIA)¹². Among these, Health Impact Assessment (HIA) is particularly appropriate in this context, as the primary objective was to identify both the direct and indirect health consequences of EMS decentralization and to translate these findings into practical, health-oriented policy recommendations prior to implementation. HIA provides a structured and participatory framework that integrates health considerations into decision-making, strengthens stakeholder engagement, and provides evidence-based insights that allow policymakers to maximize positive and minimize negative impacts^13,14. Key step in the HIA process include screening (determining the need for HIA), scoping (identifying health effects, stakeholders, and methods), assessing (analyzing health impacts), recommendations (proposing measures to enhance benefits and reduce harms), reporting (documenting and communicating findings), and monitoring and evaluation (tracking implementation and impact)¹⁵.

In Thailand, the National Health Commission Office (NHCO) adapted the World Health Organization’s six-step HIA framework to fit the national policy context¹⁶. HIA is applied in two primary ways: (1) in conjunction with other assessments such as EIA, EHIA, or SIA; and (2) as a stand-alone tool for learning and policy development. This study adopted the latter approach, applying HIA prospectively as a public policy instrument to evaluate EMS decentralization. While HIA has been widely used in infrastructure, environmental, and urban development projects^17–20, its application to EMS policy reform remains limited in Thailand, highlighting the need for empirical evidence in this area.

This study addresses this gap by employing a prospective HIA to assess the health impacts of EMS decentralization in Chonburi Province, Thailand. The conceptual framework integrated the HIA approach with four dimensions of health (physical, mental, social, and spiritual well-being) to comprehensively assess the potential effects of EMS decentralization. Each dimension was represented by specific sub-indicators identified during the scoping stage. The physical dimension encompassed the skills and competencies of EMS providers, as well as the adequacy of available equipment. The mental dimension involved work-related stress and workload among EMS providers, along with the level of satisfaction among service users. The social dimension focused on community participation, communication, and inter-agency collaboration. The spiritual dimension captured motivation, empowerment, and a sense of belonging. These sub-indicators enabled systematic identification of both positive and negative health impacts for EMS providers and recipients across the four pre-hospital care activity domains (dispatch, incident response, referral, and administrative management)²¹.

Therefore, this study aimed to identify positive and negative health impacts of EMS decentralization in Chonburi Province and generate policy recommendations to guide the transition of EMS management from the Ministry of Public Health to LAOs.

Results

Health impacts were categorized into four EMS activity domains and four well-being dimensions, as detailed in Table 1 and Table S1. The sub-indicators within each dimension reflected the impacts on both service providers and service users. Policy recommendations derived from these findings are summarized in Table 1, outlining strategic directions for EMS system development in Chonburi Province and guidelines for the establishment of the Emergency Dispatch and Command Center under the CPAO.

Table 1.

Positive and negative health impacts of EMS decentralization across four operational domains (dispatch, incident response, referral, and administrative management) and four dimensions of well-being (physical, mental, social, and spiritual), with corresponding policy recommendations.

EMS domains	Key findings (Objective 1)	Health impacts		Policy recommendations (Objective 2)
		Positive	Negative
1. Dispatch	1. EMS staff: Shortage of call-takers, unclear roles 2. Medical equipment: Outdated systems and communicable equipment, and signal interference 3. Budget: Lack of budget allocation for the maintenance of communication equipment 4. Communication related to incident reporting: Overclaim information 5. Dispatch and command center communication with EMS operational unit: Problems with the equipment and radio communication channels 6. EMS reporter: Speed in report, quality of communication, and customer satisfaction	- Physical health (human resources are expert in the EMS field) - Social well-being (public trust in reporting) - Satisfaction of EMS users on the dispatch service at the high level (= 4.23 ± 0.75)	- Physical health (delayed response times) - Physical health (limitation of traffic information of the dispatchers) - Social well-being (lack of budget allocation for the maintenance of communication equipment) - Spiritual health (overclaim information from reporter)	Supportive: Maintenance and prepare the modern equipment and other relevant resources with ready to use Problem-solving: Coordination on Contact channels and guidelines for facilitating traffic routes for emergency medical responders
2. Incident response	1. EMS staff: Skilled teams available but high workload, stress 2. Medical equipment and 3. Budget: limited budgets, reliance on personal funds 4. EMS scene communication: Providers are frustrating with communicating during rush hours 5. Safety of EMS providers: Sufficient safety equipment and related to EMS standards 6. Ambulances: Quality related to the EMS standard 7. EMS reporter: Speed of arriving on scene, desired characteristics of service providers, and customer satisfaction	- Physical health (quality of care with multidisciplinary EMS team related with NIEM standard) - Satisfaction of EMS users on the speed of EMS teams arrival at the high level (= 4.24 ± 0.74) - Service satisfaction of EMS users at the high level (= 4.41 ± 0.64)	- Physical health (high workload of personnel) - Mental health (provider stress) - Social well-being (family communication) - Social well-being (lack of budget allocation for the maintenance of communication equipment)	Supportive:Preparation a personnel plan and personnel development plan for the multidisciplinary team to suit for available resources - Organize workshops on plans to move and transfer patients by land, water, and air, or attend emergency operations workshops with other agencies Problem-solving: Organize public relations campaigns on guidelines for reporting incidents in the emergency medical system. Increasing public awareness on providing necessary information appropriately in reporting incidents - Development concrete compensation tracking system
3. Referral	1. Quality and appropriateness of operation (Land, Marine, air EMS operational unit): Quality as the EMS standards, especially the EMS team on coastal areas strong 2. Quality and appropriateness of operation (Land EMS unit): Urban congestion delayed response (failure to meet 8-min KPI)	- Social well-being (equity of access) - Satisfaction of EMS users on the EMS equipment at the high level (= 4.31 ± 0.77)	- Physical health (treatment delays) - Heavy traffic jam in urban area - Unable to provide EMS service within 8 min according to the EMS standard	Supportive: Plan and organize activities covering pre-hospital operations (Pre-hospital care) in the action plan Problem-solving: Develop and improve indicators and success criteria for emergency medicine regarding to the duration of emergency operations
4. Administrative management	1. Resource management: Share human resources with the ER, EMS, and referral unit, causing heavy workload 2. Communication: Effective collaboration between the CCC, the Chonburi Public Health Provincial Office, and NIEM, shared staffing with ER units, limited procurement flexibility, turnover of NIEM coordinators	- Spiritual well-being (provider motivation, governance participation)	- Physical health (Share human resources with the ER, EMS, and referral unit, causing heavy workload) - Social well-being (continuity and trust)	Supportive: Consideration on the feasibility and possibility of management guidelines for administrative operations units both at the primary and advanced levels Problem-solving: Consideration on personnel workload and organization structure that suitable for this unit

Health impact assessment and policy recommendations

Dispatch domain

Positive impacts

The assessment revealed that the efficiency of dispatch operations was supported by skilled EMS personnel and reliable communication during incident reporting. EMS users expressed a high level of satisfaction with the dispatch service, particularly regarding reporting speed and clarity. These findings indicate improvements in both physical performance (timely response by competent staff) and social well-being (enhanced public trust in the dispatch system).

Negative impacts

Constraints were identified in limited maintenance budgets for communication systems, unclear role boundaries between call-takers and field responders, and inadequate traffic information. Over-reporting the severity of illness by callers occasionally led to confusion and delayed dispatching.

Policy recommendations

It is recommended that the communication infrastructure of EMS dispatch centers be upgraded through the adoption of advanced digital technologies and routine maintenance programs to ensure system reliability and efficiency. Continuous professional development programs should also be institutionalized to strengthen the operational competency of dispatch personnel and enhance inter-agency coordination. Clear operational protocols and communication guidelines should be developed to delineate the responsibilities between call-takers and field responders. Collaboration with traffic management authorities is recommended to design and maintain dedicated emergency access routes, thereby reducing response time and ensuring timely patient care.

Incident response domain

Positive impacts

The presence of skilled EMS teams and adherence to NIEM standards improved service quality and patient outcomes. EMS users reported high satisfaction regarding rapid response and provider professionalism. The use of standard equipment and sufficient safety tools contributed to physical safety and user confidence.

Negative impacts

High workloads, limited budgets, and occasional reliance on personal funds among staff resulted in physical and mental strain. Communication challenges during rush hours and difficulty in contacting patient families were also reported.

Policy recommendations

Strategic workforce planning and capacity-building initiatives should be strengthened to optimize human resource utilization and enhance operational readiness. Interdisciplinary simulation training and collaborative exercises with related agencies are recommended to improve response coordination and promote a shared culture of preparedness among EMS personnel. Public awareness campaigns should be implemented to improve the accuracy of emergency incident reporting and ensure that essential information is conveyed effectively. Additionally, a standardized compensation and benefit tracking system should be established to promote fairness and job satisfaction among EMS providers.

Referral domain

Positive impacts

Coastal EMS teams demonstrated strong operational capacity and compliance with EMS standards, contributing to timely patient transfers. Users expressed high satisfaction with the quality of equipment, reflecting social well-being through equitable access to emergency services.

Negative impacts

Urban congestion hindered ambulance movement, resulting in the failure to meet the 8-min response standard and delays in pre-hospital treatment.

Policy recommendations

It is recommended that a comprehensive pre-hospital care framework be developed to integrate land, marine, and air referral operations. The adoption of digital platforms and monitoring systems should be promoted to facilitate seamless communication and data sharing, thereby enhancing continuity and quality of emergency care. Key performance indicators (KPIs) related to emergency response and referral timeliness should be reviewed and refined. Establishing evidence-based benchmarks will allow systematic monitoring and continuous improvement in the quality and efficiency of patient transfer operations, particularly in high-traffic urban zones.

Administrative management domain

Positive impacts

Decentralized administrative control promoted flexibility in local EMS planning. Physically, budget autonomy enabled better allocation of resources for equipment and maintenance. Mentally, participatory meetings empowered staff to voice opinions and solve operational problems collaboratively. Socially, inclusion of local leaders and community representatives enhanced transparency and accountability. Spiritually, staff reported greater motivation, pride, and a sense of belonging to the local service system.

Negative impacts

Limited experience in financial management among some local administrators led to delays in procurement. Overlapping roles between emergency rooms and EMS units created confusion and workload imbalance. Mentally, uncertainty regarding long-term funding generated anxiety among staff. Socially, uneven participation from some subdistricts weakened coordination at the provincial level.

Policy recommendations

An adaptive management framework should be institutionalized to empower local administrative units in managing EMS resources effectively. Participatory governance mechanisms and leadership development programs are recommended to promote accountability, transparency, and long-term sustainability of the decentralized EMS system. Personnel workloads and organizational structures should be reviewed to align responsibilities and optimize human resource allocation across operational units.

Quantitative findings

A total of 363 EMS representatives participated in the satisfaction survey (Fig. 1). Demographic characteristics of EMS users are presented in Table S2. Over 80% of respondents reported a high satisfaction level with the easy and rapid, clear information; polite service provider; giving advice; satisfaction with the EMS call and the speed to the scene; quick first aid; polite service provider; service with honesty; giving advice; prompt material; expertise in the EMS field; and satisfaction with the incident response (see Table S3). The overall satisfaction score for EMS performance across four operational domains was at a high level, with an overall mean of 4.30 ± 0.73 (95% CI 4.26–4.34). Among these domains, the highest mean score was observed in incident response (4.41 ± 0.64, 95% CI 4.37–4.45), followed by referral (4.31 ± 0.77, 95% CI 4.25–4.37), dispatch (4.23 ± 0.75, 95% CI 4.17–4.29), and administrative management (4.22 ± 0.71, 95% CI 4.17–4.27).

Fig. 1.

Percentage of EMS users (n = 363) indicating satisfaction levels with key aspects of EMS. Colors represent satisfaction levels.

For individual items within each domain, mean scores remained above 4.00, indicating generally high satisfaction levels. In the dispatch domain, clarity of information received had a mean score of 4.28 ± 0.74 (95% CI 4.22–4.34). In the incident response domain, timeliness of response and professional conduct of EMS personnel recorded mean scores of 4.40 ± 0.65 (95% CI 4.35–4.45) and 4.41 ± 0.64 (95% CI 4.37–4.45), respectively. In the referral domain, the item quality of medical equipment had a mean of 4.31 ± 0.77 (95% CI 4.25–4.37), and in the administrative management domain, participation in planning recorded a mean of 4.22 ± 0.71 (95% CI 4.17–4.27). Subgroup analyses showed consistent satisfaction scores across gender, education, and occupation categories, ranging from 4.25 to 4.42 (see Tables S4–S7 for subgroup details).

An evaluation plan for monitoring and assessment

An evaluation framework was established to support ongoing monitoring and assessment following policy implementation. The plan adopts a participatory approach with clearly defined indicators, including response time to arrival on scene within 8 min for critical cases (based on international standards), mortality and morbidity rates, staff retention and turnover, efficiency of asset management, and user satisfaction levels.

Discussion

The application of the HIA framework in this study enabled inclusive stakeholder engagement and produced evidence-based recommendations to guide the ongoing decentralization of EMS in Chonburi Province. The findings indicate that decentralization has the potential to improve service responsiveness, coordination, and community participation. However, uneven local capacities and structural challenges revealed through the assessment highlight the need for targeted policy and management interventions.

The assessment identified both positive and negative health impacts across the four operational domains of EMS (dispatch, incident response, referral, and administrative management). Translating these findings into clear and actionable policy proposals is essential to realize the benefits of decentralization. The findings summarized in Table S1 illustrate how domain-specific impacts directly informed the policy recommendations. In the dispatch domain, high user satisfaction and improved responsiveness were offset by unclear role boundaries and maintenance constraints, suggesting the need for investment in digital dispatch platforms, clear operational protocols, and scheduled system maintenance. In the incident response domain, heavy workloads and limited budgets contributed to staff stress, indicating the need for structured workforce planning, fair compensation, and psychosocial support programs. In the referral domain, delays caused by urban congestion and the lack of real-time hospital bed data support the establishment of an integrated referral coordination platform and digital tracking systems to ensure continuity of care. In the administrative management domain, decentralization improved flexibility, participatory planning, and staff motivation, but overlapping roles and procurement delays underscored the importance of leadership development, participatory budgeting, and standardized monitoring frameworks. These domain-specific insights formed the basis for the policy recommendations summarized in Table 1, ensuring that each proposal was grounded in empirical evidence rather than general assumptions.

Notably, EMS performance varied across the province’s four operational domains (dispatch, incident response, referral, and administration). In coastal areas, trained personnel, reliable communication infrastructure, and strong local governance contributed to high satisfaction. User satisfaction with EMS system in Chonburi also aligned with prior studies in other Thai provinces⁴. In contrast, urban centers struggled with signal interference, personnel shortages, and lack of dedicated dispatch systems. These disparities underscored the need for standardized national guidelines and investments in communication systems to ensure equitable service delivery across all regions. The Triagist system used in Chiang Mai, for example, has improved accuracy and reduced delays in patient triage²².

In the domain of incident response, areas equipped with full-time EMS teams and well-maintained ambulances achieved quicker response times and higher service satisfaction. However, urban traffic congestion and insufficient emergency routing infrastructure hindered response efficiency in city districts. To address this, municipalities should collaborate with traffic authorities to implement emergency route planning, adopt real-time vehicle tracking, and leverage predictive traffic technologies, as successfully practiced in China and Japan^23,24.

The referral process exhibited strengths in regions near hospitals, where effective coordination and availability of medical equipment facilitated timely patient transfers. However, delays in urban referrals were attributed to hospital overcrowding and the absence of real-time data on bed availability. Establishing a provincial referral coordination platform could mitigate these delays and improve patient outcomes, similar to systems implemented in Japan²³.

In the domain of administrative operations, EMS units that held regular meetings with hospitals and local authorities showed stronger planning, budgeting, and monitoring capacity. However, overlapping staff responsibilities, procurement limitations, and high turnover of NIEM coordinators posed operational challenges. These findings highlight the need for local EMS coordination units and integrated data-sharing platforms to support planning, monitoring, and performance evaluation. A standardized monitoring and evaluation system should also be developed at the provincial level. This would track indicators like response times, successful referrals, and public satisfaction to support performance-based funding.

Beyond operational performance, the findings of this study also highlight key impacts on health determinants. Improved EMS responsiveness enhanced physical outcomes, while greater community engagement fostered social cohesion. However, increased workload and resource constraints negatively affected the mental well-being of EMS providers, emphasizing the importance of psychosocial support and occupational health programs within decentralized systems²⁵.

From a theoretical perspective, decentralization can be categorized into three main forms (deconcentration, delegation, and devolution) which differ in the degree of authority transferred from central to local levels²⁶. The decentralization process observed in Chonburi most closely aligns with the devolution model, in which the LAOs and the CPAO assume administrative and financial responsibility for EMS²⁷. This model enhances local responsiveness, participatory planning, and contextual adaptation, but it also exposes disparities in administrative capacity and resource allocation. This study supports existing literature suggesting that decentralization, when appropriately supported, can enhance service delivery, particularly in well-resourced areas². However, without sufficient oversight and capacity-building, decentralization might exacerbate regional inequalities. These results were consistent with experiences from other countries, including Brazil, Indonesia, and the Philippines, successful decentralization depends on robust national frameworks, clear service standards, equitable financing, and continuous capacity-building^5,28–30.

In the Thai context, these insights highlight the importance of defining minimum EMS service standards, strengthening fiscal and technical support for LAOs, and institutionalizing participatory monitoring to ensure accountability and sustainability. The strategic application of the HIA framework in this study demonstrates its value as a replicable approach for assessing and guiding complex health policy reforms, ensuring that decentralization enhances not only local adaptability but also the efficiency and equity of the national health system.

This study has several limitations. The findings are specific to Chonburi Province, which is more urbanized and better resourced than many other provinces in Thailand. Therefore, the results may not be generalizable to areas with lower administrative or financial capacities. The study applied a prospective HIA using mixed methods to anticipate the potential effects of EMS decentralization. Although this approach provides valuable contextual and policy insights, it was not designed for causal comparison; thus, causal attribution to decentralization cannot be inferred. The study was conducted in one province, which limited the ability to compare EMS outcomes before and after decentralization or between decentralized and centralized provinces. Nevertheless, the findings offer early empirical evidence to guide the design of future comparative evaluations once decentralization is fully implemented. The high satisfaction scores may have been influenced by self-reporting and social desirability bias. Furthermore, while HIA offers a structured and participatory framework, it does not capture all policy and environmental dimensions of decentralization. Future research should integrate HIA with complementary approaches such as Strategic Environmental Assessment (SEA) to capture broader contextual factors, including transport, governance, and environmental planning. It should also incorporate objective indicators such as EMS response times, international benchmarks, and clinical outcomes to triangulate self-reported data and conduct comparative analyses across provinces with varying governance capacities to strengthen generalizability and causal inference.

In conclusion, the decentralization of EMS to the LAOs in Chonburi Province enhanced responsiveness, coordination, and community participation, but challenges such as workforce shortages, communication gaps, and limited budgets remain. To ensure efficiency and equity, policy recommendations should prioritize workforce development, upgraded communication and referral systems, sustainable financing, and participatory monitoring, all under clear national standards and technical support. Strengthening these elements will foster a more equitable, efficient, and resilient EMS system. This study demonstrates the HIA framework’s value as a strategic instrument for evaluating and guiding health system decentralization in Thailand and similar contexts.

Methods

Study site and design

The study was conducted between November 2023 and April 2024 in Chonburi Province, Thailand, an area undergoing active EMS decentralization. Chonburi Province, located on Thailand’s eastern coast, features a diverse landscape of coastal plains, rolling hills, and mountainous regions. The province boasts a 160-km coastline along the Gulf of Thailand, featuring sandy beaches, rocky cliffs, and mangrove forests. The EMS network in Chonburi is divided into four regional clusters, each coordinated by a lead hospital. Network 1, led by Chonburi Hospital, covers four districts (Mueang Chonburi, Phan Thong, Ban Bueng, and Nong Yai districts). Network 2, overseen by Phanat Nikhom Hospital, includes three districts (Phanat Nikhom, Bo Thong, and Ko Chan districts). Network 3, led by Queen Savang Vadhana Memorial Hospital, serves three districts (Si Racha, Bang Lamung, Ko Si Chang). Network 4, covering Sattahip District, is directed by Somdej Phra Nangchao Sirikit Naval Medical Hospital, and supported by other naval and community hospitals (Fig. 2).

Fig. 2.

Geographic map of Chonburi Province showing the four EMS network clusters. Each cluster is coordinated by a lead hospital: Network 1 (Chonburi Hospital), Network 2 (Phanat Nikhom Hospital), Network 3 (Queen Savang Vadhana Memorial Hospital), and Network 4 (Somdej Phra Nangchao Sirikit Naval Medical Hospital). The map was created by ArcGis online. Sources: Esri, TomTom, Garmin, FAO, NOAA, USGS, OpenStreetMap contributors, and the GIS User Community. All other layers were produced by the authors and are copyright-free.

We conducted a mixed-methods design in accordance with Thailand’s National Health Commission Office’s (NHCO) six-step Health Impact Assessment (HIA) framework. These steps included: (1) screening of the policy, (2) defining the scope of the study and approaches for assessment, also known as public scoping, (3) assessing the potential health impacts based on the identified scope, (4) reviewing the assessment results through public consultation, (5) communicating the findings to policymakers and preparing a monitoring and control plan, and (6) conducting the monitoring and evaluation process (Table 2). Outputs from each step were systematically reviewed in stakeholder meetings and used as inputs to the subsequent stage to ensure consistency and traceability of findings. A total of 562 participants were engaged, including EMS providers, EMS users (patients, caregivers, community members), and stakeholders from policy and administration. Purposive sampling guided qualitative interviews and focus groups, while stratified random sampling was used for quantitative data collection. The number and characteristics of stakeholders involved in the HIA process are presented in Table S8. The qualitative data from in-depth interviews and focus group discussions were analyzed using thematic analysis to identify recurring patterns and categories. Quantitative data from EMS user satisfaction questionnaires were analyzed using descriptive statistics (frequency, percentage, 95% confident interval, mean, and standard deviation) with Microsoft Excel.

Table 2.

Health impact assessment (HIA) framework as outlined by Thailand’s national health commission office (NHCO) on EMS.

HIA steps	Actions
1. Screening	A review of relevant literature on the mission transfer of EMS in Chonburi as the preliminary assessment and future impact projection. It examines five key aspects: (1) factors contributing to negative impacts, (2) severity, (3) effects on disadvantaged group, (4) community concerns, and (5) rights claim under section 11 of the National Health Act, B.E. 2550
2. Scoping	A public forum was held for EMS providers, representing both administrative units and operational units, and service recipients (users) to define the scope of the health impact assessment on EMS
3. Assessing	Stakeholder evidence was assessed and characterized to identify the positive and negative impacts and develop the recommendations on EMS system in Chonburi. There were EMS providers and EMS recipients via interview, focus groups, and the questionnaire on EMS user satisfaction
4. Reporting	Key stakeholders were organized the public forum and co-considering the draft of HIA report and co-develop the feasibility and possibility recommendations for the development of EMS system in Chonburi Province
5. Influencing	A meeting was held to present the outcomes of the HIA of EMS and the stakeholders’ recommendations for the development of EMS system to the president of the CPAO and relevant agencies, such as the Provincial public health office and hospital in Chonburi. This meeting aimed to provide stakeholders’ information for policy formulation regarding the transfer of EMS responsibilities in Chonburi Province
6. Monitoring and evaluation	Evaluation plan has been made for the monitoring and evaluation process if this policy is implemented in the future

Health impact assessment (HIA) procedure

Screening and scoping steps

A working group from the academic institutions and the staff from division of public health of the Chonburi Provincial Administrative Organization (CPAO) was formed for reviewing the importance of the transition of EMS to LAOs and arranged the public meeting for screening the importance of the development of provincial policy to prepare for the establishment of an Emergency Dispatch and Command Center by the CPAO and determined conclusions regarding the scope of health impact assessment issues, including indicators, methods, and data sources for evaluation. The data were coded and analyzed thematically to identify recurring patterns aligned with the four keys of pre-hospital care activities (dispatch, incident response, referral, and administrative management)²¹ and determinants of health impacts. In this study, health impacts were assessed across four dimensions of well-being (physical, mental, social, and spiritual health) to comprehensively capture the effects of EMS decentralization on both service providers and service recipients. Physical health sub-indicators included morbidity and mortality rates, injury severity, adequacy of medical equipment, and the skill and competency of EMS personnel. Mental health sub-indicators comprised work stress, fatigue, job satisfaction, and perceived workload among providers, as well as anxiety or sense of security among service users. Social health sub-indicators covered community participation, teamwork and inter-agency collaboration, communication effectiveness, and equity of service access. Spiritual health sub-indicators encompassed motivation, empowerment, professional pride, and a sense of belonging or moral commitment to public service. These sub-indicators were identified during the scoping stage through stakeholder consultations and literature review and were subsequently used to classify and interpret both positive and negative health impacts observed in each EMS activity domain.

Assessing step

In this procedure, the data were collected both qualitative and quantitative information. The same four well-being dimensions identified during scoping were applied in the assessment. Qualitative data were obtained from 35 EMS providers via in-depth interviews and focus groups. The Emergency Dispatch and Command Center’s EMS team, including the advanced life support and basic life support providers who registered in Chonburi’s NIEM records, were selected. For quantitative information, the data were collected from 363 EMS users (such as emergency patients, dispatchers, and family members) using EMS service satisfaction questionnaires. The questionnaires included service speed, provider competency, communication clarity, and equipment availability. The required sample size for EMS users was 367, as determined using the Krejcie and Morgan formula³¹. In the fiscal year 2023, there were 7825 emergency medical service cases. Stratified random sampling was employed, and upon verifying the completeness of the questionnaires. Data collection areas were designated across all four service networks, and participants were selected from both levels of emergency medical service units. Reliability of the questionnaire was confirmed (Cronbach’s alpha = 0.82).

Reporting step

In total, 41 stakeholders were involved in the project, participating in reviewing the completeness of the data, issues, and recommendations for preparing policy development for establishing the Emergency Medical Dispatch and Command Unit by the CPAO. An evaluation form was utilized to assess appropriateness and feasibility of proposals for developing the Chonburi Provincial Emergency Medical Service System. This process was aimed at organizing the public forum and co-considering the draft HIA report and co-developing recommendations for the development of the Chonburi Provincial Emergency Medical Service System.

Influencing step

This step aimed to inform and influence the formulation of EMS policies related to the decentralization process. The finalized HIA report and policy recommendations were presented to the President of the CPAO and the related agencies, including the Provincial Public Health Office and hospitals.

Monitoring and evaluation steps

A working group comprising academic staff and public health officers from the CPAO established the evaluation plan. This plan outlines processes for future supervision, monitoring, and evaluation should the policy be implemented. It includes both outcome indicators and implementation tracking tools. An overview of the HIA process is illustrated in Fig. 3.

Fig. 3.

The health impact assessment (HIA) process for transferring emergency medical services (EMS) to local administrative organizations (LAOs), comprising six sequential steps: screening, scoping, assessing, reporting, influencing, and monitoring and evaluation.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

HIA

Health impact assessment

LAOs

Local administrative organizations

CPAO

Chonburi provincial administrative organization

EMS

Emergency medical service

NIEM

National institute for emergency medicine

Author contributions

PH.J.: Conceptualization, Validation, Investigation, Methodology, Writing—original draft, Project administration A.B.: Methodology, Investigation, Data curation, Resources, Supervision R.J.: Formal analysis, Validation, Visualization, Writing—review & editing S.W.: Data curation, Resources, Writing—review & editing S.S.: Investigation, Public engagement, Writing—review & editing P.P.: Investigation, Public engagement, Writing—review & editing M.Y.: Methodology, Investigation, Validation, Writing—original draft & editing All authors have read and agreed to the published version of the manuscript.

Funding

This study was supported by the Health Systems Research Institute and the National Health Commission Office of Thailand. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Data availability

All data generated or analyzed during this study are available from the first or corresponding author upon reasonable request. The dataset has been de-identified to protect the privacy of study participants.

Declarations

Competing interests

The authors declare no competing interests.

Ethical approval

This study was approved by the Human Research Ethics Committee of the Chonburi Provincial Public Health Office (Approval No. 088-2566, October 27, 2023). Informed consent was signed and obtained from all participants prior to data collection. This study was conducted in accordance with the Declaration of Helsinki Guidelines.