Global changing in the 21st century which links all countries in systems of society, politics, economics, and culture, makes all countries to adapt to such changes.
In addition, health problems and various factors affecting health, such as environmental problems, chemical usage, natural disaster, risk behaviors, emerging diseases, and the advent of aging society, are more complicated, as well as changing in the definition of "Health" to "Well-being."

Persistent changes of contexts, mechanisms, measures, etc., as well as a paradigm shift, made government system reform to be the main focus of attention in every period. How do agencies under this system adapt to such changes? And, how the MoPH which is responsible for health of all Thais performs its roles and duties in cooperation with new mechanisms such as National Health Security Office (NHSO), Thai Health Promotion Foundation (ThaiHealth), National Health Commission (NHC), and Emergency Medical Institute of Thailand (EMIT), is one of the important issues contributing to roles and structural reform of the MoPH.

Health Systems Research Institute (HSRI), as a technical agency working in line with the MoPH, jointly established the Technical Working Group for developing recommendations on role shifting of the MoPH, chaired by a Deputy Permanent Secretary for Public Health, Dr. Narong  Sahamethapat, using the system approach for dividing health systems into four subsystems, i.e. (1) health services, (2) health promotion, (3) disease and health threat prevention, and (4) pharmaceutical system and consumer protection for health. Under the changing contexts - how do mechanisms in each subsystem shift their roles? how does the MoPH play its roles in those systems? Using the system approach is aimed at expanding the scope of mechanisms - not only the MoPH but also other partners play key roles in jointly driving each subsystem. After conducting research studies, observations and recommendations are as follows:

Analyzing the next step
With Recognizing the changing contexts
•    Changing in health problems which is associated with various factors from the individual to  global level
-    Most referenced data are gathered from the same source, but views of system-oriented problems are some different.

•    The increased number of partners on health, both new public mechanisms
(ThaiHealth, NHSO, NHC, EMIT and local government organizations) and civil society organizations
-    Views and positions on its partners: the MoPH should promote the participatory approach for health development and improve the clarity of models and level of participation.
-    The development of good governance mechanisms for health systems is more complicated. Thus, the MoPH should establish the committees at each level for problem solving.
•    Concepts and new management measures
-    The concept of public management and PMS (Performance Management System / Pay for Performance : P4P) dominates the whole health systems.
-    Although a financial measure is effective in solving many problems, it is widely criticized in terms of causing problems of integrated work and linkage of old work, as well as destroying conventional relations.
-    The concepts of purchaser - provider split for checks and balances and the development of good governance systems are not much recognized.
-    The concept of the establishment of public autonomous mechanisms and public autonomous hospitals is mentioned. However, there are precautions in terms of good governance mechanisms to ensure that this concept will benefit the people.

Paradigm/attitude
•    Having various parties to collaboratively drive health problem solving is deemed as strength rather than threat.
-    The MoPH should coordinate with various parties to collaboratively drive health problem solving, instead of acting as a competitive operator.
•    Participatory process
-    The MoPH should promote a participatory approach in decision making from upstream to downstream.
•    Command and finance are still more powerful than knowledge.

Noticeable issue: New roles of the MoPH
•    The MoPH should act as the National Health Authority by:
-    Seeing problems at the national level and looking beyond mechanisms and structure of the MoPH
-    Acting as the National Health Authority = Top authority or National focal point (collaborative, participatory, and integrative - soft power)
-    Supervising most public health facilities across the country (role of the Office of the Permanent Secretary for Public Health); the MoPH views this issue as strength while the academics view it as an obstacle.
-    Taking roles of a policy maker and supervisor, rather than an operator by formulating policies covering various standards such as information systems and effective knowledge management, to function as a real national authority (power of wisdom), and law enforcement agency, particularly in the case of consumer protection (legal power).

Noticeable issue:  New mechanisms of the MoPH
•    There should be the appointment of the National Health Committee to function as a new mechanism (integration/separation by each subsystem).
-    Recommendations on its roles and its duties are different in terms of the appointment of an advisory committee, policy formulation, or coordination with and linkage of various parties.
-    The National Health Committee should be composed of representatives from various sectors.
-    The problems of overlapping/separation of roles between the National Health Committee and the National Health Commission
-    Appointing many national committees cannot be effective mechanisms; this issue may be resolved by establishing an efficient secretariat equipped with information systems/mechanisms to manage knowledge for supporting the Think Tank.
•    The MoPH should recognize the importance of mechanisms at the regional and provincial levels:
-    Regional mechanisms should focus on a linkage of primary, secondary and tertiary health service systems.
-    Provincial mechanisms should focus on managing public health program.
-    Overall mechanism still lacks clarity - how is the composition of the committee? which mechanism does function as the Secretary? how is the administration at the regional level (using the model of the MoPH or the NHSO’s model), and how do they perform their roles - policy makers, coordinators, or supporters of implementation?
-    Using integrated mechanisms or separation for each subsystem
•    The MoPH at the central level should reduce the number of personnel without reducing its roles (Role shifting).
-    Allocating health personnel to health facilities deemed necessary
-    Building the capacity of personnel for supporting new roles of system managers, knowledge brokers, and policy communicators
•    The role shifting of technical mechanisms at the local level still be lacked of clarity (Regional Centers of departments), particularly the linkage to operational mechanisms
•    The mechanisms and structure must be adjusted together with the attitudes and working methods of personnel.
-    Systems thinking, strategic management, the establishment of proactive networks, development and management of knowledge for creating organizational learning, and positive thinking
-    Adjustment through the learning process among personnel and good support systems

The system approach divides health systems into four subsystems:

•    Health services system
-    The MoPH should address concepts and models of service networks. The networks may be public autonomous agencies, focusing on primary care system (the MoPH called the satellite OP). However, the recommendations on MoPH’s roles due to service system are still not clear enough, particularly health facilities outside the MoPH. The MoPH will be the owner of health facilities as the same in the past, but it should strengthen its capacity building of support systems.
-    The issue of transferring health facilities to the local government is rarely mentioned, and it may not an appropriate model of decentralization.
-    The concept of promoting development through self-organizing is mentioned, by promoting innovations from research studies such as Routine to Research (R2R) work.
-    The academics recommend that the MoPH should oversee health systems as a whole through the National Health Committee; the Director of the Bureau of Policy and Strategy acts as the Secretary.

•    Health promotion system
-    The important roles of the MoPH are surveillance, research and development, monitoring and evaluation, knowledge management, seeking partners and funding agencies, consumer protection, providing service and supporting network of health promotion and environments.

-    There should be the appointment of the National Health Committee for developing a national strategy and setting up a national agenda to drive the problem solving of key issues for achieving the unity of implementation of various agencies. Departments function as the "Think Tank" and "Monitoring and Evaluation center."
-    There should be the establishment of Regional Health Offices for supporting the administration of the MoPH, supervising the implementation of policies, coordinating, and monitoring and evaluation of performance. And, Provincial Health Offices are responsible for supporting such activities at the provincial level.

•    Disease prevention and control system
-    There should be the establishment of the National Disease Control Committee for formulating polices, chaired by Prime Minister, and the National Center for Disease Control (NCDC) functions as the Secretary and focal point for coordinating with partners and monitoring and evaluation of policy implementation under the NCDC Board.
-    The NCDC may be an autonomous government agency or an independent agency with roles of developing policies, technical support, surveillance of diseases and health threat.
-    Agencies at the provincial level and local government organizations have roles in disease prevention and control.

•    Pharmaceutical system and consumer protection for health
-    The MoPH should adjust roles and structure of the Food and Drug Administration (FDA) for preventing interference from political and business sectors
-    The FDA should be divided into three groups in order to: enhance the quality and safety of products, promote the consumption of quality and safety products, and strengthen the institutional capacity. The FDA should be in the government system as usual, but it should increase organization’s efficiency and promote horizontal relationship, headed by a Deputy Secretary-General, or the FDA should be an independent agency.
-    It is not clear that how the FDA performs it duties efficiently and free from                                                                                                                                                                                                                                                                                                                                                         any interference if it still be in the government system. Also, this system does not cover the issue of consumer protection in health services.

Recommendations on the implementation in the next phase
•    Developing a core concept to function as a focal point for further development of subsystems
•    Developing recommendations for enhancing clear roles of the MoPH in each subsystem, through collaboration among the academics/executives of departments under the MoPH and the external academics
•    Developing details of competency of new personnel for early preparation
•    Promoting research and development (R&D) for innovations regarding management.