Evolutionary Public Health: Advancing Precision Public Health and Universal Health Coverage in Thailand
Keywords:
Evolutionary public health, Universal Health Coverage, Precision Public Health, Social determinants of health, Niche constructionAbstract
Background: Thailand is experiencing rapid population ageing, a rising burden of non-communicable diseases (NCDs), and persistent health inequalities. Although Thailand has achieved near-universal health coverage and substantial reductions in catastrophic health expenditure, current policy debates remain focused largely on affordability and service availability, with limited attention to the evolutionary and historical determinants of population vulnerability. Objective: This article examines Thailand’s contemporary health challenges through an evolutionary public health framework, highlighting how evolutionary and historical factors may contribute to population vulnerability and shape current health inequalities. Methods: Using narrative review and concept paper methodology, this article examines how evolutionary mismatch and inequitable human niche construction shape Thai health outcomes, and how intergenerational cultural mismatches in health beliefs affect health literacy and resilience in rapidly urbanising communities.Results: The analysis indicates that while universal health coverage (UHC) provides essential financial protection, it does not by itself address the upstream environmental and social conditions that generate disease. We argue that precision public health should be reoriented beyond genomic risk stratification to incorporate site-specific environmental exposure and early-life developmental programming. This reoriented approach supports a community-centred model that leverages Thailand's existing primary care infrastructure, Sub-district Health Promoting Hospitals (SHPH) and village health volunteers (VHV) to modify unhealthy environments and strengthen community resilience. Conclusion: Grounding public health policy in evolutionary principles offers Thailand a pathway toward not only universal access to healthcare, but universal conditions for health.
References
1. Potempa K, Rajataramya B, Singha Dong N, Furspan P, Kahle E, Stephenson R. Thailand's challenge of achieving health equity in the era of non-communicable disease. Pac Rim Int J Nurs Res. 2022;26(2):187-203. Available from: https://he02.tci-thaijo.org/index.php/PRIJNR/article/view/256503
2. World Health Oganization. Noncommunicable diseases: Thailand [Internet]. Manila: WHO Reginal Office for the Western Pacific; 2026 [cited 2026 Jul 29]. Available from: https://www.who.int/thailand/our-work/NCDs.
3. Nation Thailand. Non-communicable diseases claim over 1,000 Thai lives a day, warns Public Health Ministry [Internet]. 2025 [updated Jun 16; cited 2026 Jul 29]. Available from: https://www.nationthailand.com/health-wellness/40051340.
4. Ciccacci F, Orlando S, Majid N, Marazzi C. Epidemiological transition and double burden of diseases in low-income countries: the case of Mozambique. Pan Afr Med J. 2020;37:49. DOI: 10.11604/pamj.2020.37.49.23310
5. Lertsakulbunlue S, Kunsuwan P, Rangsin P, Sakboonyarat B. Pulmonary tuberculosis mortality and its risk factors among patients with type 2 diabetes and pulmonary tuberculosis in four community hospitals, central Thailand. J Southeast Asian Med Res. 2022;6(1):e0120. DOI: 10.55374/jseamed.v6i0.120
6. Nikoloski Z, Alqunaibet A, Alfawaz R, Almudarra S, Herbst C, El-Saharty S, et al. Covid-19 and non-communicable diseases: evidence from a systematic literature review. BMC Public Health. 2021;21:1068. DOI: 10.1186/s12889-021-11116-w
7. Mendenhall E, Newfield T, Tsai A. Syndemic theory, methods, and data. Soc Sci Med. 2022;295:114656. DOI: 10.1016/j.socscimed.2021.114656
8. Friant S. Human behaviours driving disease emergence. Evol Anthropol. 2024;33(2):e22015. DOI: 10.1002/evan.22015
9. Tangcharoensathien V, Witthayapipopsakul W, Panichkriangkrai W, Patcharanarumol W, Mils A. Universal health coverage and primary care, Thailand. Bull World Health Organ. 2019;97(8):590-598. DOI: 10.2471/BLT.18.223693
10. Tangcharoensathien V, Patcharanarumol W, Ir P, Aljunid S, Mukti A, Akkhavong K. Health-financing reforms in southeast Asia: challenges in achieving universal coverage. Lancet. 2011;377(9768):863 - 873. DOI: 10.1016/S0140-6736(10)61890-9
11. Teerawattananon Y, Tritasavit N, Suchonwanich N, Kingkaew P. The use of economic evaluation for guiding the pharmaceutical reimbursement list in Thailand. Z Evid Fortbild Qual Gesundh wesen (ZEFQ). 2014;108(7):397 - 404. DOI: 10.1016/j.zefq.2014.06.015
12. Wells J, Nesse R, Sear R, Johnstone R, Stearns S. Evolutionary public health: introducing the concept. Lancet. 2017;390(10093):500 - 509. DOI: 10.1016/S0140-6736(17)30572-X
13. Gluckman P, Hanson M. Living with the past: evolution, development, and patterns of disease. Science. 2004;305(5691):1733 - 1736. DOI: 10.1126/science.1095292
14. Enam S, Hashmi S. The importance of Evolutionary Medicine in developing countries: A case for Pakistan's medical schools. Evol Med Public Health. 2018;2018(1):26 -33. DOI: 10.1093/emph/eoy004
15. Shotelersuk V, Tongsima S, Pithukpakorn M, Mahasirimongkol S, Eu-ahsunthornwattana J, Palittapongarnpim P, et al. Advancing precision public health at Genomics Thailand. Nature Health. 2026;1:461 - 464. DOI: 10.1038/s44360-026-00059-4
16. Baethge C, Goldbeck-Wood S, Mertens S. SANRA—a scale for the quality assessment of narrative review articles. Res Integr Peer Rev. 2019;4:5. DOI: 10.1186/s41073-019-0064-1
17. Pontzer H, Wood B, Raichlen D. Hunter-gatherers as models in public health: Hunter-gatherer health and lifestyle. Obes Rev. 2018;19(S1):24 - 35. DOI: 10.1111/obr.12785
18. Kaplan H, Thompson R, Trumble B, et al. Coronary atherosclerosis in indigenous South American Tsimane: a cross-sectional cohort study. Lancet. 2017;389(10080):1730-1739. DOI: 10.1016/S0140-6736(17)30752-3
19. Fournié G, Pfeiffer D, Bendrey R. Early animal farming and zoonotic disease dynamics: modelling brucellosis transmission in Neolithic goat populations. R Soc Open Sci. 2017;4:1060943. DOI: 10.1038/rsos.160943
20. Sikora M, et al. The spatiotemporal distribution of human pathogens in ancient Eurasia and the emergence of zoonotic diseases. Nature 2025;643:1011–1019. DOI: 10.1038/s41586-025-09192-8
21. Raja N. Edward Jenner's discovery of vaccination: impact and legacy. J Family Med Prim Care. 2024;13(9):e68993. DOI: 10.7759/cureus.68993
22. Neel J. Diabetes mellitus: a “thrifty” genotype rendered detrimental by “progress”? . Am J Hum Genet. 1962;14(4):353 - 362.
23. Hales C, Barker D. The thrifty phenotype hypothesis. Br Med Bull. 2001;60(1):5 - 20. doi: 10.1093/oxfordjournals.bmb.a005083
24. Porter D. A History of Public Health. In: Detels R, Gulliford M, Karim Q, Tan C, editors. Oxford Textbook of Global Public Health 6th ed. Oxford: Oxford University Press; 2015.
25. Rosen G. A History of Public Health. Baltimore: Johns Hopkins University Press; 1993.
26. Carter K. Ideas of contagion in eighteenth century Britain: the evolution of germ theory. In: Bynum W, Porter R, editors. Companion Encyclopedia of the history of Medicine. London: Routledge; 1993. p. 139 - 159.
27. Porter R. The Greatest Benefit to Mankind: A Medical History of Humanity from Antiquity t o the Present. London: Harper Collins; 1997.
28. Slack N. Antonie van Leeuwenhoek and the Emergence of Microbiology. In: Brock T, editor. Milestones in Microbiology. Washington, DC: ASM Press; 1999.
29. Tognotti E. Lessons from the history of quarantine, from plague to influenza A. Emerg Infect Dis. 2013;19(2):254 - 259. DOI: 10.3201/eid1902.120312
30. Riedel S. Edward Jenner and the history of smallpox and vaccination. Baylor Univ Med Cent Proc. 2005;18(1):21 - 25. DOI: 10.1080/08998280.2005.11928028
31. Centers for Disease Control and Prevention. Lesson 1, Section 8: Epidemiologic Triad. Principles of Epidemiology in Public Health Practice. 3rd. Atlanta: CDC; 2023.
32. Monteiro C, Cannon G, Levy R, et al. Ultra-processed foods: what they are and how to identify them. Public Health Nutr. 2019;22(5):936 - 941. DOI: 10.1017/S136898001800376X
33. World health organization. Non-communicable diseases country profile: Thailand. Geneva: WHO; 2022.
34. United Nation, UNDP Thailand. Prevention and Control of Non-communicable Diseases in Thailand - The Cases for Investment. Bangkok: UNDP; 2021.
35. McKeown RE. The epidemiologic transition: changing patterns of mortality and population dynamics. Am J Lifestyle Med. 2009;3(1 Suppl):19S - 26S. DOI: 10.1177/1559827609335350
36. Lea AJ, Clark AG, Dahl AW, Devinsky O, Garcia AR, Golden C, et al. Applying an evolutionary mismatch framework to understand disease risk. PLoS Biol. 2023;21(9):e3002311. DOI: 10.1371/journal.pbio.3002311
37. Lea AJ, Clark AG, Dahl AW, Devinsky O, Garcia AR, Golden CD, et al. Evolutionary mismatch and the role of GxE interactions in complex disease. Curr Opin Genet Dev. 2023;80:102065. DOI: 10.1016/j.gde.2023.102065
38. Pontzer H, Raichlen DA, Wood BM, Mabulla AZP, Racette SB, Marlowe FW. Hunter-gatherer energetics and human obesity. PLoS One. 2012;7(7):e40503. DOI: 10.1371/journal.pone.0040503
39. Hertzman C, Boyce T. How experience gets under the skin to create gradients in developmental health. Annu Rev Public Health. 2010;31:329-347. DOI: 10.1146/annurev.publhealth.012809.103538
40. Stearns S, Koella J, editors. Evolutions in health and disease. 2nd ed. Oxford: Oxford University Press; 2008.
41. Lacagnina S. The developmental origins of health and disease (DOHaD). Am J Lifestyle Med. 2019;14(1):50-59. DOI: 10.1177/1559827619879694
42. Stegemann R, Buchner DA. Transgenerational inheritance of metabolic disease. Prog Mol Biol Transl Sci. 2014;128:203 - 229. DOI: 10.1016/bs.pmbts.2014.09.006
43. Perez MF, Lehner B. Intergenerational and transgenerational epigenetic inheritance in animals. Nat Cell Biol. 2019;21(2):143-151. DOI: 10.1038/s41556-018-0242-9
44. Laland K, Odling S, Myles S. How Human niche construction is shaping our evolutionary future. Philos Trans R Soc Lond B Biol Sci. 2010;365(1556):3075 - 3082.
45. Laland KN, Odling-Smee J, Feldman M. Niche construction: implications for human science. In: Wright J, editor. International Encyclopedia of the Social & Behavioral Sciences. 2nd ed. Oxford: Elsevier; 2015. p. 290 - 295. DOI: 10.1098/rstb.2010.0034
46. Rose G. Sick individuals and sick populations. Int J Epidemiol. 1985;14(1):32-38. DOI: 10.1093/ije/14.1.32
47. Dorninger C, Menendez L, Caniglia C. Social-ecological niche construction for sustainability: understanding destructive processes and exploring regenerative potentials. Philos Trans R Soc Lond B Biol Sci. 2024;379(1893):20220431. DOI: 10.1098/rstb.2022.0431
48. United Nation Human Settlements Programme (UN Habitat). Urbanization in Thailand: Building Inclusive and Sustainable Cities. Nairobi: UN Habitat; 2020.
49. Nguyen T, Winjikul E, Virdis S. Air pollution in Bangkok: Addressing unequal exposure and enhancing public understanding of the risks. Stockholm Environment Institute; 2023.
50. Pothisiri W, Vicerra PM, Buathong T. Poverty, noncommunicable diseases, and perceived health risks among older adults during the COVID-19 pandemic in urban Thailand. Asian Soc Work Policy Rev. 2022;16(2):126-135. DOI: 10.1111/aswp.12253
51. Gelormino E, Melis G, Marietta C, Costa G. From built environment to health inequalities: An explanatory framework based on evidence. Preventive Medicine Reports. 2015;2:737-745. DOI: 10.1016/j.pmedr.2015.08.019
52. Wells JC. An evolutionary perspective on social inequality and health disparities: Insights from the producer-scrounger game. Evol Med Public Health. 2023;11(1):294-308. DOI: 10.1093/emph/eoad026
53. Henry P, Beaulieu M, Bradford A, Graves JL Jr. Embedded racism: inequitable niche construction as a neglected evolutionary process affecting health. Evol Med Public Health. 2023;11(1):112-125. DOI: 10.1093/emph/eoad009
54. Kickbusch I, Allen L, Franz C. The commercial determinants of health. Lancet Glob Health. 2016;4(12):e895-e896. DOI: 10.1016/S2214-109X(16)30217-0
55. Sattayakorn S, Sinuraibhan S, Ramasoot S, Wungpatcharapon S, Hadjri K, Durosaiye I, et al. Live-Work Interior Quality for Older People in Low-Income Housing in Bangkok. Interiority. 2023;6(2):225-248. DOI: 10.7454/in.v6i2.301
56. Kaikeaw S, Punpuing S, Chamchan C, Prasartkul P. Socioeconomic inequalities in health outcomes among Thai older population in the era of Universal Health Coverage: trends and decomposition analysis. Int J Equity Health. 2023;22(1):144. DOI: 10.1186/s12939-023-01952-0
57. Koos E. The Health of Regionville: What the People Thought and Did About It. New York: Columbia University Press; 1954.
58. Ipsos. How Addressing Transportation Barriers to Healthcare May Improve Outcomes and Reduce Costs. Ipsos; 2024 December.
59. Kabayundo J, Ahuja M, Jadhav S, Smith L, Bithi F, Shahi S, et al. Transportation barriers to healthcare access: a scoping review of measurement approaches and associated health outcomes. Transportation Research Interdisciplinary Perspective. 2025;34:101697. DOI: 10.1016/j.trip.2025.101697
60. World Bank. Lessons Learned from Thailand's Obesity Prevention and Control Policies. Washington, DC: World Bank; 2019.
61. Tangcharoensathien V, Adulyanon S, Supaka N, Munkong R, Viriyathorn S, Sirithienthong S, et al. The Thai Health Promotion Foundation: 2 decades of joint contributions to addressing noncommunicable diseases and creating healthy populations. Glob Health Sci Pract. 2024;12(2). DOI: 10.9745/ghsp-d-23-00311
62. Rasanathan K, Posayanonda T, Birmingham M, Tangcharoensathien V. Innovation and participation for healthy public policy: the first National Health Assembly in Thailand. Health Expect. 2012;15(1):87 - 96. DOI: 10.1111/j.1369-7625.2010.00656.x
63. Hu E, Pan A, Malik V, Sun Q. White rice consumption and risk of type 2 diabetes: meta-analysis and systematic review. BMJ. 2012;344:e1454. DOI: 10.1136/bmj.e1454
64. UNICEF Thailand. UNICEF finds 1 in 3 mothers in Thailand exclusively breastfeed their babies, far below target [Internet]. 2023 [updated Jul 31]. Available from: https://www.unicef.org/thailand/press-releases/unicef-finds-1-3-mothers-thailand-exclusively-breastfeed-their-babies-far-below.
65. National Health Commission Office of Thailand (NHCO). Challenges faced by the Thai health system at the local level [Internet]. 2024 [updated Aug 30; cited 2026 Jul 29]. Available from: https://en.nationalhealth.or.th/challenges-faced-by-the-thai-health-system-at-the-local-level/.
66. Burusliam N. The Thai wisdom and Thai folk medicine. Community Health Journal. 2023;48(3):283 - 288.
67. Junsongduang A, Kasemwan W, Lumjoomjung S, Sabprachai W, Tanming W, Balslev H. Ethnomedicinal Knowledge of Traditional Healers in Roi Et, Thailand. Plants (Basel). 2020;9(9):1177. DOI: 10.3390/plants9091177.
68. Lim L, Kjellstrom T, Sleigh A, Khamman S, Seubsman S, Dixon J, et al. Associations between urbanisation and components of the health-risk transition in Thailand. A descriptive study of 87,000 Thai adults. Glob Health Action. 2009;2. DOI: 10.3402/gha.v2i0.1914.
69. Kamanzi Ntakirutimana G. The Impact of Urbanization on Traditional Medicinal Plant Use in Disease Management RIJBAS. 2025;5(1):47 - 50. DOI: 10.59298/RIJBAS/2025/514750
70. Lorthanavanich D, Komazawa O. Population Ageing in Thailand: Long-term Care Model: Review of Population Ageing Practices and Policies. ERIA; 2021.
71. Khoury M, Iademarco M, Rilley W. Precision public health for the era of precision medicine. Am J Prev Med. 2016;50(3):398 - 401. DOI: 10.1016/j.amepre.2015.08.031
72. Roberts MC, Khoury MJ, Mensah GA. Precision public health in the era of genomics and big data. Nat Med. 2024;30:1865-1873. DOI: 10.1038/s41591-024-03098-0
73. Gluckman PD, Hanson MA, Low FM. Evolutionary and developmental mismatches are consequences of adaptive developmental plasticity in humans and have implications for later disease risks. Philos Trans R Soc B. 2019;374(1770):20180109. DOI: 10.1098/rstb.2018.0109
74. Evans T, Chowdhury A, Evans D, Fidler A. Thailand's Universal Coverage Scheme: Achievements and Challenges. An independent assessment of the first 10 years (2001-2010). Nonthaburi, Thailand: Health Insurance System Research Office; 2012.
75. The ArokaGO Reporter. Center for Medical Genomics Expands Precision Medicine Through Thailand's Universal Healthcare Scheme. ArokaGO; 2026 Jul 14 [cited 2026 Jul 29]. Available from: https://www.arokago.com/en/news/center-for-medical-genomics-expands-precision-medicine-through-thailands-universal-healthcare-scheme
76. Notterman DA, Mitchell C. Epigenetics and understanding the impact of social determinants of health. Pediatr Clin North Am. 2015;62(5):1227-1240. DOI: 10.1016/j.pcl.2015.05.012
77. Personal Data Protection Act B.E. 2562 (2019) (Thailand).
78. Tangcharoensathien V, Tisayaticom K, Suphanchaimat R, Vongmongkol V, Viriyathorn S, S L. Financial risk protection of Thailand's universal health coverage: results from series of national household surveys between 1996 and 2015. Int J Equity Health. 2020;19(1):163. DOI: 10.1186/s12939-020-01273-6
79. Yiengprugsawan V, Kelly M, Seubsman S, Sleigh A. The first 10 years of the Universal Coverage Scheme in Thailand: review of its impact on health inequalities and lessons learnt for middle-income countries. Australas epidemiol. 2010;17(3):24 - 26.
80. World health organization. Tracking Universal Health Coverage: 2023 Global monitoring report. Geneva: WHO; 2023.
81. Camfield L. Universal coverage but unequal access? Factors affecting the use of health services in Northeast and South Thailand. In: Moller V, Huschka D, editors. Quality of life and the Millennium challenge. Social Indicators Research Series, vol 35. Dordrecht: Springer; 2008. p. 239-64. DOI: 10.1007/978-1-4020-8569-7
82. Department of Older Persons (DOP), Ministry of Social Development and Human Security, from: BDA. Situation of the Thai older persons 2023. Bangkok: DOP; 2024.
83. Paek SC, Zhang NJ. Unmet health-care needs among older adults living alone in Thailand. Int J Popul Stud. 2025;11(2):64-74. DOI: 10.36922/ijps.1218
84. Tsai A, Venkataramani A. Syndemics: a theory in search of data or data in search of a theory? . Soc Sci Med. 2018;206:117-122. DOI: 10.1016/j.socscimed.2018.03.040
85. World bank. Thailand Monthly Economic Monitor: April 2025. Washington DC: World bank; 2025.
86. Jirophat C, Manopimoke P, Suwanik S. The Macroeconomic Effects of Climate Shocks in Thailand. Bangkok: PIER; 2022.
87. Eriksson M, Linderstrom B. Antonovsky's sense of coherence scale and the relation with health: a systematic review. J Epidemiol Community Health. 2006;60(5):376-381. DOI: 10.1136/jech.2005.041616.
88. Kitreerawutiwong N, Jordan S, Hughes D. Facility type and primary care performance in sub-district health promotion hospitals in Northern Thailand. PLoS One. 2017;12(3):e0174055. DOI: 10.1371/journal.pone.0174055
89. Pokpermdee P, Mekbunditkul T. Level categorization of sub-district health promoting hospitals in Thailand, 2017 [In Thai]. J Health Sci. 2020;29(2):323-31.
90. Healthcare Accreditation Institute (Public Organization). Primary care: transfer data of Sub-district Health Promoting Hospitals [Internet]. Nonthaburi: Healthcare Accreditation Institute; 2026 [cited 2026 Jul 29]. Available from: https://www.ha.or.th/TH/Contents/Primary%20care%20%E0%B8%82%E0%B9%89%E0%B8%AD%E0%B8%A1%E0%B8%B9%E0%B8%A5%E0%B8%81%E0%B8%B2%E0%B8%A3%E0%B8%96%E0%B9%88%E0%B8%B2%E0%B8%A2%E0%B9%82%E0%B8%AD%E0%B8%99%20%E0%B8%A3%E0%B8%9E%E0%B8%AA%E0%B8%95
91. Mittelmark MB, Sagy S, Eriksson M, et al. Antonovsky's salutogenic health theory as a guide to wellbeing, health promotion, and resilience. Health Promot Int. 2023;38(2):daad017. DOI: 10.1093/heapro/daad017.
92. Ottemöller FG, Matenga TFL, Corbin JH, Nakhuda H, Delobelle P, Ayele C, et al. Re-envisioning health promotion: thinking and acting salutogenically towards equity for historically resilient communities. Glob Health Promot. 2021;28(4):88-96. DOI: 10.1177/17579759211035089
93. Ballard T, Kepple A, Cafiero C. The food insecurity experience scale: development of a global standard for monitoring hunger worldwide. Technical Paper. Rome: FAO; 2013.
94. World Health Organization. Regional Office for the Western Pacific, International Association for the Study of Obesity, International Obesity TaskForce. The Asia-Pacific perspective: Redefining obesity and its treatment. Sydney: Health Communications Australia; 2000.
95. Marshall S. Developing countries face double burden of disease. Bull World Health Organ. 2004;82(7):556.
96. World Health Organization. Regional Office for the Western Pacific, Asia Pacific Observatory on Health Systems and Policies. Thailand health system review. WHO Regional Office for the Western Pacific; 2024.
97. National Institute for Emergency Medicine (NIEM). Emergency Call 1669 [Internet]. Nonthaburi: NIEM; 2026 [cited 2026 Jul 27]. Available from: https://www.niems.go.th/1/?lang=EN.
98. Burden of Disease Research Program Thailand (BOD Thailand), International Health Policy Program (IHPP) Foundation. Burden of disease attributable to risk factors in Thailand 2022. Nonthaburi: IHPP Foundation; 2022.
99. Burden of Disease Research Program Thailand (BOD Thailand). BOD Data Tools: life expectancy and healthy life expectancy of the Thai population, 2019–2024, national and provincial level. Nonthaburi: Burden of Disease Research Program Thailand (BOD Thailand); 2026 Available from: https://bodthai.net/en/bod-data-tools/.
100. Kark S, Kark E. An alternative strategy in community health care: community-oriented primary health care. Isr J Med Sci. 1983;19(8):707 - 713.
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