Early exposure to a primary care course: a co-created transformative approach in health systems science

ABSTRACT

As health systems science has become the third pillar of medical education (along with basic and clinical sciences), Thailand has been developing medical curricula to focus more on its health systems. Despite primary care being the driving force of Thailand’s health systems, their integration into the curricula remains a challenge, resulting in medical students having limited exposure and understanding. To address this, a course was co-created by stakeholders to provide students with early exposure to and understanding of primary care mechanisms. Forty-one first- and second-year medical students designed their learning experience with faculty staff and hospital directors based on excursions at four community hospitals. The course included interactive lectures, a one-week excursion and knowledge-sharing sessions. The authors assessed the course’s effectiveness using mixed methods: pre- and post-tests on health system concepts and reflective writings after completion of the course. The authors analysed the test scores through descriptive statistics and the writings through thematic analysis. The co-creation process was evaluated with focus group discussions among all stakeholders and visualised using a casual loop diagram (CLD). The test results showed an increase in the knowledge and understanding of primary care in health systems after the course. The reflective writings on encountering contextualised health challenges revealed an understanding of the importance of primary care and community engagement strategies; the emerging themes were the students’ learning motivation as future physicians, interest in systems thinking and understanding of leadership in healthcare. The CLD revealed how co-creation, real-world exposure, reflective practice and faculty facilitation interacted to build student ownership, transformative learning and self-efficacy through reinforcing feedback loops. This study reveals how health systems, especially on a primary care level, can be effectively taught through engaging students in course co-creation. Fostering transformative learning is a starting point towards a socially accountable medical school.

PRACTICE POINTS

• Stakeholder co-design (students–faculty–community) increased student ownership and motivation.

• Immersion in community hospitals prompted transformative learning and higher perceived self-efficacy, reinforcing continued engagement.

• Early exposure to primary care increased students’ knowledge of building blocks of health systems, their functions and the concept of disease prevention.

• Faculty mentorship and local partners facilitated the co-creation of this course and expansion to additional hospitals in a later cohort, establishing true staff-to-staff partnerships in curriculum development.

Background

Medical education is undergoing a fundamental transformation as healthcare systems worldwide grapple with increasing complexity, evolving patient needs and demands for improved population health outcomes [1]. Traditional medical curricula, historically centred on basic and clinical sciences, are increasingly recognised as insufficient for preparing future physicians to navigate the intricacies of modern healthcare delivery [2]. This recognition has catalysed the emergence of health systems science (HSS) as the ‘third pillar’ of medical education, focusing on integrating competencies essential for effective healthcare delivery and the management of a population’s health. HSS encompasses a comprehensive framework that includes population health, health policy, high-value care, interprofessional teamwork, leadership, quality improvement, patient safety and systems thinking [3]. Despite strong evidence supporting the necessity of HSS competencies in the current and future healthcare workforce, the integration of HSS into medical education has been slow and fragmented, often due to perceived complexity, limited faculty expertise and uncertainty about implementation strategies [4]. The Covid-19 pandemic and growing awareness of health inequities have further amplified the urgent need to integrate HSS content across the medical education continuum [5].

Primary care serves as the cornerstone of effective health systems, functioning as the first point of contact for patients and coordinating comprehensive, continuous care across the healthcare spectrum [6]. Research demonstrates that robust primary care systems are associated with improved population health outcomes, reduced healthcare costs and enhanced health equity [7]. However, medical education has traditionally emphasised hospital-based speciality care, often relegating primary care to brief rotations in later clinical years. As a result, the integration of primary care education into medical curricula faces considerable global challenges [8]. Medical students frequently have limited exposure to primary care settings and insufficient understanding of community-based healthcare delivery mechanisms. This educational gap contributes to a declining interest in primary care careers among medical graduates [9].

Thailand’s healthcare system exemplifies both the potential and the challenges of primary care-centred health systems. Since implementing universal health coverage (UHC) in 2002, Thailand has achieved substantial progress in health outcomes, with primary healthcare serving as the foundation for this success. The Thai UHC system demonstrates how well-functioning primary care can provide cost-effective, equitable healthcare access across diverse populations [10]. Despite Thailand’s UHC achievements anchored in primary care, medical education still faces challenges in preparing graduates for community practice, creating a critical workforce gap. Thailand’s medical education system faces particular challenges in preparing graduates for primary care practice and health systems leadership [11]. Research indicates that Thai medical graduates often feel unprepared and uninterested in community hospital work, leading to high turnover rates among newly graduated doctors under compulsory rural service contracts [12]. This preparation gap is particularly concerning given Thailand’s ageing population and evolving disease profiles, which demand physicians that are capable of providing integrated, community-oriented care.

Despite the recognised importance of HSS through primary care education, considerable gaps exist in understanding how to effectively integrate these concepts into medical curricula, particularly in resource-constrained settings such as Thailand. Studies indicate that early and sustained exposure to primary care through longitudinal curricula can significantly improve students’ attitudes towards primary care practice and increase the likelihood of pursuing primary care careers [13]. Co-creation, as an educational approach, involves students as active partners in designing and implementing their learning experiences, fostering ownership, engagement and deeper learning [14]. Recent research demonstrates that co-creation approaches in medical education can enhance student satisfaction, improve learning outcomes and promote the development of critical thinking skills [15]. Nevertheless, limited research has explored the potential of co-creation approaches for HSS, and even fewer studies have examined the integration of primary care education with HSS concepts through student-centred pedagogical innovations in their early years of medical education.

In recognition of these gaps, this study was designed to investigate how co-created educational experiences can enhance medical students’ understanding of HSS through primary care exposure. By engaging students as partners in designing their learning experiences at community hospitals, this research explores innovative approaches to medical education that could transform how future physicians understand and engage with health systems. The importance of this research extends beyond Thailand’s borders, as it offers insights for medical educators globally who seek to prepare physicians capable of addressing complex health system challenges.

Method

Setting

The Faculty of Medicine Ramathibodi Hospital, Mahidol University, has recently introduced a dual degree programme—Doctor of Medicine and Master of Management (MD–MM)—in which the curriculum objectives focus on equipping students with knowledge of managerial functions and comprehensive perspectives of health systems. Medical students in this track undergo one year of intercalated study towards a master’s degree in healthcare and wellness management between their preclinical and clinical years at the College of Management, Mahidol University. All the students who designed and participated in the course described in this research were studying in this programme.

Course co-creation

This was a pioneering effort in which first- and second-year medical students in the MD–MM programme initiated, coordinated and synthesised the course while the faculty staff and community hospital directors supervised every process. This effort was divided into six main phases and the summary is depicted in Table 1:

Table 1.

Early exposure to primary care course co-creation steps.

Course co-creation	Short descriptions	Timeline
Student-Led Course Proposal	First- and second-year M.D.–M.M. students draughted the initial course concept to address early exposure to primary care and health system levels.	January 2023
Faculty Consultation & Needs Assessment	Proposal was discussed at a student–faculty seminar; faculty supported the idea and advised a student-wide needs assessment to build shared goals.	March 2023
Co-created Course Design	Students, faculty, and four community hospitals co-designed learning objectives, activities, and logistics over three months, including lectures, excursions, and peer learning.	March - May 2023
Early Exposure to Primary Care Course	Mixed-year student groups joined week-long hospital visits, followed by joint reflection sessions with faculty and hospital directors to consolidate transformative learning.	June - July 2023
Knowledge Dissemination	Students presented the model at faculty board meetings and national conferences to promote student–staff partnership and advocate for curricular development.	August 2023

• 1.Student-led course proposal

In the first year of the MD–MM programme, the students were required to learn the basic concepts of healthcare management and leadership. One of the main discussion points among the students was the need for early exposure to different levels of health systems, particularly at the primary care level with which many students were unfamiliar. Thus, the first draft of the course was created by the students.

• 2.Faculty consultation and needs assessment

This initial proposal was brought for discussion with faculty staff at the annual student–faculty seminar. The faculty staff members agreed to initiate this course with all stakeholders and advised the students to conduct further needs assessment with other students. Thus, a needs assessment was conducted with all MD–MM students in two cohorts (first- and second-year medical students) through open-ended questionnaires focused on their perceptions of the course and further requests, suggestions or concerns they had. Subsequent online meetings were arranged to achieve a consensus, thus consolidating a shared vision and goals of this course from all students. As the course was initiated by this group of students, it was not considered a compulsory course, and the students could decide whether to join based on their interest.

• 3.Co-created course design

Multiple discussions among the students, faculty staff and hospital directors were held to design a learning experience that was contextualised to the areas of each community hospital. After discussing aspects of the community hospitals that exhibited unique perspectives on the importance of primary care, the faculty staff recommended four community hospitals: Ubonratana Hospital (Khon Kaen Province), Namphong Hospital (Khon Kaen Province), Dan Sai Crown Prince Hospital (Loei Province) and Umphang Hospital (Tak Province). All four community hospitals expressed interest in co-designing the course. Thus, meetings among the students, faculty staff and hospital directors were arranged regularly to finalise the learning agenda, course expectations and logistics details.

Regarding the excursion details, the students were able to choose to visit one of the four affiliated community hospitals for one week. The time slots were flexible, depending on the specific co-designed course agenda and time availability of the students and community hospital staff. To ensure that the students could learn from the diverse perspectives of both peer groups (juniors and seniors), each excursion group consisted of 5–6 students with a mix of both first- and second-year students.

• 4.Early exposure to the primary care course

After the conclusion of the course, the students and faculty staff gathered at the faculty, with all the community hospital directors joining online, to reflect on the experience and learning points. All students collaborated to create presentations that reflected their learning points from all four hospitals. These sessions were not only an opportunity to learn from one another to promote transformative learning but were also a mechanism to further strengthen the commitment of all the stakeholders to ultimately integrate this course into the medical curriculum.

• 5.Knowledge dissemination

As this course was a pioneering effort in course design for promoting student engagement in medical education, the faculty staff invited the students to share the course design at various faculty board meetings and the Thai Medical Education Conference (TMEC2024), with the aim of promoting a culture of students as partners in curriculum design.

Course outline

The overall course development and implementation spanned approximately six months. Initial student-led proposal development and needs assessment occurred between January and February 2023. Co-creation meetings with faculty and community hospital partners took place from March to April 2023. Interactive preparatory lectures were delivered in May 2023, followed by staggered one-week community hospital excursions between June and July 2023.

The main aim of this course was to equip students with sufficient background knowledge and learning tools for them to understand more about their experiences and exposure to community hospitals. From various discussions among all the stakeholders, this course included interactive lectures from HSS instructors, a one-week excursion to one of the community hospitals, regular lesson sharing sessions involving the students and a final presentation with the faculty and community hospital staff.

• 1.Interactive Lectures Before the Excursion

During May 2023, the HSS instructors conducted a three-hour interactive lecture introducing the concept of HSS that covered key areas, such as the structure and functions of health systems, the concept of universal health coverage and disease prevention principles. The lecture also briefly explained the unique structure of primary care in each affiliated community hospital so that the students could choose one based on their interests.

• 2.One-Week Excursion at a Community Hospital

Hospital Directors and Medical Staff Shadowing. During the excursion, students in each group took turns shadowing different hospital staff members, including hospital directors, general practitioners, nurses, pharmacists, physical therapists and social workers, to gain insights into the details of their work and how each role contributes within the hospital system. This was especially important for the MD–MM students, as this would help them develop a comprehensive understanding about care coordination later in their study.

Hospital Ward Exploration. The learning experience included observing the workflow of different wards to understand the entire journey of the patients from their admissions to their discharges. Students were also notified of cases that required referrals to provincial hospitals to gain a better understanding of the collaboration between various hospitals in the system.

Community Health Visit. Students were invited to participate in community activities involving local citizens, such as health promotion programmes and elderly care workshops. As Thailand’s primary care also includes proactive policies in health promotion and the prevention of diseases, hospital staff and community leaders regularly arrange activities to educate and care for nearby citizens. The students also travelled with family medicine doctors to experience home visits in different villages. This allowed the students to communicate with villagers to learn more about their perspectives on the hospitals’ service delivery.

Regular Group Sharing Sessions. During the excursion, the hospital directors and students arranged regular meetings to reflect on their daily experiences and discuss additional learning opportunities at certain locations based on the students’ interests. These short sessions helped ensure that the learning experience matched the students’ expectations while they were being overseen by the hospital staff.

• 3.Mini Projects After the Excursion

After every student had completed their excursion, subsequent meetings were arranged to reinforce what they had learned and their plans for applying this experience to their future education. Students from every group agreed to create mini-projects in terms of short videos and infographics about their experiences at each community hospital to promote unique activities each hospital had arranged to elevate the well-being of the patients and the general population.

Course assessment

To evaluate the learning outcomes and the co-creation process of the course, we employed a mixed-methods approach comprising outcome and process evaluation.

Learning outcomes

A mixed-methods design was used to evaluate the impact of the course. Each MD–MM student who was enroled in the course (n = 41) completed a pre- and post-course test consisting of 10 multiple-choice questions on the introduction to health systems. These tests assessed each student’s understanding of fundamental aspects, including the building blocks of health systems, their functions and the concept of disease prevention. We used the Shapiro-Wilk test and Wilcoxon signed-rank test in R Studio for macOS to examine the differences between the pre- and post-test scores. Each student also wrote a self-reflective essay following the structure of ‘What?’, ‘So what?’ and ‘Now what?’: ‘What?’ refers to the student’s observations and acquired knowledge; ‘So what?’ refers to their interpretations and feelings towards those observations; and ‘Now what?’ refers to their future actions or ambition to learn after completing the course. We used thematic content analysis to examine these self-reflective writings by synthesising the main themes that the students as a whole gained from the sources. All included essays were coded and grouped using ATLAS.ti software version 22. We then conducted inductive coding and applied a triangulation process as a group to resolve any discrepancies between the two independent investigators, Piwat (PS) and Phanuwich (PK).

Systems thinking analysis of the co-creation process

The co-creation process was systematically evaluated through a series of focus group discussions involving all the key stakeholders, including students, faculty members and the community hospital directors. These discussions were conducted at multiple points throughout the course during the planning, implementation and reflection phases to capture diverse perspectives on the collaboration dynamics, decision-making and perceived value of the co-creation approach. Qualitative data from these sessions were analysed thematically to identify facilitators, barriers and feedback loops that shaped the course development. Insights from this analysis were then conceptualised by the authors (PS and PK) using a causal loop diagram (CLD) to illustrate the interactions among co-creation, engagement, empowerment and transformative learning. A CLD is a systems thinking tool that maps variables and the direction and polarity of causal links to make reinforcing and balancing feedback loops explicit. It is used to synthesise qualitative insights into a coherent structure, build a shared understanding of system behaviour and reveal leverage points for change. This CLD was validated by both the involved stakeholders (n = 5) and an expert in systems thinking (n = 1) to ensure its theoretical accuracy and validity. The CLD was constructed and visualised using Stella Architect Software version 1.9.1.

Ethics

This study involved the evaluation of an educational course and the co-creation process among medical students and faculty members. No patient data were collected, and all activities took place within the educational setting. Ethical approval for the study was obtained from the Human Research Ethics Committee, Faculty of Medicine Ramathibodi Hospital, Mahidol University (Approval No. MURA2024/345). Participation was voluntary, and all student participants provided informed consent prior to data collection. All procedures were conducted in accordance with the Declaration of Helsinki and the relevant institutional ethical guidelines.

Results

Participant demographics

The demographics of the MD–MM students who participated in this course are shown in Table 2. As English proficiency is a compulsory admission requirement of this programme, all students were able to communicate in English fluently (International English Language Testing System [IELTS] score ≥ 7.0). Thus, all the assessments, including the multiple choice questions and reflective writings, were conducted in English.

Table 2.

Participant demographics.

Variable	Category	Frequency	Percentage
Nationality	Thai	41	100%
Age	18–20 years	41	100%
Gender	Male	14	34.1%
	Female	27	65.9%
	Not specified	0	0%
High School Curriculum	Thai Curriculum (Regular)	31	75.6%
	Thai Curriculum (Bilingual/Trilingual)	4	9.8%
	International Curriculum	6	14.6%

Learning outcomes

Pre- and post-course assessments

After finishing the course, 98% of the students (n = 40) completed the pre- and post-tests. According to the Shapiro-Wilk test, the students’ pre- and post-test scores were not normally distributed (p ≤ .05). Therefore, the non-parametric Wilcoxon signed-rank test was used to compare the group’s before and after measurements. This statistical analysis revealed a statistically significant improvement in the students’ scores as expected (pre-test median = 6; post-test median = 8; Z = 3.1, p = .002). The effect size was calculated and indicated a moderate-to-large effect (r = .54). Table 3 depicts the distribution of the responses for all the students on both the pre- and post-tests by each specific question.

Table 3.

Aggregrated distribution of Students’ Score for Both Pre-test and Post-test.

Question	Assessed topic/Concept	Pre-test	Post-test	Percentage of increase (%)
		Students’ correct answer	Students’ correct answer
1	WHO building blocks (focusing on health financing/health insurance)	19 (46.3%)	31 (75.6%)	+29.3
2	Levels of prevention	28 (68.3%)	32 (78.0%)	+9.7
3	Comprehensive Definition on Health (focusing on social health)	33 (80.5%)	38 (92.7%)	+12.2
4	Levels of prevention	8 (19.5%)	18 (43.9%)	+24.4
5	Health system performance (focusing on equity)	39 (95.1%)	41 (100%)	+4.9
6	Comprehensive Definition on Health (focusing on mental health)	31 (75.6%)	32 (78.0%)	+2.4
7	Levels of Prevention (focusing on primary prevention)	23 (56.1%)	24 (58.5%)	+2.4
8	WHO building blocks (focusing on Health information systems)	22 (53.7%)	25 (61.0%)	+7.3
9	Social determinants of health	24 (58.5%)	27 (65.9%)	+7.4
10	Health system performance (focusing on efficiency)	36 (87.8%)	38 (92.7%)	+4.9

Self-reflective writing

The results reflected the students’ transformative learning through their encounters with health challenges in the community and the interconnectedness of each building block of the health system that forms Thailand’s primary care structure. The themes, codes (including frequency) and example quotations are presented in Table 4.

Table 4.

Theme codes and example quotations of self-reflective writings.

Main theme	Codes	Frequency (Out of 40 students)	Example quotations
Primary Care Importance	Community-based Care	38/40	“Observing the Primary Care Unit (PCU) allowed me to shadow a family medicine doctor and see the Three Doctors Policy in action while offering door-to-door care. A doctor from Nam Phong Hospital worked hand-in-hand with a Village Health Volunteer and PCU staff, forming a solid and practical system when visiting and providing treatment to elderly or bedridden patients.”
	Community Improvement	35/40	“By conducting research, engaging in projects, and developing guidelines, we can contribute to improving the health system at the community level.”
	Health Literacy for Citizens	34/40	“To address this, the hospital organised community activities to foster social connections, encourage health checkups, and teach financial management, creating an environment where children would want to return and live with their parents.”
	Healthcare Management	32/40	“I think that the primary care unit movement achieved the goal although it lacked good management. I’ll use my management skill and medical knowledge to push this issue even more, maybe through research or through the future position I’ll be in the medical circle.”
	Empathy	31/40	“Fulfilled and energised as I was given the opportunity to visit a fellow T1D school girl, the only child in Ubolratana, to have the disease. I saw a great disparity of opportunities between her and myself (and other fellow T1 diabetics in urban areas). As a medical student in the MM programme, I visualise myself doing something to better this at a national/international healthcare system level in the future.”
	Awareness	29/40	“In the short-term, my team and I would publish a video on youtube to broadcast the needs and encourage the audience to donate for the hospital. I will take this experience as a markpoint of how struggle it is for people in rural areas to receive proper health care. … I aspire to be part of the effort to improve the system in the future”
	Health Policy and Systems Research Endeavours	27/40	“we can leverage the knowledge and identify gaps for improvement to initiate projects., engaging in research endeavours… for driving transformation in Thailand's primary care system.”
Learning Motivation	Hospital Directors as Role Models	35/40	“The director (doctor) in the hospital… improve their patients' lives by teaching them about sufficient economic models and offering life advice. I realised that there is no limit to helping others and that it is the duty of doctors to assist those who cannot help themselves, regardless of their circumstances.”
	Desire for Knowledge	33/40	“I feel that I have gained a lot of knowledgA e, but at the same time, I realise that there is still a lot I don't know.. if I had a better understanding of medical or management concepts, I would be able to enjoy this observation experience even more.”
	Social Responsibility	31/40	“solidified my understanding of what it means to be a doctor and has motivated me to pursue a career in medicine. “Witnessing the hospital's dedication. to help others inspired me to follow the same path … unity is a source of strength in a positive impact on people's lives.”
	Commitment	28/40	“I’m willing to be responsible for treating patients and developing the health system in the future. I will engage more people, understand the feelings of another more, and I will keep learning further. This early exposure is just the beginning of my path, i will keep my eyes wide and be ready to change my perspective and keep being a better version of me.”
Systems Thinking	Health System Building Blocks	27/40	"I have learned an important concept of health system building blocks including service delivery, health workforce, information, leadership, etc. This excursion provided me an opportunity to experience each building block closely and understand how it works together."
	Stakeholders Collaboration	23/40	"The learning experience here has made me realise that providing patient care requires collaboration… help the patients from the root cause requires a comprehensive understanding of management, finance, and constant learning about the existing problems."
	Problem-Solving Approach	22/40	"However, I also witnessed effective problem-solving approaches, the capabilities of volunteers, data management in the hospital, behind-the-scenes operations that are often overlooked, and the use of various tools."
	Quality Improvement	20/40	“Eyes and mindset opting for the betterment are the first requirements: a good feedback loop would lead to the better well-being of medical staff and patients.”
Healthcare Leadership	Leadership Perspectives	18/40	“Leadership is not a label and can be found anywhere. From my observation in this excursion, I summarised attributes of an effective leader into 6Rs: 1. Relation to passion (stemmed from personal experiences or steppingstones), 2. Realise (the problem(s)) 3. Resolve to initiate 4. Regularly act/do the effective and find ways to improve; keep updated, 5. Respecting towards and Respected by the general public/subordinates (both by charisma and performance; being trustworthy and selfless leading to being a sustainable leader), 6. Reach and communicate well.”
	Change Agency	15/40	“I aspire to be a leader rather than a mere manager, … positive change in their physical, mental, and social well-being. … collaborating with the hospital on future projects to make a difference in the community. My ultimate objective is to leverage my medical knowledge to improve the lives … health and well-being of the community.”

Across the reflective essays, three dominant themes emerged with varying frequency. The most frequently articulated theme was enhanced understanding of primary care importance and learning motivation, reflected in nearly all student submissions. This was followed by systems thinking, which appeared consistently across reflections describing its applications in enhancing the current health systems. Healthcare leadership emerged less frequently but with greater depth, often linked to observations of hospital directors and interdisciplinary teamwork.

Primary care experience

This course adopted an experiential learning approach to educate students on the importance of primary care through hands-on activities involving interdisciplinary teams that provide proactive care. Although based at community hospitals, students’ exposure extended beyond inpatient services to encompass frontline primary care functions, including outpatient clinics, home visits with family medicine teams, community health promotion activities, and coordination with local public health and social services. These experiences allowed students to observe how primary care in Thailand operates as a hub for prevention, continuity of care, and community-based problem solving rather than as hospital-centred clinical care alone. The students realised how community-based care provided an effective function in primary care, especially for the aged in Thai society. They also learned that effective health policies should consider the community context and involve other stakeholders from the planning through to the implementation process. In addition, the course illustrated some of the disparities in the health literacy of local citizens as an underlying cause of patients’ illnesses, which are often the result of their daily lifestyles and decisions. Thus, the students acknowledged that educating local citizens about self-care and financial management would be an important part of a sustainable solution.

Moreover, the student reflection exercise also motivated them to foresee their potential future career paths in addition to considering some common hospital-based specialties. For instance, some students were interested in health policy and systems research, as being a researcher would require both medical knowledge and an understanding of health systems to enhance primary care and the overall health system.

On a personal level, this course was the first time that many students had a chance to visit community hospitals and their corresponding local communities. Despite the cultural differences between the students and the local citizens they encountered, they were able to empathise with the patients and wanted to raise awareness of the struggles affecting those patients. One example was how a medical student with T1 diabetes had the opportunity to connect with a child with the same disease and was able to propose actions to improve how T1 patients were cared for in the community. Moreover, the students were also more aware of contextualised healthcare challenges that not only require human resources and equipment but also additional funding and planned to help a hospital raise funds through social media.

Emerging themes

In addition to the acquired knowledge and experience of primary care, emerging themes included learning motivation, systems thinking and healthcare leadership. Many students’ academic motivation increased after completing the course. They perceived that learning primary care helped them appreciate Thailand’s health system and see potential areas for improvement. They also saw hospital directors as role models who not only effectively managed the hospitals but also elevated the quality of life of citizens. At the same time, as first- and second-year medical students, they were inspired to learn more to contribute to strengthening the healthcare provided. In addition, their reflections indicated an increased sense of social responsibility as future physicians committed to treating patients and uniting to elevate health systems as a whole.

As healthcare challenges are complex and adaptive, the students’ reflections show their attempts to view problems through systems thinking. They reported that this course helped them perceive the importance of each building block of a health system. They saw that the collaboration of all the stakeholders was needed to formulate effective problem-solving approaches that could lead to solving healthcare problems. In addition, the students mentioned how quality improvement projects are important to complete to obtain feedback on certain policies. Finally, the students provided their unique perspectives on leadership. One student explained that leadership is a role for everyone and requires intrinsic motivation. Leaders should have the courage to identify problems and initiate strategies with all related stakeholders. Others elaborated that mutual respect is also a fundamental quality needed to successfully work at both local and national levels to promote systemic change.

Systems thinking analysis of the co-creation processes

Information from the meeting minutes and summary during the planning, implementation and reflection phases can be conceptualised through the CLD in Figure 1.

Figure 1.

Student–Staff Partnership in Course co-creation.

First, the ‘Co-creation & Engagement Loop’ (R1) demonstrates that when students, faculty and community partners jointly design the curriculum, the students’ sense of ownership and empowerment increases. Empowered students report higher motivation to learn, which in turn drives deeper engagement in course activities. This heightened engagement feeds back into richer contributions during the subsequent co-creation phases, sustaining a virtuous cycle of collaborative design. Second, the ‘Exposure–Transformation–Efficacy Loop’ (R2) shows how exposure to situations involving real-world gaps within local health systems triggers transformative learning. Confronting dilemmas in authentic settings can provoke critical reflection, fostering shifts in perspective that enhance perceived self-efficacy. As the confidence of students grows, they are more likely to seek further exposure and contribute new insights to course design, reinforcing both empowerment and engagement.

In addition, driven by self-reflection tasks, it is possible to substitute traditional testing with structured reflective writing. This reflective practice deepens students’ awareness of their own learning gaps and consolidates transformative insights, which further bolster self-efficacy and prompt renewed engagement and co-creative input. Across all the loops illustrated in the CLD, facilitation by faculty and local healthcare teams acts as a critical enabler. Through mentorship and role modelling, facilitators legitimise student contributions and exemplify ‘can-do’ attitudes, effectively scaffolding legitimate peripheral participation.

Discussion

This study demonstrates that early exposure to primary care, when intentionally designed around health systems science concepts, can meaningfully enhance medical students’ understanding of how health systems function in real-world settings. While co-creation served as an important enabling strategy, the primary educational value of the curriculum lay in students’ sustained engagement with primary care practice, community contexts, and system-level problem solving. Improvements in knowledge scores and reflective depth suggest that experiential exposure to primary care functions was central to students’ developing understanding of HSS.

Traditional teaching to transformative co-creation

The paradigm shift in primary care education

Traditional medical education approaches to primary care typically follow a didactic model in which faculty deliver content about primary care systems and subsequently arrange clinical exposures for students [16]. This conventional approach, while providing foundational knowledge, often fails to engage students as active partners in their learning journeys and may inadequately prepare them for modern health system complexities. Our study demonstrates how co-creation serves as a transformative bridge between traditional pedagogical approaches and socially accountable medical education.

The co-creation approach implemented in this study represents a fundamental shift from passive knowledge consumption to active learning partnerships. By engaging students as co-designers of their educational experience, we observed enhanced student engagement that extended beyond mere participation to genuine ownership of the learning process. This finding aligns with recent research demonstrating that co-creation in medical education promotes belonging, identity maturation and workplace integration [15].

Transformative learning through disorienting dilemmas

The community hospital experiences in our study created numerous disorienting dilemmas that catalysed transformative learning among the participants. Exposure to Thailand primary care settings enabled students to situate abstract HSS concepts within observable practice. Students described seeing how financing constraints, workforce shortages, referral systems, and community engagement intersected in day-to-day care delivery. This contextualised exposure appeared to strengthen students’ conceptual grasp of health system building blocks and their interdependence, transforming HSS from an academic framework into a lived experience grounded in primary care realities. The reflective writings revealed how students grappled those complex health system challenges, community needs and their evolving understanding of the roles of physicians. Their experiences aligned with Mezirow’s transformative learning framework [17].

Research demonstrates that transformative learning in medical education occurs through stages of disorientation, critical reflection, discourse and action [18]. Our findings suggest that co-created primary care exposure provided multiple opportunities for students to engage in these transformative processes. The significant improvement in knowledge scores, combined with qualitative evidence of perspective shifts regarding primary care importance and community engagement, indicate that the students experienced meaningful transformation in their understanding of health systems and their future professional roles.

The clinical teachers in our study adopted roles as ‘fortifiers, connoisseurs, mediators and monitors’, facilitating transformative learning rather than delivering traditional instruction. This shift towards facilitation represents a broader trend in medical education towards learner-centred pedagogies that emphasise active learning, critical thinking and professional identity formation [19].

Steps towards social accountability

The progression from co-creation through transformative learning represents concrete steps towards social accountability in medical education. Social accountability requires medical schools to direct their education, research and service activities towards addressing priority health concerns of the communities that they serve [20]. Our study demonstrates how co-created educational experiences serve as a foundation for developing socially accountable physicians who understand community needs and health system complexities.

The co-creation approach embodies social accountability principles by engaging multiple frontline stakeholders who face health systems challenges in educational design and implementation, fostering student understanding of community health priorities and developing future physicians who can contribute meaningfully to the strengthening of the health system. This transformation from traditional to co-created learning represents a critical step in preparing physicians capable of addressing Thailand’s evolving healthcare challenges while contributing to broader health system improvements.

Limitations

This study has some limitations. First, as a pioneering course delivered to the inaugural MD–MM cohort, the findings may reflect start-up effects (e.g., high novelty and enthusiasm) that limit generalisability [21], and the intensity of student ownership observed may not be fully replicable in subsequent cohorts without continued institutional support and structured mechanisms for student–staff partnership. Second, self-selection bias is likely: MD–MM students typically choose this track due to pre-existing interests in health systems and social accountability, which may inflate engagement, reflective depth and knowledge gains relative to their peers in other tracks. Third, the sample size was relatively small (41 individuals from two cohorts) and underpowered for subgroup analyses, constraining precision and external validity.

Future directions

At the moment, the course is being scaled into a voluntary project open to all first-year medical students from all programmes and has expanded across additional affiliated hospitals. To gain insights into how education on HSS beginning with students’ early years of education benefits them later, the course outcomes should be further compared with those of other traditional methods of educating students on primary care and health systems, such as didactic lectures and designated projects. Furthermore, the faculty should also compare the knowledge of students in the course with that of other students before their intracurricular community medicine excursion in Year 3. At present, longitudinal data on graduates’ subsequent engagement with primary care or health systems roles are not yet available. Future research should incorporate graduate tracking and career pathway analysis to assess whether early exposure to primary care and HSS influences long-term professional choices and system-level engagement. Finally, the faculty should consider establishing a student–staff partnership committee. This committee must comprise medical students and faculty staff members to monitor programmatic assessments and feedback on the medical curriculum. With collaboration between both parties, new co-created courses could foster competencies and skills that are still absent in the curriculum.

Author contributions

P.S (Piwat). and P.K. (Phanuwich) conceptualised and organised the study, P.S (Piwat) and P.K. (Phanuwich) prepared figures and were responsible for data analysis, P.S. (Piwat) wrote the main manuscript text, and facilitated data acquisition. P.K. (Phanuwich) and P.S. (Peerasit) revised the manuscript. P.K. (Pongsak) and S.L. supervised the whole process. All authors engaged in the interpretation of data and reviewed the manuscript.

Disclosure statement

The authors (P.S (Piwat)., P.K., P.K. (Phanuwich)) participated in this study. The authors declare that they have no competing interests.

Funding

There was no funding for this study.

Data availability statement

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Ethical approval

This research is granted ethical approval by the the Faculty of Medicine Ramathibodi Hospital, Mahidol University COA No. MURA2024/345.

Consent for publication

Not applicable.