Surgery for congenital heart disease in Thailand-lessons to be learnt.

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Learn more: PMC Disclaimer | PMC Copyright Notice Indian J Thorac Cardiovasc Surg . 2024 Oct 12;41(6):792–800. doi: 10.1007/s12055-024-01827-1 Surgery for congenital heart disease in Thailand—lessons to be learnt Piya Samankatiwat 1, ✉ Author information Article notes Copyright and License information 1 Division of Thoracic Surgery, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama 6 Road, Thung Phyathai, Rajthevi, Bangkok, 10400 Thailand ✉ Corresponding author. Received 2024 Feb 16; Revised 2024 Aug 25; Accepted 2024 Aug 26; Issue date 2025 Jun. © Indian Association of Cardiovascular-Thoracic Surgeons 2024. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law. PMC Copyright notice PMCID: PMC12102039  PMID: 40417603 Abstract Congenital heart disease (CHD) is a significant global health issue affecting millions of children. This manuscript provides a detailed examination of the status of CHD surgery in Thailand, encompassing geographical facts, demographic considerations, the burden of CHD, availability of services, organization of delivery, funding mechanisms, training of surgeons, support services, outcome data, and a glimpse into the future of CHD surgery in the country. Above all, the lessons to be learned are critical to helping CHD surgery programs to be lifelong and sustainable. Keywords: Congenital heart disease, CHD surgery, Thailand Introduction Background Congenital heart disease (CHD) is a prevalent health concern worldwide, necessitating specialized surgical interventions for affected individuals. This manuscript focuses on the landscape of CHD surgery in Thailand, providing a holistic view of the current state and future possibilities. Geographical facts and demography Geography Thailand, officially the Kingdom of Thailand, is a Southeast Asian country located in the middle of the region. This “unitary state” comprises 76 provinces in the division of four geographic regions, i.e., Northern, Northeastern, Central, and Southern. Bangkok is its capital city (Fig. 1 ). Fig. 1. Open in a new tab Thirteen health zones—Bangkok and outskirt is the 13th health zone. Four geographic regions are also demonstrated. For the names of provinces in English, please refer to Fig. 5 . Source: Blueprint of Health Service and Human Resource from 2020 to 2024, Ministry of Public Health Population Thailand features a diverse population characterized by a unique demographic profile, including birth rates, infant mortality, gross domestic product (GDP), and per capita income. Population in 2023 was 70.02 million people, with its birth rate in 2023 of 9.532 births per 1000 people, a 1.91% decline from 2022. The National Statistics Office reports that the number of births in the year 2021 was found to be 544,570, a decrease of 42798 from 2020. Meanwhile, the number of deaths in 2021 was 563650, which differs from the number of births by 19,080, marking the first year with a birth rate lower than the death rate in Thailand [ 1 ]. Additionally, infant mortality rate was 4.52 and 4.21 deaths/1000 live births in 2019 and 2020, respectively [ 2 ]. In 2022, Thailand’s GDP was 495.42 billion United States dollars (USD), with a per capita income of 7540 USD. Furthermore, the prediction was an increase of 2.7% of GDP in 2023. The decline in the growth of the GDP of the country was a result of the coronavirus disease (COVID-19) pandemic [ 3 ]. Burden of CHD in Thailand Prevalence An in-depth analysis of the prevalence and trends of CHD in Thailand was attempted, exploring whether there was an upward or downward trajectory in the incidence of congenital heart conditions. In a year, Thailand has around 5000–6000 newborns with CHDs, accounting for 0.8–1% of live births. Over the past decade, a trend of stable prevalence has likely been attributed to improved diagnostic capabilities and increased awareness. Of these newborns with heart defects, around 50%, or over 3000 infants, require surgery or transcatheter intervention. Twenty percent needed surgery within 1 month; otherwise, there was a risk of mortality or inability to undergo surgery. Availability of services for CHD surgery Proportion of access We examined the proportion of children born with CHD who have access to surgical interventions, considering factors such as geographical disparities and socioeconomic status. By the constitutional law of the Kingdom of Thailand, everyone born of Thai nationality has full access to healthcare services that the Thai government provides. Therefore, the Ministry of Public Health (MOPH) is responsible for providing people with proper and rational medical services. The ministry divides healthcare services into 13 health zones according to regions of Thailand (Fig. 1 ). Each zone groups 4–5 neighboring provinces, as shown on the map. Every province has its own provincial general hospital, but there is at least one regional hospital, usually allocated in the largest city of each region. Moreover, a major city has a university hospital, for example, Chiang Mai, Khon Kaen, and Hat Yai, implying that there are two large hospitals providing advanced medical services and facilities, including CHD surgical care. Despite the rising prevalence of CHD, access to surgical interventions remains limited for many children in Thailand. Only 20–30% of children born with CHD receive timely surgical care due to various barriers, including geographical disparities, financial constraints, and limited healthcare infrastructure in rural areas. There are long waiting lists in public hospitals and prohibitive costs in private care create access disparities. Organization of delivery of CHD surgery Historical aspects We present a historical overview of CHD surgery in Thailand, highlighting key milestones and evolutions in delivering surgical services. The first closed heart surgery in Thailand, which is ligation of persistent ductus arteriosus, was performed by Professor Smarn Muntarbhorn at King Chulalongkorn Memorial Hospital in 1953 [ 4 ]. He also accomplished the first closure of atrial septal defect (ASD) using a heart-lung machine in 1959. Regarding operative repair of more complex lesions, the first successful complete repair of tetralogy of Fallot was done by Professor Kumpol Prachuabmoh a few years later at Siriraj Hospital. Three landmark procedures, namely arterial switch operation, Fontan-Kreutzer operation, and Norwood operation, were also successfully developed in the country between the 1970s and 1990s by Professor Somchai Sriyoschati (arterial switch and Fontan-Kreutzer operation) and Professor Vichai Benjacholamas (Norwood operation). Current system of care We explore the contemporary landscape of CHD surgery in Thailand, encompassing the organization, structure, and distribution of services. The Thai healthcare system does not rely on the family physician or general practitioner system. Therefore, patients with CHD can liberally enter or be referred for treatment to the provincial, regional, or university hospitals, if they need an appropriate capacity and facility. The initial hospital basically contacts the referral institute for the patients. Nevertheless, primarily responsible hospitals (described in the next section) are mainly in the government sector, both university and public hospitals (Fig. 2 ). If they have adequate capacity and facility for CHD management, particularly surgical treatment, the patients receive proper services at the hospital; if not, the patients are transferred to more capable institutions. For example, if a baby is born with a critical CHD in a provincial hospital where CHD surgery is unavailable, in that case, the patient will be transferred from the hospital to a capable regional or university hospital in the region. Currently, CHD surgeries are predominantly performed in specialized pediatric cardiac centers, primarily located in urban areas. The delivery of care involves a multidisciplinary approach, encompassing cardiology, anesthesia, intensive care, and surgical teams. Fig. 2. Open in a new tab Number of hospitals performing more than 5 CHD operations per year from 2011 to 2023. CHD, congenital heart disease In view of accumulation of grown-up congenital heart patients, Thailand offers specialized services for adults with congenital heart disease (ACHD), ensuring comprehensive and continuous care. Facilities like Faculty of Medicine, Ramathibodi Hospital, provide state-of-the-art treatments and diagnostics, supported by multidisciplinary teams of adult and pediatric cardiologists, cardiac surgeons, and specialized nurses. These centers emphasize early detection and management of CHDs to improve long-term outcomes for adults. Thailand’s healthcare system is committed to integrating advanced diagnostic tools, such as echocardiography, cardiac magnetic resonance imaging (MRI), and cardiac catheterization, to tailor treatment plans to each patient’s unique needs. Overall, Thailand’s ACHD services are designed to provide lifelong care, focusing on improving the quality of life and health outcomes for adults living with CHD. Location of CHD surgery Government vs. private hospitals Majority of CHD surgeries are performed in government hospitals, while some private institutions provide surgical repair with foundation support. The government sector has multiple parts, depending on the governing structure of each Ministry, apart from MOPH, for example, university hospitals under the Ministry of Higher Education and Innovation, while Royal Army, Royal Naval, or Royal Airforce hospitals under the Ministry of Defence, and Police Hospital under the Royal Thai Police. Most congenital cardiac operations are performed in the MOPH hospitals. The number of public hospitals providing CHD surgery has increased over time. Recently, the Thai National Database of Cardiothoracic Surgery has revealed an increase in the number of hospitals capable of performing operations for CHD from 15 to 41 over 20 years. The number of hospitals in the private sector has also increased over time (Figs. 2 and 3 ). Fig. 3. Open in a new tab The number of CHD surgery in total and performed by public hospitals by year from 2011 to 2023. CHD, congenital heart disease National health priority Governmental focus CHD surgery holds a prominent place on the national health agenda in Thailand. According to the United Nation’s Sustainable Development Goals (UN SDG), especially goal 3, maternal and neonatal health is one of the major concerns (Fig. 4 ). This goal has been conveyed directly to the MOPH. CHD is one of the most critical causes of neonatal and infantile mortality. If the neonatal mortality rate is decreased by proper CHD management, this goal will be significantly achieved. Therefore, MOPH’s cardiac service plan on CHD aims to promote pediatric cardiac surgery, including CHD and non-CHD, in MOPH hospitals. Initially, the MOPH program encouraged its hospitals to develop life-saving congenital cardiac procedures, i.e., ligation of the persistent ductus arteriosus (PDA) and modified Blalock-Taussig-Thomas (mBTT) shunt. This plan also attempts to upgrade the services of general and regional hospitals to perform more complex congenital cardiac surgery, for example, arterial switch operation and Fontan-Kreutzer procedure. The success of this plan requires expertise and supervision from experts at university hospitals through bilateral collaboration. Fig. 4. Open in a new tab United Nation’s sustainable development goals (UN SDG). The highlighted one is goal no. 3, which focuses on health and well-being. Source: https://sdgs.un.org/goals Funding mechanisms Financial support We investigated the financial aspects of CHD surgeries, including the roles of the government, insurance, and self-payment by patients. Government financial support for healthcare is mandatory by constitutional law. Thai citizens have at least one reimbursement subsidy from the government. Health expenditure on GDP increased noticeably due to the spread of COVID-19 in fiscal years 2020–2021. This accounted for 4.3% and 5.2% of the total domestic product in those respective years. In fiscal year 2021, health expenditure constituted 21.1% of the total government expenditure (general government expenditure, GGE). For 2021, current health expenditure (CHE) amounted to 22.575 billion USD, representing 5.2% of the GDP and 21.1% of the GGE. Moreover, the domestic general government health expenditure (GGHE-D) as a percentage of CHE increased from 42.4% in the fiscal year 1994 to 70.4% in the fiscal year 2021. Health expenditure per capita has also consistently risen to 315 USD in 2021 [ 5 , 6 ]. In addition, the Thai government offers financial support through reimbursement and payment schemes, which will be explained in the next section. For instance, if a baby is diagnosed with a ventricular septal defect (VSD) and requires surgical closure of the defect, the total expense in a public hospital is approximately 5400 USD. This cost of treatment will be entirely subsidized by the government. However, if the patient opts for premium care in a private hospital, the total cost of treatment will be four to five times higher than that in a public hospital. Reimbursement and payment scheme Besides self-payment and personal health insurance, reimbursement in Thailand is done through three different systems for individual patients based on the source of income and occupation. The National Health Security Office (NHSO) is responsible for national universal coverage. This scheme covers the payment of health services for Thai citizens or people of Thai nationality. Thus, the scheme reimburses most of the Thai population. Individuals serving the government are automatically enrolled in the government scheme and are reimbursed by the Comptroller General’s Department (CGD). The CGD scheme incorporates reimbursement for every government employee, including soldiers, policemen, and civil and university officials. The next-of-kin members of their family are included in this reimbursement scheme, but their children are covered until they are 20 years old. The last system is the Social Security Office (SSO) plan, which takes care of only people under the payroll in the private sector. Employees’ children are not eligible for reimbursement through this scheme. In terms of access to health services, patients in every scheme have access to any government hospital, but they can enter contracted private counterparts. Hence, pediatric patients with CHD are basically enrolled in NHSO and CGD schemes based on their parents’ reimbursement plans. Adults with CHD are registered with local and regional governments and contracted private sectors. Government subsidies cover some public hospital surgeries, but gaps remain. Insurance penetration is increasing, but affordability and coverage variations persist. Self-pay is still a significant burden for many families. Training of surgeons Local vs. overseas training We explored the opportunities and challenges associated with training congenital cardiac surgeons in Thailand, including the availability of local training programs and the necessity of overseas education. The number of congenital/pediatric cardiac surgeons has increased from less than 20 two decades ago to approximately 55 surgeons now. Most Thai general cardiothoracic surgeons have been trained in domestic programs. Nowadays, those surgeons who are interested in congenital cardiac surgery participate in a specific domestic fellowship program or opt for international training. Only two institutions offer in-country fellowship programs and provide internal official certificates [ 7 ]. Training opportunities for pediatric cardiac surgeons in Thailand are limited, with a significant portion of professionals opting to pursue training abroad. Efforts to establish more specific local training programs and enhance expertise in CHD surgery are ongoing, but require further investment and collaboration. One of the academic organizations in the CHD surgical arena is the Thai Society of Pediatric and Congenital Heart Surgeons (TSPCHS), established on 24 September 2021 with full support from the Society of Thoracic Surgeons of Thailand (STST). TSPCHS was founded with the purpose of promoting and persuading young cardiac surgeons to pursue and achieve more in CHD surgery. The society has created an ecosystem of academics, learning, sharing, and friendship through various activities, including lectures, webinars, and hands-on workshops. Support services Cardiology, anesthesia, and intensive care An overview of the availability and adequacy of support services such as cardiology, anesthesia, and intensive care for CHD surgeries in Thailand revealed that currently, all collaborating and supporting specialities are available in the country, but the distribution is inhomogeneous, as the services, particularly cardiologists and cardiac anesthetists, are concentrated in Bangkok and big cities, for example, Chiang Mai (Fig. 5 ). Access to support services such as cardiology, anesthesia, and intensive care is crucial for ensuring successful outcomes in CHD surgery. While major urban centers in Thailand offer comprehensive support services, rural areas may face challenges in accessing these resources. Fig. 5. Open in a new tab Distribution of cardiac surgeons regularly performing CHD operations by province. Bangkok and its outskirts have the most concentrated amount of surgeons. CHD, congenital heart disease. Source: https://commons.wikimedia.org/wiki/File:Thailand_provinces_en.svg Technology advancement The integration of cutting-edge technologies in congenital cardiac surgery has played a pivotal role in improving diagnostic accuracy, surgical planning, and postoperative care. Leading university hospitals have applied three-dimensional (3D) printing and advanced imaging modalities in the context of pediatric cardiac interventions, particularly complex CHD. Outcome data Citing relevant publications, this section provides an overview of outcome data related to CHD surgeries in Thailand, showcasing the country’s achievements and challenges. Dr Panpis Sakornpant and Dr Vichao Kojaranjit, with full support from the STST, published “The First National Congenital Database Report” in 2014 [ 8 ]. This report presents an in-depth analysis of congenital cardiac surgery practices and the outcomes of congenital cardiac surgery performed by 26 hospitals, and the database for analysis comprised 13,099 patients between 2006 and 2011. It is the first and only national congenital report ever. The salient features of this report are as follows: National database establishment The report signifies the establishment of the first national database for congenital cardiac surgeries in Thailand. This is a significant step in the systematic collection, analysis, and reporting of surgical data on CHDs. Data collection and analysis Data was collected from various hospitals and surgical centers across Thailand. The report includes detailed data on patient demographics, types of congenital heart defects treated, and postoperative outcomes. Performance metrics The report evaluates the performance of congenital cardiac surgery in Thailand by analyzing key metrics such as surgical success rates and morbidity and mortality rates. Outcomes and challenges The report highlights the outcomes of various surgical interventions, including the survival rates and complications associated with different procedures. It also discusses the challenges faced by the healthcare system in Thailand, including resource limitations, variability in surgical expertise, and access to advanced medical technologies. Quality improvement and recommendations The findings of the report are used to identify areas for quality improvement in congenital cardiac surgery within the country. Impact on healthcare policy This report serves as a foundational document for shaping healthcare policies related to CHD in Thailand. It provides evidence-based insights that can guide future investments and policy decisions aimed at improving cardiac care for children and adults with congenital heart defects. Collaborative effort The report underscores the importance of collaboration among various stakeholders, including surgeons, healthcare institutions, and governmental agencies, to ensure the continuous improvement of congenital cardiac surgery practices in Thailand. Educational value The report serves as an educational resource for healthcare professionals in Thailand, providing them with comprehensive data and insights that can inform clinical practice and improve patient outcomes. International relevance Although focused on Thailand, the report has international relevance as it contributes to the global understanding of congenital cardiac surgery practices, especially in middle-income countries. The data can be compared with other national databases to identify global trends and disparities in CHD treatment. This report is a critical milestone in the development of congenital cardiac care in Thailand, offering valuable data and insights that can help improve patient outcomes and inform future healthcare strategies. Several studies have investigated the outcomes of CHD surgery in Thailand, highlighting successes and improvement areas. Reference to important publications detailing outcome data provides insights into the quality of care and identifies areas for further research and intervention. Future prospects Anticipated developments This section of the article focuses on the future of CHD surgery in Thailand, addressing potential advancements, challenges, and opportunities for improvement. The future of CHD surgery in Thailand hinges on addressing existing challenges and implementing evidence-based interventions to improve access, quality, and outcomes. Collaborative efforts between government agencies and their private counterparts, healthcare providers, and international partners are essential for developing sustainable solutions and ensuring equitable access to care for all children with CHD in Thailand. Conclusion This article aims to contribute insights into the current state of congenital heart surgery in Thailand, shedding light on key aspects such as demographics, prevalence, service availability, funding and finance, training, and support services. Additionally, it offers a glimpse into the future, highlighting areas for growth and development in the field of CHD surgery in Thailand. Most importantly, the sustainability of congenital heart surgical programs depends on government support, reimbursement schemes, availability of medical staff, and incentives. The landscape of CHD surgery in Thailand reflects a complex interplay of demographic, economic, and healthcare factors. By examining the lessons learned from the Thai experience, stakeholders can identify strategies to enhance CHD services and improve outcomes, ultimately reducing the burden of disease on individuals, families, and society as a whole. Author contribution The author is totally responsible for creating content, writing, and corresponding the manuscript. Funding None. Data availability Not applicable. Code availability Not applicable. Declarations Ethics approval Not applicable. Consent to participate Not applicable. Consent for publication Not applicable. Conflict of interest No conflict of interest and no disclosure. Footnotes Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. References 1. National Statistics Office. https://www.nso.go.th/nsoweb/nso/interactive_view/es?set_lang=en . 2. Ministry of Public Health. Health KPI. http://healthkpi.moph.go.th/kpi2/kpi-list/view/?id=1601 . 3. International Monetary Fund. World Economic Outlook Database, October 2023. International Monetary Fund. https://www.imf.org/en/Publications/WEO/weo-database/2023/October/weo-report . 4. Chaiseri P. Development of coronary artery bypass graft (CABG) in Thailand. Thai J Surg. 2010;31:39–42. [ Google Scholar ] 5. Office-in-Charge, International Health Policy Program Foundation. Thai National Health Accounts 2020–2021 and projection of health expenditure 2022–2024. 2023. https://ihppthaigov.net/sa22/publication/download/fl_1700627367561.pdf . 6. Thai National Health Accounts 2020–2021 and projection of health expenditure 2022–2024. (Published in Thai). https://ihppthaigov.net/sa22/publication/download/fl_1700627367561.pdf 7. Tchervenkov CI, Herbst C, Jacobs JP, Al-Halees Z, Edwin F, Dearani JA, et al. Current status of training and certification for congenital heart surgery around the world: proceedings of the meetings of the Global Council on Education for Congenital Heart Surgery of the World Society for Pediatric and Congenital Heart Surgery. World J Pediatr Congenit Heart Surg. 2021;12:394–405. 10.1177/21501351211003520. [ DOI ] [ PubMed ] 8. Sakornpant P, Kojaranjit V. First National Congenital Cardiac Surgical Database Report: demonstrating “Practice of congenital cardiac surgery in Thailand: analysis of performance and outcome” . Bangkok (Thailand): The Society of Thoracic Surgeons of Thailand; 2014. https://www.ncbi.nlm.nih.gov/books/NBK220448/ . [ PubMed ] Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Data Availability Statement Not applicable. Not applicable. 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