Data were collected from respondents at the region, province, and district levels. Data from 73 (96%) provinces were made available through respondents in 765 districts (765/834, 92%). Full data from all province institutions were provided from 53 (70%) provinces. Data from Bangkok were provided solely by public hospitals.

To determine total availability of provincial and national resources and account for missing data, we estimated the resource availability in districts where data were unavailable and extrapolated these estimations. We assumed that districts with similar numbers of hospital beds would have the same quantity of other resources available. The Ministry of Health determines bed quotas, and data were derived from routine data sources.

The average quantity of province resources is listed in the Table 1. The estimated average province resources are the result of extrapolation and correction when data points were missing. Because few data points were missing, the estimates were very similar to the averages derived from hard data. The estimated resources were further analyzed to determine resource gaps. Substantial differences in resource availability exist across provinces. We found no correlation of resources with gross provincial product (a measure of a province’s economic well-being) or with province poultry density. We found, however, correlations between some resources (for example, healthcare personnel, hospital beds, and ventilator equipment) and both population size and density (Table 1).

The differences in resource availability across provinces are illustrated through 7 selected resources (Figures 1, 2). These selected resources offer insights into the geographic variations in preparedness in relation to surveillance capacity (surveillance and rapid response team [SRRT] personnel), case investigation capacity (SRRT, internal medicine doctors), case-patient treatment capacity (oseltamivir treatment courses, respirators, critical care nurses), and capacity to prevent spread of disease in the community (negative-pressure rooms, isolation rooms, surgical masks).

Gaps in resources existed in some provinces under scenario 1 (and thus for subsequent scenarios). These resource gaps include infrastructure, personnel, and materials and potentially limit capacity in all 4 control areas (surveillance capacity, case-investigation capacity, case-treatment capacity, and capacity to prevent spread of disease in the community) (Technical Appendix ). If care for case-patients is limited to negative-pressure rooms or isolation beds, then bed availability is likely to be problematic, even with a small numbers of cases. However, if beds dedicated to wider use are made available, then shortfalls are unlikely when limited cases occur. Most resource gaps are linked to critical care and include lack of trained personnel and respirators. For example, by scenario 3, 92% of provinces will have insufficient negative-pressure rooms to respond effectively to case-patients, and a severe shortage of critical care nurses will occur. However, if isolation beds are used, the proportion of provinces with insufficient resources falls to ≈75%, and if single occupancy rooms are also used, bed capacity across the country is sufficient. As the number of case-patients and contacts increases through scenarios 2 and 3, the number of provinces with gaps in resources grows. The geographic distribution of resource gaps varies, depending on resource and scenario (Figure 3–Figure 5).

The need for 4 selected resources changed over time, assuming the epidemic curve (Figure 6). The gap in available resources was limited to only a few days for respiratory support. For beds, likewise, when small numbers of cases occur and case-patients are cared for in negative-pressure rooms or isolation rooms, shortages are likely to arise for only a few days. Sufficient stocks of oseltamivir are currently held at the provincial level to meet the needs of a few case-patients and their contacts.

Resource gaps exist on the national level if scenario 3 occurs simultaneously in all provinces across Thailand (Table 2). Such an event represents WHO phase 6, that is, sustained human-to-human transmission, albeit on a relatively small scale. Despite this small scale, national resource gaps are substantial if the same standard of clinical care is maintained when fewer cases arise. For some critical resources, such as internal medicine physicians and oseltamivir tablets, the problem is mitigated if we assume perfectly effective, timely, and efficient movement of resources from provinces with surplus capacity to provinces with gaps. Some resources, however, are limited in number (such as critical care nurses), and even effective redistribution may make little difference in outcome.

We showed that Thailand is likely to have some resource gaps in responding to clusters of cases in an emergent influenza pandemic and that these gaps vary across different provinces. These gaps are, however, likely to occur over a limited duration if the cases occur over several weeks and the numbers of cases are limited. As the number of cases increases, however, provincial and national capacity is likely to be tested in certain ways if clinical care and surveillance are expected to remain at a similar standard as when cases are limited. The results of such a scenario are similar for some countries of western Europe (21). Although policy makers will, in all likelihood, need to consider issues of rationing and priority setting explicitly in national strategic planning, resources in Thailand are substantial overall, although geographic distribution likely poses logistical challenges. In the event of a modest outbreak of pandemic influenza (WHO phase 6) similar to these locally developed scenarios, Thailand, a relatively affluent country in Southeast Asia, might encounter relatively modest gaps in available resources. However, if a pandemic is substantial in terms of the severity of illness and proportion of deaths, resources are likely to be insufficient, and policy makers will have to consider whether such resource gaps can be closed in reality. This conclusion has important policy implications and raises several questions. Should most resources and planning be focused explicitly on early containment potentially at the expense of mitigation, particularly in developing countries? How, to whom, and where should the deployment of scarce resources be planned (22)? A further issue raised is how realistic simulation exercises are and whether they effectively inform preparedness planning. Investment to address gaps in resources can be focused where the most important gaps exist. Some gaps, however, for example, in clinical and nursing staff, will take time and considerable investment to fill. We show at the province level where resource gaps are most profound and thus where future investment might be focused.

The variations of resources correlate strongly with both the population size and the population density of a province. Historically, healthcare resources have been distributed on the basis of provincial population size and not according to poverty indices. To date, risk assessments related to pandemic influenza have not informed planning and deployment of resources. This circumstance has potentially important implications for future preparedness planning. Provinces with relatively less dense populations, in which communication facilities are stretched to their limit and access to services is already likely to be problematic, may be further challenged by their relatively fewer resources (23). Focused investment in resources may be needed if the response to an emergent pandemic is to be equitable. Variations exist also among provinces in their resource capacity for surveillance, case investigation, case-patient treatment, and control of community spread.

Responding effectively and in a timely manner to gaps we have highlighted will be a managerial challenge. Moreover, using available resources most effectively and efficiently on a national scale also demands considerable managerial and administrative capacity (issues we did not examine). The timely mobilization of most resources remains to be planned.

This study has several limitations. First, our survey focused on the narrow clinical response and ignored the capacity of management, administrative systems, financial systems, and communications, capacities that are likely to be needed to efficiently mobilize resources (24). Second, we assumed that the relationship between resource need and case-patients is linear, and we estimated gaps on the basis of assumptions that care for case-patients as the pandemic unfolds will draw upon similarly characterized resources as in earlier phases. This assumed relationship is unlikely to occur, and care for case-patients is likely to be different from our study assumptions. However, few strategic plans explicitly acknowledge this change in resource use and thus do not plan for it (9). Third, our scenarios, although based on tabletop exercises conducted across the country, are limited in terms of anticipated case-patients and their contacts. Even though we extended our scenario to a modest pandemic, an alternative real-life scenario under which large numbers of cases occur is likely to test the health system profoundly. Fourth, we assumed that resource sharing between provinces would be limited on the basis of an analysis of formal strategic arrangements. Fifth, some data points were missing. Although the missing data were few, and corrections were possible, some of these data were from Bangkok. In Bangkok, any determination of the city’s overall resources is a challenge because of the many private autonomous healthcare facilities and their lack of systematic integration into the public health system. This factor means that our interpretation of Bangkok’s capacity to respond should be considered with caution. Bangkok has 65 private hospitals with >50 beds (14,000 beds in total), and these institutions were excluded from our survey. The challenge of coordinating the city’s resources in the event of a pandemic is substantial. Without an understanding of what and where those resources are, their management will be much more challenging. This lack of knowledge would have profound implications for Thailand because Bangkok is a city of 10 million persons, the economic powerhouse of the country, and a hub for transportation and communications with the rest of Thailand. The missing information also has important implications for the global control of a pandemic because of Bangkok’s role as a major international transport hub. If emergent pandemic influenza cannot be controlled in Bangkok, the world will be affected. The same lack of complete information would apply to other major cities where complex health systems exist.

We have shown that the health system resources available to Thailand are likely to be sufficient to respond to emergent pandemic influenza if the pandemic is modest and occurs in a manner similar to the assumptions informing Thailand’s simulation exercises. Other countries in the region, which is acknowledged to be at high risk for being at the epicenter of the next global pandemic of influenza (25), are likely to have fewer resources than Thailand (3). We are currently investigating the capacity of Thailand and neighboring countries to respond to more profound pandemic influenza scenarios. Policy makers in the region may need to reflect on where health system resources in the region might best be positioned and further expanded; what scenario assumptions are used to inform preparedness planning; whether containment, mitigation, or both, should be the focus of attention; and whether provinces with the largest probable gaps should be supported further in strengthening response capacity. Policy makers should also consider how the capacity of the private healthcare sector can, if a public health crisis occurs, be drawn upon in a timely and effective manner. In the event of a major pandemic, difficult decisions regarding the use of scarce resources will need to be made, and explicit planning ahead for the pandemic is advised.