Country context

Located at the center of the Indochina Peninsula, Thailand’s economy grew at 7.5 percent annually from 1960 to 1996 and emerged from the Asian Financial Crisis with a sustained annual growth rate of 5 percent from 1999 to 2005, making it an upper middle-income country today. The government of Thailand established the Universal Health-care Coverage Scheme (UCS) in 2001, which has since become a model for low- and middle-income countries seeking to expand health care equity and access. As a result of its health reforms and alongside decades of socioeconomic progress, Thailand’s out-of-pocket health expenditure is one of the lowest in the region at 10.5 percent of total health expenditure, compared to the East Asia and the Pacific average of 25.3 percent in 2020. Despite these achievements, Thailand is not immune to the challenges brought about by non-communicable diseases (NCDs), which account for 74 percent of deaths in Thailand annually, with lung cancer representing the sixth highest cause of death in 2021.

Lung cancer incidence and mortality rates have significantly decreased since the early 1990s, but recent data suggests an increasing trend beginning in 2015 (Figure 1), underscoring the need to re-examine strategies to contain the disease. Disaggregating by gender, lung incidence among men stands at 25.9 cases per 100,000 while the incidence among women is 11.7 cases per 100,000. As with other countries in the region, the primary risk factor for lung cancer in men is smoking, while other environmental, occupational, and hereditary factors were key determinants in women’s cases. Shedding light on risk factors unique to geography, a 2022 study conducted in northern Thailand and published in Nature identified radon exposure as a significant risk factor for lung cancer, linking it to 28 percent of lung cancer deaths in women and 26 percent in men in that region. Further, the risk factors for lung cancer are compounded by population aging: Thailand has been classified as an aged society since 2010 and will become a “super-aged” society in the next decade, at which point around one-third of the population is projected to be 60 years old and above.

Cancers exert a heavy socioeconomic burden in Thailand, chiefly by escalating medical expenses and disrupting participation and productivity in the labor force. In 2019, one study estimated that cancer cost Thailand THB 184.6 billion (USD 5.9 billion), equivalent to 1 percent of GDP, in 2019, of which 85 percent was linked to “premature withdrawal of work.” This effect on workforce exacerbates existing challenges associated with an increasingly aging population as well as the “middle-income trap”—the stagnation of Thailand’s economic productivity in recent years preventing its graduation to high-income status. To counter these socioeconomic costs, the implementation of policy packages aimed at preventing cancer and other NCDs—such as tobacco and alcohol control, salt reduction, and physical activity (WHO Best Buys)—not only reduces health care expenses but also yields a total return on investment (ROI) of 2.7 for every Thai baht invested.

Assessing policies and programs

Thailand published its National Cancer Control Program (NCCP) in 1997, which was updated most recently in 2018. The National Cancer Institute of Thailand led its development and review, with the participation of government agencies, the private sector, academia, and non-government organizations (NGOs). The 2018 NCCP specified seven strategic priorities, each accompanied by indicators for monitoring and evaluation and designated responsible government agencies. These strategies focus on the prevention of risk factors, early cancer detection, treatment, palliative care, a cancer information strategy, cancer control research, and organizational capacity strengthening. It also recommended that the Ministry of Public Health, Office of the Civil Service Commission, and other relevant agencies prepare a budget plan to support the strengthening of personnel and organizational capacity for cancer prevention and control. Lung cancer was identified as an explicit priority for research, along with the other most common cancers such as liver, breast, colon, and cervical. However, lung cancer was excluded from the strategy for early detection, which outlines screening and early detection activities for specific cancers such as breast, cervical, and liver. The NCCP’s approach to lung cancer focused on mitigating its known risk factors.

Most lung cancer cases are diagnosed at advanced stages in Thailand. Indeed, Thailand does not have a dedicated control and early detection program for lung cancer, nor is there a nationwide lung cancer screening program in the country. In a 2023 survival analysis covering a decade (2012–2021) of observing lung cancer cases in a hospital in Thailand, 96 percent of patients observed (1,528) were diagnosed at either stage III or IV, with a five-year survival rate of just 6 percent. To help address late cancer diagnosis, a public-private partnership has been established to leverage AI for early lung cancer detection, initially implemented at Phyathai 2 Hospital in Bangkok, the nation’s capital.

The National Cancer Institute has clinical practice guidelines for lung cancer diagnosis, treatment, and palliative care. Lung cancer is usually diagnosed through CT scans. A 2020 report indicated that there is limited availability of more advanced PET (positron emission tomography) scan machines in the country, with seven machines located in Bangkok, one in Chiang Mai province, and one in Kho Kaen province. The shortage and uneven distribution of PET scanners demonstrate that advanced cancer resources are concentrated in urban areas, particularly in Bangkok, meaning that large segments of the Thai population lack easy access. The same 2020 report noted that there were only 261 medical oncologists in Thailand, with the majority of them practicing in the capital, not enough for a country with 183,541 new cancer cases in 2022. Biomarker tests—such as EGFR mutation testing and ALF testing—for diagnosis and treatment are mostly available in university-based hospitals, limiting the use of such procedures to specific regions. Further, next-generation sequencing (NGS) testing has started to become available but remains costly for patients to access, as it is not reimbursed by government health insurance schemes.

In addressing lung cancer risk factors, Thailand was the first country in Asia to require plain packaging for tobacco products. The Tobacco Products Control Act of 2017 replaced earlier anti-tobacco laws and, in part, banned the sale of single cigarettes and the sale of tobacco products to anyone under 20 years old. Smoking is currently banned in most public places, offices, public transport, and tourist destinations. The country has increased excise taxes on tobacco, including a 2 percent surcharge to fund NCD prevention and health promotion initiatives. Despite air pollution levels in Thailand averaging six times higher than the WHO-recommended limits, there is currently no comprehensive law on air pollution. However the Thai cabinet recently approved a draft version of a clean air law, bringing it a step closer to enactment. Meanwhile, the government passed the Occupational and Environmental Diseases Control Act in 2019, imposing fines for employers or medical facilities that fail to disclose information about environmental risks at their locations, demonstrating Thailand’s proactive approach to addressing hazards emanating from exposure to toxic substances at work.

FIGURE 2

GRIP: Gains, Risks, Innovations, Prospects in Policies and Programs

Opportunities ahead

In many ways, Thailand is a trailblazer in health care reforms in the region: it has one of the lowest out-of-pocket health expenditure averages in the region and has effectively reduced the impacts of grave illnesses on poverty incidence, a feat for a country not yet classified as high-income. However, lung cancer and NCDs in general are still evidently a challenge in the country, with prevalence trends indicating no signs of reduction. Despite the laws and frameworks to address risk factors, there is work to be done on effectively implementing the laws. To illustrate, while selling e-cigarettes is banned by law, enforcement remains an issue, as the use of e-cigarettes is on the rise among the youth from 3.3 percent in 2015 to 8.1 percent in 2021.

Measures to increase the early detection of lung cancer are a priority for the country, as most patients are detected at advanced stages, with lower chances of survival. To improve early detection of lung cancer, the feasibility of screening needs to be explored, possibly through conducting research trials to generate evidence on its cost-effectiveness. Public-private collaborations to leverage AI and other digital technologies in detecting lung cancer could be further explored to expand access to cancer care and financing given current limitations in public health resources. Addressing barriers to cancer care accessibility is also crucial, especially in rural areas where lack of facilities and skilled personnel force patients to seek care in far-flung urban areas. Furthermore, as “premature withdrawal of work” poses a problem for cancer patients, strategies to reintegrate cancer survivors into the workforce need to be fully developed. Lastly, the country needs to enact and enforce an integrated anti-pollution law to help advance its goals of addressing environmental risk factors for lung cancer.