1Public deliberation has emerged as an essential component of modern democratic governance, offering a response to some of the fundamental limitations of representative democracy. In policy domains characterized by complexity, uncertainty, and value pluralism—such as health policy—deliberative processes serve not only to enhance the legitimacy of decisions but also to improve their substantive quality (Bächtiger et al., 2018; Baker et al., 2021; Thompson, 2008). Deliberative democracy envisions a model of governance in which citizens engage in reasoned dialogue to influence public decisions, guided by mutual understanding, respect, and inclusion (MacKenzie, 2021; Reber, 2023). This stands in contrast to top-down policymaking approaches that often prioritize technical expertise and elite-driven processes. As such, deliberative governance seeks to redistribute power, deepen civic engagement, and ensure that policies reflect the lived experiences and diverse preferences of the population (Burkhalter et al., 2002; Clark, 2018).
2Within this framework, public deliberation refers to an organized process through which citizens, stakeholders, and policymakers come together to discuss societal issues, evaluate policy options, and formulate collective recommendations (Buss et al., 2014). These processes are designed to be inclusive, reflective, and dialogical, incorporating participatory mechanisms such as citizen assemblies, consensus conferences, deliberative polling, and issue forums (Fishkin, 2009; Friess & Eilders, 2015). Among their many benefits, public deliberation can enhance transparency, strengthen public trust, and yield more socially legitimate policy outcomes (Karpowitz & Raphael, 2014). Moreover, by integrating the perspectives of historically marginalized groups, deliberative approaches contribute to democratic equity and social justice (Beauvais & Bächtiger, 2016).
3Globally, the health sector has increasingly embraced deliberative practices, driven by recognition that health outcomes are shaped not only by clinical interventions but also by political, economic, and social determinants (Flynn, 2021; Lynch, 2023; Safaei, 2015). Deliberation allows for the integration of community knowledge, ethical reasoning, and stakeholder interests into health policy processes (Degeling, Carter, & Rychetnik, 2015). Countries such as Canada, the United Kingdom, and Australia have implemented deliberative mechanisms in health governance to inform decisions on contentious issues including resource allocation, vaccination mandates, and end-of-life care. These experiences suggest that deliberation strengthens the legitimacy, responsiveness, and sustainability of health systems (Goodin, 2012; World Health Organization, 2024).
4Thailand presents a particularly compelling case for the study of deliberative health governance. With a robust civil society, a constitutional commitment to participatory governance, and legal mandates supporting citizen involvement, Thailand has institutionalized public deliberation in health policy through formal mechanisms. A key turning point was the enactment of the National Health Act, B. E. 2550 (2007), which established the National Health Commission Office (NHCO) and mandated the creation of the National Health Assembly (NHA), a platform for multi-stakeholder deliberation involving civil society, healthcare professionals, and public officials. Complementing this is the National Health Security Act, B. E. 2545 (2002), which created the National Health Security Office (NHSO) to manage the Universal Coverage Scheme (UCS) and embed participatory mechanisms into health service governance. Together, these two institutions—NHCO and NHSO—constitute the backbone of Thailand’s participatory health governance. The NHCO facilitates multi-stakeholder deliberation and consensus-building through the NHA and regional assemblies (Rasanathan et al., 2012), while the NHSO embeds citizen participation into the design, monitoring, and evaluation of the UCS (Marshall et al., 2021b; World Health Organization, 2023). Their collaboration forms a dual model that links deliberative policymaking with participatory accountability in service delivery.
5Over the past decade, the NHCO and NHSO have played distinct yet complementary roles in fostering participatory governance. NHCO has focused on upstream agenda-setting, capacity building, and policy integration (Rajan et al, 2019). NHSO, on the other hand, has prioritized citizen engagement in operational decision-making, particularly regarding benefit packages and service quality (Chunharas, 2020). Their combined efforts have influenced a wide range of health policies, including those related to elder care, universal health coverage, mental health services, and environmental health protections (Chuengsatiansup et al., 2018; Rahbari Bonab et al., 2023). Importantly, the Thai model emphasizes inclusion, with targeted efforts to engage rural residents, ethnic minorities, persons with disabilities, and other marginalized groups (Rahbari Bonab et al, 2023; Rasanathan et al, 2012; Tangcharoensathien et al., 2018). Nonetheless, challenges remain. Ensuring demographic representativeness in deliberative forums, translating recommendations into enforceable policies, and overcoming bureaucratic resistance and resource constraints all pose barriers to sustained deliberative effectiveness (Hoppe, 2011; Setälä, 2017). These issues were exacerbated during the COVID-19 pandemic, as the shift to digital platforms highlighted significant disparities in internet access and digital literacy (Bejarano, 2022; Hofstra et al., 2023).
6This article investigates the role of public deliberation in Thai health policy development by analyzing a decade of participatory governance initiatives. Drawing on qualitative methods—including document analysis, field observations, focus groups, and stakeholder interviews—it provides an empirically grounded assessment of Thailand’s deliberative infrastructure. The study identifies the enabling conditions for successful deliberation, assesses its policy impacts, and evaluates the institutional, methodological, and societal challenges that shape its effectiveness. By examining Thailand’s experience, the article contributes to a broader understanding of how deliberative democracy can be operationalized in health governance, particularly in middle-income countries. It argues that while deliberation alone cannot resolve all governance challenges, it serves as a vital mechanism for enhancing inclusivity, legitimacy, and effectiveness in health policymaking. In doing so, the study offers practical lessons for scholars, practitioners, and policymakers committed to building resilient, participatory, and people-centered health systems.
7Deliberative democracy emphasizes reasoned dialogue among equal participants in the formulation of public decisions. Beyond procedural legitimacy, it seeks epistemic gains and more just outcomes (Bächtiger et al., 2018; Thompson, 2008). In health governance, deliberation addresses complex trade-offs and value conflicts by enabling pluralistic input (Degeling et al., 2015). The process allows for broader societal values, ethical perspectives, and lived experiences to be incorporated into technical policy considerations, thereby improving both the acceptability and effectiveness of health policy interventions (Clark, 2018; Lynch, 2023).
8Deliberative democracy is grounded in the idea that legitimate lawmaking arises from the public deliberation of free and equal citizens (Bächtiger et al., 2018). It builds on the notion that citizens are capable of engaging in meaningful discussion, not only to express preferences but to justify them in relation to the common good. This model contrasts sharply with aggregative democratic theories, which focus primarily on the tallying of individual preferences through voting mechanisms. Instead, deliberative democracy privileges communicative processes that foster mutual understanding, rational persuasion, and the transformation of preferences considering collective reasoning (Burkhalter et al., 2002). In the context of public policy, particularly in morally and technically complex areas like health, deliberation plays a vital role in balancing expertise with public values (Bosché et al., 2025; Leino et al., 2022). Policies regarding healthcare resource allocation, vaccination mandates, or end-of-life decisions are not merely technical—they are deeply ethical and social. Deliberative spaces allow these dimensions to be surfaced and engaged with in ways that traditional top-down decision-making often neglects. The integration of citizens into these discussions enhances not only the perceived legitimacy of resulting policies but also their alignment with community values (Karpowitz & Raphael, 2014; Fishkin, 2009).
9In operational terms, public deliberation takes on diverse forms. Mini publics such as citizen juries, deliberative polls, and consensus conferences bring together a small, representative group of citizens to deliberate on policy questions over a defined period (Parry et al., 2025). These models are often complemented by large-scale assemblies, such as health forums or national policy dialogues, that engage a broader public. Deliberative methods emphasize structured, inclusive, and informed discussion facilitated by neutral moderators and supported by accessible information (von Schneidemesser et al., 2023). They are designed to mitigate common barriers to participation, such as power imbalances, knowledge asymmetries, and logistical constraints (Beauvais & Bächtiger, 2016; Friess & Eilders, 2015; Selin et al., 2017). Despite their promise, deliberative processes must contend with significant challenges. One of the most persistent is ensuring that forums are genuinely inclusive and not dominated by well-resourced or better-educated participants. Research highlights the risk that socially marginalized groups may be excluded or feel alienated in formal deliberative settings (Setälä, 2017). Another concern is the translation of deliberative outcomes into actual policy. Without institutional pathways or political will, deliberation may become a symbolic exercise that fails to influence decision-making (Fung, 2015; Hoppe, 2011). This challenge underscores the need for institutional embedding, where deliberative practices are not standalone experiments but integrated into the broader policy cycle (Niemeyer et al., 2024).
10Moreover, deliberation must be supported by a robust infrastructure, including trained facilitators, accessible venues (physical or virtual), and continuous feedback loops. Deliberative legitimacy rests on more than procedural fairness, it also requires demonstrable policy responsiveness and follow-through. Evaluative research has shown that when participants see their input reflected in outcomes, trust in public institutions increases, as does their willingness to engage in future democratic activities (Clark, 2018; Buss et al., 2014). Deliberative democratic theory has evolved to account for these implementation challenges. Recent scholarship emphasizes the importance of deliberative systems—a constellation of formal and informal spaces, actors, and processes through which deliberation occurs across society (Bächtiger et al., 2018; Goodin, 2012). From this systems perspective, no single forum needs to meet all deliberative ideals. Rather, the democratic legitimacy of policymaking is assessed based on how well the overall system supports inclusive, reasoned, and consequential public discourse. This systems approach is particularly relevant to national health governance, where deliberation occurs across multiple levels and institutional arenas.
11Importantly, the theory of deliberative systems introduces three core dimensions—epistemic, ethical, and democratic—which are essential for evaluating deliberative quality (Dryzek et al., 2019). The epistemic dimension focuses on the production of well-informed decisions grounded in diverse knowledge. The ethical dimension emphasizes mutual respect and reciprocity among participants. The democratic dimension concerns inclusiveness, representativeness, and equality of voice. A well-functioning deliberative system should perform well across all three, but in practice, these dimensions often exist in tension. For example, technical expertise may dominate epistemic quality at the expense of inclusive dialogue, or efforts to maximize participation may dilute in-depth discussion. Navigating these trade-offs is a key challenge in designing deliberative processes, especially within institutional contexts such as health governance where decisions are high-stakes and time-sensitive.
12Another development in deliberative theory is the increased emphasis on digital deliberation and hybrid formats, particularly in response to the COVID-19 pandemic (Elstub et al., 2021; Hofstra et al., 2023). While traditional in-person deliberation offers depth and immediacy, digital platforms provide scalability and accessibility, especially for geographically dispersed populations (Bonina et al., 2021). However, digital formats introduce new concerns about digital literacy, online behavior, and the integrity of the deliberative environment (Kozyreva, Lewandowsky & Hertwig, 2020). Scholars advocate for a blended approach that combines the strengths of both modalities while mitigating their weaknesses (Polizzi & Harrison, 2022). As countries like Thailand expand their use of digital engagement tools, attention to design, facilitation, and digital equity becomes increasingly important (Robru et al., 2024; Tantivess et al., 2017; Teerawattananon et al., 2023).
13Applying these theoretical insights to Thailand, this article assesses how institutions such as the NHCO and NHSO have sought to construct a deliberative system within the health policy domain. The Thai case demonstrates how a middle-income country with a history of centralized decision-making can embed deliberative principles into national governance structures. It also illustrates the tensions and trade-offs inherent in institutionalizing public participation within bureaucratic settings. The Thai case illustrates that inclusiveness, representativeness, and equality of voice rarely advance in parallel. Efforts to broaden inclusiveness through the recruitment of rural residents, ethnic minorities, and marginalized groups often result in uneven demographic representation, as logistical and socioeconomic barriers restrict full participation. Likewise, facilitation strategies designed to equalize voice within deliberative forums cannot fully offset disparities in education, digital literacy, and social capital—revealing that expanding the scope of inclusion can inadvertently deepen asymmetries in influence. The analysis that follows explores how design choices, stakeholder engagement strategies, and political context have shaped the practice and outcomes of health-related deliberation in Thailand. By doing so, it aims to extend deliberative theory through grounded empirical inquiry and to inform the practice of democratic health governance globally.
14Thailand’s participatory health governance rests on two institutional pillars: the National Health Commission Office (NHCO) and the National Health Security Office (NHSO). Both agencies emerged from reform efforts in the early 2000s and derive their authority from legislation that enshrined citizen participation as a statutory principle of health policymaking.
15The NHCO, established under the National Health Act B.E. 2550 (2007), serves as the secretariat to the National Health Commission chaired by the Prime Minister and coordinates participatory health governance across state agencies, academia, and civil society. Its central instrument is the NHA, a recurring multi-stakeholder forum where diverse actors identify health priorities, deliberate on policy options, and adopt non-binding resolutions (Rasanathan et al., 2012; Kantamaturapoj et al., 2018). Although NHA resolutions do not carry legal force, the NHCO is mandated to submit them to relevant ministries and advocate for their uptake. Over the past decade, several resolutions have informed cabinet decisions, national strategies, and policy commissions—such as those on universal access to medicines and health impact assessment (Kantamaturapoj et al., 2019; Rahbari Bonab et al., 2023). The NHA has also expanded through regional assemblies, digital participation tools, and targeted capacity building to strengthen inclusion of marginalized groups, contributing to Thailand’s international reputation as a pioneer of “healthy public policy” (Rajan et al., 2019).
16The NHSO, established under the National Health Security Act B.E. 2545 (2002), is responsible for managing the Universal Coverage Scheme (UCS), which now covers more than 99 percent of the population. Its governance structure embeds public accountability through citizen seats on the National Health Security Board and participatory processes such as annual public hearings, beneficiary feedback mechanisms, grievance channels, and local Health Security Funds (Tangcharoensathien et al., 2018; Marshall et al., 2021b; Viriyathorn et al., 2023). These mechanisms allow citizens and civil society groups to influence benefit-package design, service standards, and resource allocation. In recent years, NHSO consultations have extended to emerging policy domains, including telemedicine, chronic disease management, and long-term care, reflecting a broader shift toward participatory health financing (Kantamaturapoj et al., 2018).
17Although the NHCO and NHSO differ in mandate—deliberative agenda-setting versus participatory implementation—they remain complementary. The NHCO generates upstream consensus on national health priorities, while the NHSO translates these priorities into operational frameworks, budgets, and service standards. In some cases, NHA resolutions have directly influenced NHSO policy, including long-term care initiatives and expanded mental health services (Chuengsatiansup et al., 2018). Together, they form a multi-scalar participatory architecture that institutionalizes deliberation both as a forum for civic voice and as a mechanism for policy accountability. This integrated model continues to attract attention as a potential blueprint for middle-income countries seeking to democratize health governance without undermining administrative functionality.
18To explore how public deliberation has influenced health policy development in Thailand, this study employed a qualitative research design incorporating multiple data sources and collection methods. The use of qualitative methods is particularly suited to capturing the rich, contextualized experiences and perceptions of stakeholders engaged in deliberative processes (Jacobs et al., 2021) It also facilitates the analysis of non-quantifiable dimensions such as legitimacy, inclusivity, and discursive quality—key concerns in deliberative democratic theory (Plamondon et al., 2015). The research design involved four complementary methods: document analysis, participant observation, focus groups, and in-depth interviews. These methods were selected to enable triangulation of data and ensure a comprehensive understanding of both the processes and outcomes associated with deliberative health governance.
19Document analysis provided a foundational understanding of the evolution, scope, and institutionalization of public deliberation in Thailand’s health sector. Primary sources included policy documents, government reports, strategic plans, and resolutions issued by the NHA). Additional sources included meeting minutes, procedural guidelines, NHCO and NHSO annual reports, and briefing materials distributed at deliberative forums. These documents were systematically coded and analyzed to trace how deliberation was formally structured, operationalized, and embedded into policy processes.
20Observation was conducted at three deliberative events organized by the NHCO and NHSO, including two regional health assemblies and one NHA. Both direct and participatory observation techniques were used. Direct observation focused on facilitation styles, participant interaction, and discursive dynamics. Participatory observation enabled the researcher to engage in informal conversations and gain firsthand insight into deliberative norms, power asymmetries, and the authenticity of inclusion. Detailed field notes were kept throughout the observation period, and key moments were transcribed and coded thematically.
21A total of six focus groups were conducted to capture a range of stakeholder perspectives. Participants included community health volunteers, local government officials, healthcare providers, representatives from civil society organizations, and members of marginalized groups (e. g., ethnic minorities, persons with disabilities). Each group comprised six to 10 participants and was guided by a semi-structured discussion guide. Topics included perceptions of inclusiveness, effectiveness of facilitation, accessibility of information, and the influence of deliberation on health policy outcomes. Sessions were audio-recorded and transcribed verbatim, and thematic analysis was applied to identify recurring themes and divergent viewpoints.
22Twenty-five semi-structured interviews were conducted with key informants across the deliberative system. Interviewees included NHCO and NHSO officials, deliberation facilitators, local community leaders, and academic experts. Interview questions focused on institutional design, recruitment strategies, perceived barriers to participation, and mechanisms for linking deliberation to policy implementation. Interviews lasted between 45 and 90 minutes, were conducted in Thai or English depending on respondent preference, and were transcribed, translated (if necessary), and coded thematically.
23All qualitative data were analyzed using a thematic analysis approach supported by NVivo software. The analysis focused on identifying patterns related to deliberative inclusivity, institutional design, policy influence, and perceived legitimacy. Codes were developed inductively based on emergent themes and refined iteratively through team discussion. Data from the four methods were triangulated to validate findings and enhance interpretive rigor. The study adhered to ethical research standards, with approval obtained from the Institutional Review Board of the researchers’ home institution. Informed consent was secured from all participants. Anonymity and confidentiality were maintained throughout, and participants were informed of their right to withdraw at any point. By combining diverse data sources and collection techniques, this methodological approach provides a robust basis for evaluating the design, functioning, and impact of public deliberation in Thai health policy.
24The findings from this study provide insight into how public deliberation has shaped Thailand’s health policy development over the past decade. Thematic analysis of the collected data revealed five major themes that collectively demonstrate both the promise and challenges of deliberative governance in practice. These themes include: (1) representative recruitment; (2) inclusive and adaptive engagement methods; (3) linking deliberation to policy outcomes; (4) capacity building; and (5) ongoing challenges and opportunities.
25Ensuring a representative cross-section of Thai society within deliberative forums has been a central goal for the NHCO and NHSO (Rahbari Bonab et al, 2023; Rasanathan et al, 2012; Tangcharoensathien et al., 2018). The findings from document analysis, participant observation, and stakeholder interviews indicate that both institutions employed mixed recruitment strategies, combining random selection with targeted outreach to underrepresented groups. Recruitment efforts consistently prioritized rural residents, ethnic minorities, older adults, youth, and persons with disabilities—populations that have historically been marginalized in formal policy processes. NHCO policy documents and procedural guidelines revealed the use of community mapping and quota criteria to identify these groups, while observation at regional assemblies showed how civil society partners and local health volunteers were mobilized to carry out on-the-ground outreach. Focus group participants frequently emphasized that these intermediaries played a crucial role in building trust and overcoming skepticism, particularly in communities with limited prior engagement in national policy forums. Interviews with community-based organizations further highlighted their function as cultural and linguistic brokers, helping bridge communication gaps among ethnic minority participants. In several sites, local leaders acted as conveners, using their social capital to encourage participation and legitimize the deliberative process within their communities.
26Document analysis and interviews with NHCO officials confirm that the NHA applies a stratified sortition model designed to balance representation across three constituencies—government agencies, academia and professional associations, and civil society organizations—each comprising roughly one-third of total participants. Within the civil society constituency, annual quota adjustments were documented in NHCO procedural guidelines, and observation of preparatory meetings showed how these adjustments aimed to enhance participation among underrepresented groups such as ethnic minorities, persons with disabilities, and youth. Interview data further revealed that civil society networks play an advisory role in proposing oversampling criteria, offering recommendations through consultative forums convened by NHCO. However, as several informants emphasized, the ultimate authority over quota approval rests with the NHCO Secretariat. This collaborative yet asymmetric arrangement—visible both in meeting transcripts and in stakeholder accounts—illustrates how participatory recruitment mechanisms can broaden inclusion without fully democratizing decision-making over representation.
27Logistical and economic barriers were among the most frequently cited challenges to achieving broad representation in deliberative forums (Angst et al., 2022; Dienel et al., 2024; Zuhair & Kurian, 2016). Many potential participants, particularly those from remote provinces or economically disadvantaged households, expressed concerns about the financial and time-related costs associated with participation. These included expenses related to travel, lost income from time away from work, and the absence of childcare support. A focus group participant from a rural southern province stated, “I wanted to join, but I couldn’t afford to leave my market stall for a whole day without losing income.” Another community member from the northern highlands shared that, “traveling to the provincial capital takes a full day and costs more than I make in two days.”
28Recognizing these constraints, the NHCO implemented a range of support measures, including transportation stipends, meal provisions, and modest honoraria for participants’ time. One interviewee from a civil society organization noted that “this kind of support was essential—without it, many grassroots participants simply wouldn’t show up.” These accommodations were widely appreciated and often described by participants as instrumental in making participation feasible. A mother of three from a peri-urban district recalled, “They helped me with transport and even allowed me to bring my child. That made all the difference.” By directly addressing these logistical and economic hurdles, NHCO demonstrated a strong institutional commitment to lowering participation thresholds and ensuring that voices from the margins could be included in national policy deliberations.
29The document review and observation of assembly preparations showed that pre-deliberation workshops and capacity-building sessions were central features of Thailand’s participatory design. These sessions aimed to strengthen participants’ procedural understanding, build confidence, and reduce knowledge gaps, thereby enabling meaningful contributions regardless of prior policy experience. Observation notes indicate that the workshops covered both substantive policy content and deliberative norms—such as respectful dialogue, evidence-based argumentation, and collaborative problem-solving—contributing to higher-quality exchanges during formal sessions. Focus group testimony reinforced these observations, with participants frequently citing the training as a key factor in feeling prepared to speak. These preparatory activities ultimately laid the groundwork for the inclusive facilitation and adaptive engagement strategies examined in Section 5.2.
30Despite these proactive measures, interview, observation, and focus group data showed that achieving full demographic parity remained challenging. Representation of rural residents and ethnic minorities increased, but transient populations—such as migrant workers, informal laborers, and urban poor communities—were consistently underrepresented due to weak organizational ties and unstable living conditions. The shift to online and hybrid formats during COVID-19 created additional obstacles for individuals lacking devices, reliable internet, or digital skills. These findings indicate that, while NHCO and NHSO have expanded the breadth of inclusion, further innovations in outreach will be required to engage highly mobile and hard-to-reach groups. Strengthening collaboration with labor unions, urban advocacy networks, and mobile community teams may help close this gap and ensure that those most affected by policy decisions can participate on more equal footing.
31The quality and legitimacy of deliberative processes depend not only on who is included, but also on how they are engaged (Niemeyer et al, 2024; Pogrebinschi & Ryan, 2018). Document analysis, observation, and interview data show that both NHCO and NHSO employed inclusive and adaptive engagement methods tailored to diverse participant needs. Observations of regional and national forums revealed a structured approach combining plenary sessions—used to introduce key themes—with small-group deliberation that enabled more personal, reflective exchange. This format helped reduce participation barriers by encouraging quieter or less confident individuals to speak, particularly in groups with mixed socioeconomic and educational backgrounds. Interviews with facilitators confirmed that targeted training in inclusive dialogue and power-sensitive moderation was essential for managing dominant voices and fostering respectful deliberation. Document analysis and workshop materials also showed sustained investment in informed-engagement tools, including simplified information packets, infographics, and visual aids, often translated into regional languages. Technical experts were made available during sessions to answer questions—an arrangement that, according to focus group accounts, improved comprehension of policy trade-offs and complex evidence.
32At the same time, the empirical data underscore that formal inclusion did not automatically translate into equitable participation. Field observations showed that, although recruitment processes brought rural participants, ethnic minorities, persons with disabilities, and grassroots civil society actors into the room, deliberative exchanges were often dominated by participants with higher education levels, professional affiliations, or prior policy experience. Interview responses pointed to technical vocabulary, formal presentation norms, and bureaucratic procedures as discursive filters that privileged experts, NGO leaders, and health professionals. As reflected in multiple focus groups, this dynamic produced breadth without balance: marginalized actors were present and visible, yet their influence on consensus formation remained limited. These patterns demonstrate the persistence of epistemic hierarchies in deliberative spaces, where asymmetries in knowledge, language, and social capital continue to shape whose voices carry weight in final recommendations.
33An important adaptation in Thailand’s deliberative model was the deliberate attention to cultural and regional diversity (Boossabong & Chamchong, 2019; Buchenrieder et al., 2017). Recognizing the country’s multiethnic composition, particularly in northern and border provinces, the NHCO and NHSO implemented culturally responsive strategies to ensure effective and inclusive engagement (Rajan et al., 2019). In regions with large ethnic minority populations—such as the Karen, Hmong, or Malay-Muslim communities—deliberative sessions were conducted in local dialects with the assistance of trained community translators. This linguistic accommodation not only improved comprehension and participation but also affirmed the legitimacy of minority worldviews and traditional knowledge systems. Participants often emphasized that the use of local language and culturally appropriate communication methods contributed to their comfort, sense of belonging, and sustained participation. In some cases, culturally adapted visual aids, storytelling techniques, and religious references were also used to bridge conceptual gaps and support dialogue on sensitive issues such as reproductive health or mental illness.
34The COVID-19 pandemic catalyzed a rapid digital transformation of deliberative processes (Bejarano, 2022; Dienel et al., 2024). To maintain continuity, NHCO and NHSO transitioned to virtual and hybrid models, which expanded the geographic reach of deliberation, enabling participation from remote and previously underserved areas. These virtual deliberations were primarily conducted through Zoom and Microsoft Teams, which enabled both plenary discussions and smaller breakout sessions for focused dialogue. For asynchronous communication and coordination, participants relied on LINE and Facebook Groups, allowing ongoing exchange of documents, photos, and discussion threads between sessions. Google Forms and Mentimeter were employed to collect feedback, conduct live polls, and gauge levels of agreement during real-time sessions. These tools were chosen for their accessibility across devices, including smartphones, and their familiarity among Thai users, which helped mitigate digital literacy barriers and sustain engagement despite connectivity limitations. However, the digital shift also exposed significant inequities in infrastructure and literacy. Many participants, particularly older adults and low-income individuals, faced difficulties with unstable internet connections, unfamiliarity with conferencing platforms, and a lack of private or quiet space at home.
35To deepen engagement and ensure that deliberation moved beyond a one-off event, the NHCO designed deliberative processes to unfold over multiple sessions (Marshall et al., 2021a; World Health Organization, 2023). This multi-phase structure allowed participants to reflect on discussions, revisit unresolved issues, and build upon earlier dialogue. Between sessions, participants received plain-language summaries of key points, updates on how their contributions were incorporated, and opportunities to revise or refine draft resolutions. This iterative process promoted continuity, reduced misunderstandings, and enabled the integration of evolving perspectives. By fostering ongoing dialogue and shared ownership of outcomes, the approach strengthened trust, improved the quality of recommendations, and reinforced the legitimacy of the process. The design and distribution of these onboarding materials—ranging from simplified policy briefs and visual aids to local-language summaries—played a key role in reducing informational asymmetries and enabling participants from diverse educational backgrounds to engage meaningfully. The impact of these materials on participant learning and deliberative depth is discussed further in Section 5.4.
36Finally, process tracing revealed that inclusion affected substance, not merely procedure. Focus-group accounts and observation data showed that community health volunteers, grassroots networks, and civil society organizations reframed problem definitions and broadened policy criteria—prioritizing distributive impacts, local feasibility, and rights-based language. These interventions pushed working groups to integrate lived experience alongside expert evidence, demonstrating that inclusive recruitment was substantively consequential in shaping policy recommendations.
37A critical measure of deliberative effectiveness lies in whether public input meaningfully influences policy development and implementation (Bua, 2017; Bua & Escobar, 2018). In Thailand, the NHCO has established formal mechanisms to ensure that resolutions and recommendations from the NHA are systematically transmitted to relevant government bodies. This linkage between deliberation and policy has helped legitimize participatory processes and demonstrate their utility within formal governance structures. In particular, deliberative forums such as the NHA serve not only as symbolic spaces but also as institutional mechanisms that connect citizen input with formal policy processes. These forums enable a structured pathway for translating public concerns into actionable policy recommendations. The resolution process facilitated by the NHCO typically begins with thematic working groups that gather and synthesize stakeholder input to develop draft proposals. These proposals are then brought forward during assembly sessions, where they are thoroughly debated, revised, and finalized through consensus-building among diverse participants. Once adopted, the final resolutions are formally transmitted to the relevant government ministries or agencies for consideration. Ministries are expected to provide a response, which may involve incorporating the resolutions into national strategies, launching pilot projects to test feasibility, or issuing a formal explanation when a proposal cannot be implemented. This feedback loop strengthens transparency and reinforces the legitimacy of participatory policymaking.
Figure 1. Procedural Pathway from NHA Resolution to Policy Action
Source: the Authors
38A number of health policy initiatives in Thailand trace their origins to deliberations conducted through the NHA. One prominent example is the development of national policies on elder care, which emerged from multiple years of discussion emphasizing the needs of aging rural populations (Chuengsatiansup et al., 2018; Tejativaddhana et al., 2022). A local health volunteer from the northeast recalled, “We spoke about how elders in our village live alone without proper care, and the assembly helped bring attention to that.” This dialogue eventually contributed to the formulation of long-term care models adopted by the Ministry of Public Health and the NHSO. Other deliberative successes include environmental health regulations addressing community exposure to hazardous chemicals, especially in areas near industrial zones (Kanchanachitra et al., 2018). One civil society representative interviewed noted that “people affected by pollution finally had a platform to share their evidence and push for stricter oversight.” Similarly, guidelines for mental health promotion—particularly within the primary care system—were shaped through stakeholder discussions led by professionals, caregivers, and affected individuals (Buasai et al., 2007; Pandey et al., 2022). A participant with lived experience of mental illness stated during a focus group that “sharing my story in the assembly made me feel heard, and now I see parts of it reflected in the new mental health screening tools.” These outcomes underscore the ability of deliberative processes to surface emerging health concerns that may be underrepresented in traditional policy channels. They also illustrate how community-informed proposals, when deliberated in inclusive and structured forums, can influence national policy agendas and institutional priorities.
39However, triangulated evidence from document analysis, interviews, and participant observations indicates that the translation of NHA resolutions into concrete policy action remains hindered by entrenched structural constraints. Interviewees and observation notes consistently pointed to bureaucratic inertia, weak inter-agency coordination, and fragmented mandates, which slowed policy follow-through even after deliberative consensus. These findings align with policy documents and prior studies that show that fiscal limitations and competing agendas frequently prevented ministries from operationalizing resolutions (Marshall et al., 2021b; Tejativaddhana et al., 2022; Watabe et al., 2017). Resolutions involving politically sensitive issues or challenges to established interests faced institutional resistance and low political incentives, resulting in delays or non-uptake (Rasanathan et al., 2011; Thondoo et al., 2019; Thondoo & Gupta, 2021). Participants and stakeholders cautioned that without stronger institutional commitment, deliberation risked becoming a “talking shop,” underscoring how the absence of binding authority, stable budgets, and bureaucratic incentives can render participatory outputs symbolic rather than transformative.
40Over time, however, the degree of policy uptake has varied significantly. Triangulated evidence from document analysis, interviews, and observation shows that the responsiveness of state agencies to NHA resolutions and NHSO participatory outputs has risen and receded alongside broader political shifts. Periods of elected government were generally associated with higher bureaucratic engagement and stronger follow-through, whereas episodes of authoritarian consolidation weakened implementation by re-centralizing decision-making authority and limiting inter-agency coordination. Since 2019, renewed—though uneven—policy receptiveness has emerged, supported by digital participation tools and selective cross-agency collaboration. As summarized in Table 1, these fluctuations illustrate that bureaucratic resistance and political fragmentation are cyclical rather than constant, shaped by changing political incentives and institutional conditions.
Table 1: Timeline of Bureaucratic Responsiveness to NHA Resolutions and NHSO Deliberative Outputs, 2008–2024
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Period
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Political Context
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Deliberative Phase
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Characteristics of Responsiveness and Policy Uptake
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|
2008 – 2013
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Elected governments; expansion of universal health coverage
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Initial Consolidation
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High bureaucratic engagement; NHA resolutions on essential drug access and health impact assessment adopted into ministerial policies; strong collaboration between NHCO, NHSO, and civil society.
|
|
2014 – 2018
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Military rule and bureaucratic centralization
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Constraint Phase
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Reduced implementation of deliberative resolutions; emphasis on administrative control and regime stability; limited inter-agency coordination and participatory follow-through.
|
|
2019 – 2024
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Return to semi-electoral governance; digital reform initiatives
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Adaptive Renewal
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Gradual recovery of participatory mechanisms; introduction of hybrid (online/offline) forums, renewed cross-agency collaboration, and incremental reintegration of NHA outcomes into national strategies.
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Source: the Authors
41Learning from prior implementation challenges, both the NHCO and NHSO introduced accountability mechanisms to mitigate constraints on policy uptake. These included post-assembly monitoring reports, annual stakeholder review forums, participatory public hearings, and the publication of resolution-uptake metrics, all of which enhanced transparency by tracking follow-through and identifying gaps requiring renewed advocacy. Interview data further indicated that when resolutions informed successful NHSO-led policy pilots—particularly in service delivery and benefit-package reforms—the results were leveraged to build political momentum and secure ministry-level budget commitments. Observation of repeated agenda cycles also showed that the iterative design of the NHA process enabled unresolved issues to be revisited across multiple years, creating a durable platform for incremental policy development and sustained engagement on complex or contested topics. Despite these institutional safeguards, the durability and quality of deliberative outcomes still hinged on the capacity of participants to contribute on equal footing, which in turn made systematic capacity building an essential next pillar of the deliberative system, as discussed in the next section.
42Capacity building is a cornerstone of Thailand’s approach to deliberative health governance. Ensuring that all participants are adequately prepared and supported to engage in meaningful dialogue is essential for equitable and effective deliberation (Beauvais & Baechtiger, 2016; Plamondon et al., 2024). The importance of capacity building was especially visible in the preparatory materials used to scaffold participant understanding before deliberation. For example, the Facts and Figures briefing document produced by NHCO and its partners (available online at http://digital.nlt.go.th/dlib/files/original/6f548e7eb2ceadbf979ca5a073e103c7.pdf) provided a clear, non-technical synthesis of Thailand’s health system challenges, including political conflict, socioeconomic disparities, and environmental threats, all framed through the Social Determinants of Health (SDH) perspective. Focus group participants noted that such materials helped them “see the whole picture” prior to discussion, while observation confirmed that these tools were essential for marginalized participants who lacked prior policy exposure and typically had less time to fact-check or review complex sources on their own. By combining simplified evidence with structured orientation sessions and trained facilitators, NHCO and NHSO strengthened cognitive accessibility at the individual level, enhanced facilitator preparedness to navigate sensitive or technical topics, and reinforced an institutional practice of providing shared baselines of knowledge as part of every deliberative cycle.
43At the individual level, NHCO regularly organized pre-deliberation orientation sessions for participants. These sessions covered the basics of the health issue under discussion, the objectives of the deliberative process, and the principles of respectful and constructive dialogue. For participants from disadvantaged or marginalized backgrounds, these sessions were especially critical in boosting confidence and enabling substantive contributions. One ethnic minority participant from a northern province remarked during a focus group that “before the training, I didn’t know how to speak in a big group, but they made us feel it was okay to ask questions and give our ideas.” Similarly, a youth participant noted that “the orientation helped me realize that even as a student, I had something valuable to contribute.”
44Facilitators also received specialized training in deliberative methods, inclusive facilitation, and conflict resolution. According to one NHCO official interviewed, this training was “vital to ensuring that the quieter voices are heard, especially in diverse groups with differing education levels or social backgrounds.” These skills proved essential in managing group dynamics, addressing unequal power relations, and encouraging broad participation. The NHSO also maintained a peer-learning network among facilitators, enabling the exchange of experiences and best practices across regions. One facilitator from the southern region described how this network allowed her to “adapt techniques that worked well in the northeast to our own context with local adjustments.”
45At the institutional level, NHCO and NHSO developed comprehensive guidelines and operational manuals to standardize deliberative processes. In addition, partnerships with academic institutions and non-governmental organizations were leveraged to provide technical support, develop training curricula, and enhance institutional knowledge. An interviewee from a university public health department emphasized that such collaborations “ensured academic rigor while remaining grounded in real-world community needs.”
46Despite these advances, capacity-building challenges remain. Limited resources constrained the frequency and geographic reach of training activities, especially in rural or remote provinces. Several local officials noted that “we wanted more refresher trainings, but budget and time were always a problem.” There was also a need to adapt materials and delivery modes for digital formats as deliberation shifted online. One community health volunteer from a border province explained, “the training was good, but once it went online, many elders couldn’t follow without help.” Moving forward, enhancing decentralized training capacity and tailoring support for specific groups such as youth, persons with disabilities, and informal workers will be essential for deepening inclusive participation.
47While Thailand’s deliberative infrastructure has evolved considerably over the past decade, several persistent challenges continue to affect the depth, breadth, and sustainability of public deliberation. These challenges exist across structural, procedural, and societal dimensions and must be addressed to realize the full potential of deliberative governance in the health sector.
48One of the most pressing challenges is resource limitation. Both NHCO and NHSO operate under budgetary and staffing constraints that limit the scale and frequency of deliberative activities. Organizing inclusive and meaningful deliberative events requires significant investment in facilitation, outreach, training, translation, and logistics. This is especially true in rural or underserved regions where additional supports—such as travel allowances and capacity-building workshops—are essential for participation. These costs often strain the resources of coordinating institutions and hinder long-term planning.
49Bureaucratic resistance also poses a significant obstacle to the full integration of deliberative processes into formal governance structures. While some government agencies have demonstrated openness to incorporating citizen-generated inputs, others remain skeptical, cautious, or altogether dismissive. This study found that the responsiveness of ministries and implementing bodies often depended on the prevailing political climate, the personal inclinations of agency leadership, and their perception of the legitimacy and utility of the deliberative forum. One NHCO staff member observed during an interview that “some departments see the NHA as a meaningful consultative space, while others still treat it as a side activity with little consequence.”
50Several participants reported experiencing disappointment when resolutions they helped draft were not acted upon or were significantly watered down during policy translation. A civil society representative described how “our mental health resolution was well-received at the assembly, but when it reached the ministry, only a few points were taken seriously.” Another rural participant expressed frustration, saying, “We spent months discussing these issues, but there was no feedback, no update—it felt like our voices went into a black hole.” Such inconsistencies can weaken institutional trust and risk undermining the very participatory ethos that deliberative governance aims to foster. While some interviewees acknowledged that ministries face competing priorities and bureaucratic constraints, they emphasized the need for clearer pathways, follow-up mechanisms, and political commitment to ensure that citizen inputs are not merely symbolic but substantively reflected in final policy decisions.
51Another challenge involves the digital divide, which became especially visible during the COVID-19 pandemic. As deliberation moved online, disparities in digital access and literacy hindered participation among older adults, persons with disabilities, and residents in areas with limited infrastructure. Although NHCO took steps to mitigate these effects—through digital literacy training and hybrid models—long-term solutions require more investment in accessible digital infrastructure and inclusive design.
52Despite these challenges, several promising opportunities have emerged. The growing institutionalization of the NHA, along with increasing intersectoral collaboration, has strengthened the legitimacy and visibility of deliberative processes. Partnerships with civil society organizations, academic institutions, and local governments offer new channels for outreach, innovation, and co-implementation. There is also a rising awareness among policymakers and the public about the value of participatory governance. As public trust in top-down decision-making declines globally, deliberative methods are gaining traction as viable, credible, and constructive alternatives. International recognition of Thailand’s deliberative practices, including through WHO and development partners, reinforces the country’s leadership role in participatory health governance.
53The findings of this study underscore Thailand’s unique and evolving model of embedding deliberative democratic practices within its health policy system. By institutionalizing public deliberation through agencies such as the NHCO and NHSO, Thailand has created a participatory infrastructure notable for its inclusivity, adaptability, and long-term continuity. These features distinguish the Thai case from more ad hoc or externally driven participatory initiatives, such as short-term donor-funded consultations or pilot projects that lack long-term institutional integration. Unlike these often fragmented efforts, Thailand’s model is sustained through legal mandates, recurrent forums like the NHA, and formal mechanisms linking public input to state policy channels. This distinctiveness becomes clearer when viewed in comparative perspective. Compared with short-lived deliberative initiatives such as the Leicester citizens’ jury in the United Kingdom (Goodin & Dryzek, 2006), Thailand’s experience demonstrates how a polycentric network—anchored in the NHCO–NHA and NHSO systems—can institutionalize deliberation across scales and sustain it beyond episodic consultation. The Thai case thus provides an important lesson on how deliberative legitimacy can be consolidated through iterative, connected mechanisms rather than isolated mini-publics.
54 The Thai experience contributes meaningfully to deliberative systems scholarship by demonstrating how participation can be institutionalized across multiple, interconnected venues rather than confined to a single forum (Bächtiger et al., 2018 ; Goodin, 2012). Within this architecture, the NHCO and NHSO serve as coordinating hubs that translate public input into policy pathways—one through norm-setting and consensus-building, the other through operational planning and budget implementation. Yet, the system remains largely consultative ; deliberation is continuous and procedurally robust, but agenda control stays top-down. Unlike empowered models such as Ostbelgien (Junius, 2025) or the Paris Citizens’ Assembly (Galván Labrador & Zografos, 2024), the NHA cannot independently set issue salience or trigger binding reform, limiting its capacity to shape political “agon” or assert issue ownership (Bauböck & Nicolaïdis, 2025). This structural choice raises broader questions about which policy domains states are willing to open to citizen input and how resource constraints shape the boundaries of participatory experimentation. Even so, Thailand’s hybrid system offers a valuable reference for future research on how consultative mini-publics might gradually expand agenda-setting roles without destabilizing institutional cooperation.
55The perceived legitimacy of Thailand’s model is closely tied to its procedural design. Evidence from prior studies shows that inclusive facilitation, transparent rules, and accessible information correlate with higher participant trust and satisfaction (Karpowitz & Raphael, 2014 ; Fishkin, 2009). Thailand’s emphasis on inclusive recruitment, multilingual communication, and trained facilitators reflects a deliberate effort to counterbalance unequal voice and elevate marginalized perspectives. The NHA’s iterative format—revisiting issues over multiple years—further supports policy learning and reinforces the link between participation and responsiveness.
56However, persistent structural constraints continue to limit deliberative equality. Resource disparities hinder outreach in remote areas, political turnover disrupts policy uptake, and digital inequities restrict participation among disadvantaged groups. These conditions illustrate a broader normative tension : inclusiveness, representativeness, and equality of voice cannot be simultaneously maximized in contexts marked by socioeconomic and institutional asymmetries. The goal, therefore, is not to eliminate these asymmetries but to manage them transparently and adaptively. This challenge is especially visible in representation rules, where civil society can advise on quotas but lacks binding authority over final decisions. Strengthening feedback loops is essential to ensure that early participation in design translates into consequential influence over implementation and evaluation. Thailand’s experience also offers important insights into the sustainability of deliberative governance. The long-term viability of such systems depends not only on institutional design but also on cultural and normative shifts that embrace participation as a core democratic value. This includes investing in civic education, promoting dialogue-based policymaking within the bureaucracy, and incentivizing inter-agency cooperation. Without these supporting conditions, deliberation risks being confined to symbolic gestures rather than delivering substantive contributions to policymaking.
57Despite Thailand’s progress in institutionalizing deliberative health governance, the system remains vulnerable to shifts in the political landscape. Although the National Health Act provides a durable legal foundation, the effectiveness of participatory mechanisms ultimately hinges on the willingness of state actors to share authority. This tension between legal durability and political adaptability reveals both the strength and fragility of Thailand’s model : institutions can preserve deliberative form, but their democratic substance depends on sustained commitment from governing elites, bureaucrats, and civic actors.
58At the same time, Thailand’s trajectory presents meaningful opportunities. International recognition—including endorsements from the World Health Organization and development partners—has reinforced support for participatory approaches. Thailand aligns closely with emerging WHO frameworks on social participation for Universal Health Coverage, which emphasize institutionalized consultation and accountability. Yet unlike the climate domain, where Article 6 of the UNFCCC has enabled multi-level citizens’ assemblies, WHO guidance remains consultative rather than mandate-driven, limiting trans-scalar linkage. Thailand therefore illustrates the next frontier for global health governance : connecting national deliberative systems to regional and transnational participatory networks. Expanding hybrid participation, strengthening civil society co-design, and extending deliberation to additional policy sectors offer promising pathways for deepening impact.
59In conclusion, Thailand’s model of deliberative health governance demonstrates that public deliberation—when embedded within supportive institutions and guided by inclusive design—can serve as a powerful mechanism for both democratic deepening and policy innovation. While challenges remain, the trajectory of Thailand’s participatory reforms suggests that deliberation can evolve from a peripheral experiment into a central pillar of policymaking. This case affirms the relevance of deliberative democracy not just as a theoretical ideal, but as a practical approach to governance—particularly for societies navigating complex, pluralistic, and rapidly changing policy environments. Future research should continue to investigate the long-term impacts of deliberative participation on public health outcomes, explore the dynamics of deliberation in decentralized administrative settings, and examine the intersection of digital technology and democratic inclusion. Expanding comparative analyses across countries at different income levels would further enrich understanding of how contextual factors shape the institutionalization and effectiveness of deliberative systems in the Global South.
