Exploring the Policy Feedback Effects of a No-Fault Compensation Scheme for COVID-19 Vaccine Injuries in Thailand: A Qualitative Study

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This policy aimed to promote vaccine confidence, reduce litigation and enhance healthcare system resilience. This study investigates the policy feedback effects of Thailand’s NFCS and its implications for healthcare governance in low- and middle-income countries (LMICs). Methods A qualitative multi-method approach was employed. Data sources included government policy documents, peer-reviewed literature, media content, official NHSO reports, five semi-structured interviews with key stakeholders and a focus group discussion with public health experts. Media content analysis included over 100 news reports published between March 2021 and October 2022. The analysis was guided by Policy Feedback Theory to identify self-reinforcing and self-undermining feedback loops. Results Between April 2021 and September 2023, 22,695 compensation claims were filed, with 84.0% approved. The NFCS reduced litigation risks, built public trust and contributed to high vaccine uptake. Self-reinforcing feedback effects were observed in administrative innovations, public engagement strategies and cross-scheme equity. However, self-undermining effects such as financial strain and increased public expectations emerged. Media narratives and public interviews confirmed the importance of rapid compensation and transparent communication in driving public acceptance. Conclusions Thailand’s NFCS illustrates how a well-designed compensation mechanism can enhance vaccine confidence and public trust during health emergencies. However, sustained political and financial commitment is necessary to mitigate unintended fiscal and administrative challenges. The findings offer relevant policy lessons for LMICs in designing resilient, inclusive compensation systems during future health crises. Universal Health Coverage health system resilience emergency services health policy vaccines Key policy implications No-fault compensation schemes can reduce vaccine hesitancy and litigation in LMICs. Integrating compensation across fragmented health insurance schemes promotes equity. Strong communication mechanisms, such as 24/7 hotlines and digital platforms, are essential to build public trust. Fiscal sustainability must be built into NFCS frameworks to prevent long-term strain. Background The COVID-19 pandemic posed unprecedented challenges to healthcare systems worldwide, necessitating rapid adaptations to ensure equitable vaccine distribution and maintain public trust in immunization programmes. The crisis tested the resilience of national health systems, exposing gaps in service delivery and amplifying concerns around vaccine safety. One policy tool that gained renewed attention during this period was the no-fault compensation scheme (NFCS), which provides financial redress for individuals experiencing vaccine-related adverse events without requiring proof of fault or negligence. These schemes have proven effective in mitigating vaccine hesitancy, fostering public confidence and ensuring timely support for affected individuals. While NFCS mechanisms are well established in high-income countries—such as the United States’ Vaccine Injury Compensation Programme (VICP), and similar programmes in Canada, Japan, Australia and parts of Europe (1–3)–their adoption in low- and middle-income countries (LMICs) remains rare (1,4). This gap is largely attributed to fiscal constraints, limited institutional capacity and competing health policy priorities. Nevertheless, Thailand stands out as a notable exception. As an upper-middle-income country with a strong commitment to Universal Health Coverage (UHC), Thailand integrated a no-fault compensation mechanism into its health system well before the pandemic. During the COVID-19 crisis, this mechanism was rapidly scaled to address emerging vaccine safety concerns and bolster the national vaccination campaign. Thailand’s UHC system consists of three schemes: the Universal Coverage Scheme (UCS), the Civil Servant Medical Benefit Scheme (CSMBS) and the Social Health Insurance (SHI). The UCS—administered by the National Health Security Office (NHSO)—covers around 75% of the population and includes provisions for no-fault compensation under Article 41 of the National Health Security Act of 2002. This article enables preliminary compensation for individuals experiencing medical treatment-related injuries, including vaccine-related events, without establishing legal fault (5). The provision is designed to reduce litigation, facilitate trust in health services and strengthen the relationship between patients and the healthcare system. Empirical data from 2004 to 2020 illustrate the scheme’s effectiveness, with 82.4% of compensation claims successfully resolved (6). In response to COVID-19, Thailand formally extended the NFCS’s principle to cover all vaccine recipients—regardless of insurance scheme—as of 5 April 2021. The system introduced a tiered compensation structure based on severity of injury, thereby ensuring timely and equitable disbursement of funds. As of December 2023, 83.7% of COVID-19 vaccine-related claims filed under the scheme had been approved (7). These developments contributed to high vaccine uptake rates in Thailand despite global trends of vaccine hesitancy. Thailand’s NFCS emerged as a key component of its pandemic response—supporting vaccine acceptance, addressing equity concerns and reinforcing the legitimacy of state-led health interventions. However, the expansion of the scheme also introduced fiscal and administrative challenges, raising questions about long-term sustainability and public expectations for future compensation programmes. Despite growing interest in NFCS models, limited research has examined their long-term policy impacts in LMICs or how such policies generate feedback effects across administrative, fiscal and sociopolitical dimensions. Thailand’s experience offers a rare opportunity to explore these dynamics through an empirical case. This study applies Policy Feedback Theory (PFT) to analyse how Thailand’s NFCS shaped public trust, institutional behaviour and financial governance during the COVID-19 vaccination campaign. In doing so, it addresses key knowledge gaps and contributes practical lessons for LMICs seeking to strengthen their health systems in the face of public health emergencies. Methods This study employed a qualitative, multi-method design to examine the policy feedback effects of Thailand’s National No-Fault Compensation Scheme (NFCS) during the COVID-19 vaccination campaign. The study was conducted in accordance with the principles of the Declaration of Helsinki. It was approved by the Institutional Review Board of the Institute for Population and Social Research (IPSR-IRB), Mahidol University (COA. No. 2022/06-138). Study design and data sources We applied a triangulated qualitative approach to ensure the robustness and credibility of findings. Data sources included: (1) peer-reviewed literature; (2) government policy documents and official NHSO reports; (3) semi-structured interviews and a focus group discussion (FGD) with key stakeholders; and (4) media content analysis of over 100 print and online news reports published between March 2021 and October 2022. Documentary and policy analysis We first conducted a comprehensive review of policy and legal documents, including the Government Gazette and NHSO administrative guidelines. These sources provided insights into the design, implementation, and governance mechanisms of the NFCS, particularly under Article 41 of the National Health Security Act. Semi-structured interviews and focus group discussion Between March and September 2022, five semi-structured interviews and one expert focus group discussion were conducted with NHSO policymakers, programme staff and healthcare policy experts. Interviews lasted 45–60 minutes and were recorded and transcribed with informed consent. Discussions explored policy rationale, implementation challenges, procedural efficiency, fiscal management and public engagement strategies. To ensure anonymity and confidentiality, all participant names and identifying details were removed and replaced with role-based descriptors (e.g., “senior NHSO official” “expert group participant”). The semi-structured interview and FGD guides were designed specifically for this study (see Supplementary Files 1 and 2 for English versions). Media content analysis To assess public perception and media framing, we reviewed 100+ news articles from major Thai outlets, in both Thai and English (e.g., Bangkok Post and other national news). Inclusion criteria required that articles address vaccine-related adverse events, NFCS implementation, or public commentary on compensation. Using thematic coding, we extracted direct quotes from stakeholders, recurring themes and shifts in public discourse. Analytical framework This study applies Policy Feedback Theory (PFT) to analyse how Thailand’s no-fault compensation scheme (NFCS) for COVID-19 vaccine-related injuries produced effects on administrative governance, fiscal dynamics and public trust. PFT provides a useful lens for understanding how policies, once implemented, not only resolve immediate issues but also reshape political and institutional landscapes through feedback mechanisms (8,9). PFT distinguishes between two main types of feedback effects—self-reinforcing and self-undermining. Self-reinforcing feedback occurs when a policy generates benefits or incentives that bolster political support, institutional legitimacy and societal acceptance. For example, accessible and timely financial compensation may reinforce public trust and reduce litigation, creating stronger public buy-in. In contrast, self-undermining feedback arises when a policy inadvertently creates costs, tensions, or misalignments that reduce its sustainability—such as increasing public expectations beyond fiscal capacity or exposing administrative bottlenecks (10). In the context of this study, PFT was used to guide the analysis of data collected from policy documents, interviews, media coverage and administrative dashboards. Specifically, the theory informed the coding and interpretation of themes related to: 1) The administrative structures and coordination mechanisms created or adjusted in response to NFCS demands; 2) The fiscal implications of rapidly scaling compensation for vaccine-related adverse events; and 3) The sociopolitical consequences, including shifts in public confidence, perceived fairness and expectations of government responsibility. Data triangulation and integration Findings were triangulated across all data sources. Media narratives and public statements were cross-referenced with NHSO documents and stakeholder interviews. Quantitative data from the NHSO vaccine compensation dashboard complemented the qualitative findings, enabling a holistic interpretation of feedback effects within Thailand’s health governance system. Integrating diverse data sources provided a nuanced understanding of how the NFCS influences broader governance frameworks and shapes the evolving social contract between the state, healthcare institutions and citizens (11). Results Between 5 April 2021 and 30 September 2023 (the end of Thailand’s fiscal year), a total of 22,695 claims were filed under the no-fault compensation scheme for COVID-19 vaccinations, with 84.0% (19,057 cases) approved (7,12,13). These figures underscore the policy’s operational reach and the Thai government’s commitment to public reassurance during the vaccine rollout. The results are presented across three key domains: administrative, sociopolitical, and fiscal feedback effects. Administrative effects The implementation of the NFCS during the COVID-19 pandemic required rapid administrative innovations. The National Health Security Office (NHSO) established multiple access points for claims, including healthcare units, provincial public health offices and its 13 regional branches (14). This decentralised system enabled claims to be resolved within one to two weeks, with payments made within five days (15). Moreover, the eligibility period for filing claims was extended from one year to two years to provide greater accessibility during the pandemic. Interviews with NHSO officials revealed a strategic emphasis on administrative speed: “Prompt payment is a form of justice. If we pay quickly, patients will be satisfied… so we tried to organise the system to make it fast” (Interview, NHSO official, March 2022). Despite improvements, challenges persisted. Initial claimants, especially those covered under the Social Health Insurance (SHI) scheme, experienced procedural delays and confusion due to differing administrative protocols between the NHSO and the Social Security Office (16,17). Verification delays and inconsistent guidance on eligibility criteria occasionally undermined the public’s perception of fairness. Nevertheless, compensation was issued relatively efficiently. In the first eight months alone (April–December 2021), 72.3% of claims (8,470 out of 11,707) were approved, totalling nearly one billion baht (approximately USD 30 million) (18). As of the end of 2023, over 84.0% of claims had been approved, affirming the system’s effectiveness in responding to grievances (7). Administrative feedback loops also emerged. Inter-agency coordination, especially among NHSO, the Ministry of Public Health and local health offices, fostered implementation efficiency. For example, provincial sub-committees—including medical and civilian representatives—were tasked with assessing compensation claims, enabling localised decision-making. Meanwhile, the NHSO provided administrative oversight, ensuring adherence to established standards and facilitating the timely disbursement of compensation. Importantly, the scheme was extended beyond UCS beneficiaries to include individuals under the Civil Servant Medical Benefit Scheme (CSMBS) and SHI, promoting administrative equity. UCS beneficiaries represented 41.7% of claims in 2021, rising to 61.1% in 2022, while CSMBS and SHI represented 22.6% and 14.2% respectively in 2022 (12,13). Sociopolitical effects During early phases of the COVID-19 vaccine rollout, public concern regarding vaccine safety and government transparency posed significant risks to vaccination uptake. Survey data from May 2021 indicated that 67.3% of respondents were concerned about side effects, while 36.4% expressed doubt in the government’s vaccine strategy (19). The NFCS addressed these concerns by enhancing government accountability (20). Expert interviews confirmed that adaptation of Article 41 for vaccine-related compensation was key to securing vaccine supply: “Pharmaceutical companies refused to sell vaccines unless there was guaranteed responsibility towards citizens because companies would not bear any responsibility” (Expert group participant, April 2022). One expert also noted, “ We adapted the existing Article 41 [NFCS] system, making it more flexible and responsive. We compensated upfront because it directly boosted public confidence in vaccination ” (Expert group participant, April 2022). The scheme reassured the public and improved perceptions of fairness. Initial reactions were mixed, with concerns regarding transparency, eligibility and adequacy of compensation (21). A public poll found that 56.6% questioned policy effectiveness, and 29.2% had doubts about its fairness (22) However, approval rates increased over time: 5,187 out of 6,571 allergy-related claims were compensated in 2021, followed by 10,865 out of 11,165 claims in 2022 (National Health Security Office, 2023, 2022). Public communication mechanisms played a crucial role in trust-building. The NHSO 24-hour hotline (1330) expanded from 300 to 3,000 lines to handle public inquiries, and digital engagement increased through virtual public hearings. Between October 2020 and September 2021, 642,700 out of 2,585,915 inquiries were related to COVID-19 (12). By the following year, COVID-related inquiries surged 5.3 times, reaching 3,461,031, reflecting increased public engagement and improved access to accurate information (13). As one senior NHSO official observed: “Before COVID, only about 20% knew 1330. During the pandemic, it became a lifeline, receiving up to 70,000 calls at peak” (Interview, NHSO official, March 2022). Despite concerns over vaccine supply and distribution inefficiencies, the campaign achieved notable progress, with 71.2% of the population receiving the first dose and 64.0% receiving the second dose by December 2021. By the following year, coverage increased to 82.7% for the first dose and 77.7% for the second dose (23,24). Fiscal effects The NFCS had considerable fiscal implications. From April 2021 to September 2023, the Thai government spent approximately USD 72.2 million on vaccine-related compensation. Compensation was stratified: Level 1 (death or permanent disability) offered up to THB 400,000 (approximately USD 12,121); Level 2 (major disability) THB 240,000 (approximately USD 7,272); and Level 3 (temporary injury) THB 100,000 (approximately USD 3,030) (12). These expenditures represented 2.1% of the Universal Coverage Scheme (UCS) budget in 2022—exceeding the statutory threshold of 1% stipulated in the National Health Security Act (5). NHSO managed this overrun through reallocation of pandemic response funds (25). According to NHSO leadership, efforts to maintain fiscal responsibility included refining eligibility grading and ensuring that claims were not automatically linked to vaccination but described as “possibly associated.” As one official stated: “Not every claim is compensated; there’s a grading system. We never say it is directly from the vaccine; we say it might be associated” (Interview, May 2022). The rapid scale-up of NFCS placed pressure on the broader healthcare budget. However, the policy reduced litigation risks, freeing administrative and legal resources. Compared to pre-pandemic years when claims averaged 900–1,000 annually with costs under USD 6.5 million (26), the pandemic saw a fivefold rise in cases and over a tenfold rise in expenditure (13). Despite this, the Thai government maintained fiscal discipline. The policy’s expansion to include all health schemes was viewed as a signal of equity and state accountability, despite mounting financial demands. Future sustainability may require the establishment of reserve funds, enhanced cross-agency cost sharing, or refinements to eligibility thresholds. Discussion This study contributes to the growing literature on health systems responsiveness by examining Thailand’s no-fault compensation scheme (NFCS) for COVID-19 vaccine-related injuries through the lens of Policy Feedback Theory (PFT). The implementation of the NFCS highlights the dynamic interactions between public health policy, institutional adaptation and fiscal sustainability. During the COVID-19 vaccination rollout, the policy’s self-reinforcing effects—such as enhanced public trust, administrative efficiency and reduced litigation—contributed to system stability and rapid uptake. However, the policy also generated self-undermining consequences, including heightened public expectations and financial pressures. These dual feedback loops offer important insights for other low- and middle-income countries (LMICs) considering similar approaches. Institutional adaptation and reinforcing universal healthcare rights A significant early challenge in implementing the NFCS arose from Thailand’s fragmented public health insurance landscape. Differences in eligibility criteria and administrative procedures across the Universal Coverage Scheme (UCS), Social Health Insurance (SHI) and the Civil Servant Medical Benefit Scheme (CSMBS) led to disparities in access to compensation. To address this, the NFCS was expanded to cover beneficiaries under all schemes, thus reinforcing Thailand’s commitment to UHC (27,28). This harmonisation reduced inequities in access to redress, particularly among beneficiaries previously excluded from compensation, such as CSMBS members. Policymakers noted the uncertainty surrounding the initial implementation of the scheme. As one senior NHSO official explained, “No one could predict COVID-19. We learned as we implemented, but that learning by doing was guided by theory, evidence and existing tools surrounding UHC 20-year implementation” (Interview, March 2022). This exemplifies the adaptive and responsive nature of institutional decision-making under crisis conditions. Administrative innovation and its dual feedback effects Thailand’s NFCS spurred notable innovations in health system administration. These included the development of a real-time claims review process, decentralised evaluation committees at the regional level, and the extension of the filing period for claims from one to two years. These changes made the scheme more accessible, increased its perceived fairness and contributed to high claim approval rates. Such procedural efficiency reinforced public trust and reduced the likelihood of legal disputes, serving as a self-reinforcing mechanism. These administrative reforms are consistent with literature on institutional learning in health emergencies, where real-time adaptations are critical to sustaining trust (9). However, these administrative expansions also led to increased burdens on processing capacity and heightened the risk of fraudulent or exaggerated claims. These issues reflect the self-undermining feedback loops posited by PFT, wherein expanded access and flexibility may jeopardise the sustainability of the very systems they seek to improve. As one participant in an expert consultation remarked, “Few countries worldwide have a no-fault compensation system. Our [Thai] system operated very quickly; we promptly presented it to the [NHSO] Board and issued formal announcements swiftly” (Expert group participant, April 2022). Strengthening public trust and institutional legitimacy The NFCS significantly influenced public trust in government health interventions. Key to this was the implementation of a centralised customer relationship management (CRM) system and the substantial expansion of NHSO’s 24-hour hotline (1330). During the pandemic, public awareness of the hotline increased significantly, demonstrating the power of effective communication strategies. Public statements made by NHSO leadership were widely disseminated in the press, further bolstering the credibility of the scheme (29). These communication mechanisms played a pivotal role in countering vaccine hesitancy and reinforcing the social contract between the state and citizens. They also enhanced state legitimacy in crisis management (30). The inclusive scope of the NFCS—extending coverage to all public health beneficiaries—underscored a rights-based, citizen-centric approach that could serve as a model for LMICs aiming to bolster public health system responsiveness. Managing financial risks and public expectations Despite its success in strengthening trust and coverage, the NFCS imposed considerable fiscal demands. Compensation expenditures surpassed the 1% statutory threshold of the UCS budget, reaching 2.1% in 2022 (13). These fiscal pressures prompted NHSO to reallocate funds and eventually led to a temporary suspension of the scheme for review (21). These developments exemplify the self-undermining effects described in PFT, wherein a policy’s success in one dimension (e.g., trust-building) generates sustainability challenges in another (e.g., fiscal management). An NHSO official noted, “Not every claim is compensated; there’s a grading system. We never say it is directly from the vaccine; we say it might be associated” (Interview, March 2022). This carefully calibrated language reflects an effort to manage public expectations and maintain the scheme’s integrity. Nonetheless, the growing number of appeals and rising compensation demands demonstrated the need for clearer communication, stronger fiscal planning and more robust verification mechanisms. Unmitigated fiscal strain could undermine the sustainability of Thailand’s broader UHC goals, unless fiscal buffers or reserve funds are institutionalised. To summarise the dual feedback dynamics observed in the NFCS, Table 1 presents a structured synthesis of both self-reinforcing and self-undermining effects across administrative, sociopolitical, fiscal, legal and policy domains, along with their implications for long-term sustainability. Table 1 Feedback effects of the no-fault compensation policy in Thailand Feedback Type Negative Feedback (Self-Undermining) Positive Feedback (Self-Reinforcing) Implications for Long-Term Sustainability Administrative Effects Delays in claims processing lead to administrative inefficiencies and backlogs. Strengthens healthcare system resilience through efficient claim processing and emergency responsiveness. Sustainability depends on improving administrative capacity, digitising claims management and enhancing inter-agency coordination. Sociopolitical Effects Raises public scepticism regarding transparency and fairness of compensation mechanisms. Increases public trust, boosts vaccine uptake and fosters confidence in government-led health initiatives. Transparent governance and effective communication are crucial to sustaining trust and preventing resistance to future policies. Fiscal Effects Rising compensation expenditures create long-term financial strain and potential budget reallocation. Reduces litigation costs, allowing reallocation of funds to other healthcare services. Structured financial planning, budget caps, reserve funds and external funding sources are needed to ensure sustainability. Legal and Ethical Effects May create unrealistic expectations, leading to demands for similar compensation in other medical scenarios. Strengthens rights-based approaches to healthcare by ensuring compensation for vaccine-related injuries. Clear legal frameworks and public education are required to manage expectations and prevent policy overextension. Policy Adaptability and Scalability Variability in healthcare systems and governance structures may limit direct applicability in other contexts. Serves as a model for other LMICs seeking to enhance health system resilience. Adaptability to different national contexts requires flexible implementation strategies. Source: synthesised by the authors Considerations and lessons learned for other LMICs Thailand’s experience with the NFCS highlights several actionable insights for LMICs: Integrated health systems: Harmonising multiple insurance schemes into a unified compensation framework enhances equity and accessibility. Transparency and engagement: Public trust can be strengthened through inclusive communication, CRM systems and multi-platform information dissemination. Administrative capacity: Decentralised claims processing and real-time digital tools are critical for scalability and efficiency. Flexible fiscal mechanisms: Budget thresholds should be supplemented with contingency reserves for emergency health spending. Cross-sectoral coordination: Multi-agency collaboration is essential for effective implementation and sustainability. As LMICs prepare for future pandemics and other health-related shocks, Thailand’s experience illustrates the importance of embedding adaptive, equitable and financially sound governance mechanisms into emergency response systems. Thailand’s NFCS demonstrates that no-fault compensation can serve as an effective risk mitigation and trust-building mechanism during public health crises. However, its long-term viability depends on balancing responsiveness with fiscal responsibility, clear communication, and adaptive governance frameworks aligned with Policy Feedback Theory. Conclusion Thailand’s no-fault compensation scheme (NFCS) for COVID-19 vaccine-related injuries offers a compelling case study of policy responsiveness under crisis conditions. The scheme strengthened vaccine confidence, reduced litigation and reinforced public trust in health institutions—demonstrating critical self-reinforcing feedback effects. However, it also exposed vulnerabilities, including rising fiscal burdens and expanding public expectations, which highlight self-undermining dynamics that could threaten long-term sustainability. This study contributes to understanding how no-fault compensation schemes function in middle-income settings by applying Policy Feedback Theory to examine their administrative, fiscal and sociopolitical effects. Thailand’s experience underscores the importance of harmonised health financing mechanisms, robust administrative systems, transparent communication, and inter-agency coordination. For low- and middle-income countries (LMICs), these lessons are especially valuable in designing policies that enhance trust and resilience while maintaining fiscal accountability. Moving forward, institutionalising contingency reserves, improving data-sharing systems and establishing clear guidelines for eligibility and appeals will be essential to preserving the legitimacy and sustainability of such compensation schemes. While no-fault compensation is not a panacea, Thailand’s NFCS demonstrates that, when designed with foresight and equity, it can serve as an effective component of pandemic preparedness and broader health systems governance. Declarations Ethics approval and consent to participate The study was conducted in accordance with the principles of the Declaration of Helsinki. It was approved by the Institutional Review Board of the Institute for Population and Social Research (IPSR-IRB), Mahidol University (COA. No. 2022/06-138). All participants in interviews and a focus group discussion provided informed consent prior to participation. Participation was voluntary, and confidentiality and anonymity were assured throughout the research process. Consent for publication All participants involved in interviews and focus group discussion provided informed consent for the use of anonymised quotations in this publication. No identifiable personal data are included in the manuscript. Availability of data and materials The data supporting the findings of this study are based on publicly available literature, official reports and media sources. Due to the ethical restrictions and confidentiality commitments made to participants, interview and focus group transcripts are not publicly available. However, the semi-structured interview guide and FGD protocol used in this study have been included as supplementary materials (Supplementary Files 1 and 2). Competing interests The authors declare no competing interests. The funder had no role in study design, data collection, data analysis, interpretation, or manuscript preparation. The views expressed in this publication are solely those of the author and do not necessarily reflect the opinions or official positions of the United Nations. Funding This research was conducted as part of the project “Changes and Policy Feedback Effects of the No-Fault Compensation System in Thailand,” supported by the Office of the Permanent Secretary, Ministry of Higher Education, Science, Research and Innovation, Thailand (Grant No. RGNS 64-144). Authors’ contributions Assistant Professor Nucharapon Liangruenrom, Ph.D. Data collection, Data analysis and interpretation, Drafting the article, Critical revision of the article, Final approval of the version to be submitted Nattanee Satchanawakul, Ph.D. Data collection, Data analysis and interpretation, Drafting the article, Critical revision of the article, Final approval of the version to be submitted Napaphat Satchanawakul, Ph.D. Conception or design of the work, Data analysis and interpretation, Critical revision of the article, Final approval of the version to be submitted Acknowledgements We want to thank the Office of the Permanent Secretary of the Ministry of Higher Education, Science, Research and Innovation of Thailand for providing capacity-building grants to support research of early-career faculty. The authors wish to express their sincere gratitude to Emeritus Professor Churnrurtai Kanchanachitrafor her guidance as the academic advisor to this research project. 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Available from: https://ddc.moph.go.th/vaccine-covid19/pages/%E0%B8%A3%E0%B8%B2%E0%B8%A2%E0%B8%87%E0%B8%B2%E0%B8%99%E0%B8%84%E0%B8%A7%E0%B8%B2%E0%B8%A1%E0%B8%81%E0%B9%89%E0%B8%B2%E0%B8%A7%E0%B8%AB%E0%B8%99%E0%B9%89%E0%B8%B2%E0%B8%81%E0%B8%B2%E0%B8%A3%E0%B9%83%E0%B8%AB%E0%B9%89%E0%B8%9A%E0%B8%A3%E0%B8%B4%E0%B8%81%E0%B8%B2%E0%B8%A3%E0%B8%89%E0%B8%B5%E0%B8%94%E0%B8%A7%E0%B8%B1%E0%B8%84%E0%B8%8B%E0%B8%B5%E0%B8%99%E0%B9%82%E0%B8%84%E0%B8%A7%E0%B8%B4%E0%B8%94-19 Ministry of Public Health. Report on progress of COVID-19 vaccination services as of December 29, 2022 [Internet]. Ministry of Public Health; 2021. Available from: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://ddc.moph.go.th/vaccine-covid19/getFiles/7/1672906417174.pdf Sachdev S, Viriyathorn S, Chotchoungchatchai S, Patcharanarumol W, Tangcharoensathien V. Thailand’s COVID‐19: How public financial management facilitated effective and accountable health sector responses. Int J Health Plann Manage. 2022 Jul;37(4):1894–906. National Health Security Office. NHSO Annual Report 2020. Bangkok: National Health Security Office; 2021. Wiig S, Aase K, Billett S, Canfield C, Røise O, Njå O, et al. Defining the boundaries and operational concepts of resilience in the resilience in healthcare research program. BMC Health Serv Res. 2020 Dec;20(1):330. Debie A, Nigusie A, Gedle D, Khatri RB, Assefa Y. Building a resilient health system for universal health coverage and health security: a systematic review. Glob Health Res Policy. 2024 Jan 4;9(1):2. Bangkok Post. Vaccine death claims refuted. 2022 Jun 18; Lyng HB, Macrae C, Guise V, Haraldseid-Driftland C, Fagerdal B, Schibevaag L, et al. Capacities for resilience in healthcare; a qualitative study across different healthcare contexts. BMC Health Serv Res. 2022 Dec;22(1):474. Additional Declarations No competing interests reported. Supplementary Files Supplementary1interviewguideline.pdf Supplementary2FGDguideprotocol.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 28 May, 2025 Editor invited by journal 06 May, 2025 Editor assigned by journal 18 Apr, 2025 Submission checks completed at journal 17 Apr, 2025 First submitted to journal 17 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6438801","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":463152233,"identity":"6ee58628-b245-4354-a9ab-643be0607bda","order_by":0,"name":"Nucharapon Liangruenrom","email":"","orcid":"","institution":"Institute for Population and Social Research, Mahidol University","correspondingAuthor":false,"prefix":"","firstName":"Nucharapon","middleName":"","lastName":"Liangruenrom","suffix":""},{"id":463152234,"identity":"11f756ba-06f7-4159-b350-315f3956bb51","order_by":1,"name":"Nattanee Satchanawakul","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABD0lEQVRIiWNgGAWjYNCDDwwMCWwMCYwHwDwJXMqYGRugLMbGGRAtDGAtPMRoaeYBamEgpMWc/fzxBz932Mgx8B9+/tg2xy6Pjz35wAGGGjsGe+kGrFose5IZG3vPpBkzSKQZNuduSy5m43mWcIDhWDIDj8wBrFoMDiQzNvC2HU5skGAAaWFObJPIMTjAwHYA6LAE7FrOP2Zs/Nv2v76B//jHZstt9VAt//BouZHM2MzbdgAom2PYzLjtMEQLYxs+LY8NZ8u2JRsCVRbO7N12PLEN5JfEvmQenhu4HJb44OPbNjt5fv7jGz783FadOL89+eCDD9/s5NhnYNcCB2woPKBiHvzqR8EoGAWjYBTgAwDVSWCPF1FgzAAAAABJRU5ErkJggg==","orcid":"","institution":"Faculty of Liberal Arts, Mahidol University","correspondingAuthor":true,"prefix":"","firstName":"Nattanee","middleName":"","lastName":"Satchanawakul","suffix":""},{"id":463152239,"identity":"13a0bcb1-b3b8-4176-81a5-4ab7fa8daa25","order_by":2,"name":"Napaphat Satchanawakul","email":"","orcid":"","institution":"United Nations Economic and Social Commission for Asia and the Pacific","correspondingAuthor":false,"prefix":"","firstName":"Napaphat","middleName":"","lastName":"Satchanawakul","suffix":""}],"badges":[],"createdAt":"2025-04-13 11:08:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6438801/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6438801/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83674094,"identity":"3f31e451-014b-4920-a68a-f2538dd549d9","added_by":"auto","created_at":"2025-05-30 14:22:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":717162,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6438801/v1/ca7f3bbe-1647-43a7-ba37-63ccd6af12ac.pdf"},{"id":83673902,"identity":"66ca22ca-116b-4379-a6d3-a331a69d9598","added_by":"auto","created_at":"2025-05-30 14:14:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":204199,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementary1interviewguideline.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6438801/v1/119cc75648a9b32c0d64e3f1.pdf"},{"id":83673903,"identity":"d96c30bc-526e-4b63-b17c-281e08e72164","added_by":"auto","created_at":"2025-05-30 14:14:52","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":197069,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementary2FGDguideprotocol.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6438801/v1/abdb973cfe40403da5498aa1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring the Policy Feedback Effects of a No-Fault Compensation Scheme for COVID-19 Vaccine Injuries in Thailand: A Qualitative Study","fulltext":[{"header":"Key policy implications","content":"\u003cul\u003e\n \u003cli\u003eNo-fault compensation schemes can reduce vaccine hesitancy and litigation in LMICs.\u003c/li\u003e\n \u003cli\u003eIntegrating compensation across fragmented health insurance schemes promotes equity.\u003c/li\u003e\n \u003cli\u003eStrong communication mechanisms, such as 24/7 hotlines and digital platforms, are essential to build public trust.\u003c/li\u003e\n \u003cli\u003eFiscal sustainability must be built into NFCS frameworks to prevent long-term strain.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Background","content":"\u003cp\u003eThe COVID-19 pandemic posed unprecedented challenges to healthcare systems worldwide, necessitating rapid adaptations to ensure equitable vaccine distribution and maintain public trust in immunization programmes. The crisis tested the resilience of national health systems, exposing gaps in service delivery and amplifying concerns around vaccine safety. One policy tool that gained renewed attention during this period was the no-fault compensation scheme (NFCS), which provides financial redress for individuals experiencing vaccine-related adverse events without requiring proof of fault or negligence. These schemes have proven effective in mitigating vaccine hesitancy, fostering public confidence and ensuring timely support for affected individuals.\u003c/p\u003e\n\u003cp\u003eWhile NFCS mechanisms are well established in high-income countries—such as the United States’ Vaccine Injury Compensation Programme (VICP), and similar programmes in Canada, Japan, Australia and parts of Europe (1–3)–their adoption in low- and middle-income countries (LMICs) remains rare (1,4). This gap is largely attributed to fiscal constraints, limited institutional capacity and competing health policy priorities. Nevertheless, Thailand stands out as a notable exception. As an upper-middle-income country with a strong commitment to Universal Health Coverage (UHC), Thailand integrated a no-fault compensation mechanism into its health system well before the pandemic. During the COVID-19 crisis, this mechanism was rapidly scaled to address emerging vaccine safety concerns and bolster the national vaccination campaign.\u003c/p\u003e\n\u003cp\u003eThailand’s UHC system consists of three schemes: the Universal Coverage Scheme (UCS), the Civil Servant Medical Benefit Scheme (CSMBS) and the Social Health Insurance (SHI). The UCS—administered by the National Health Security Office (NHSO)—covers around 75% of the population and includes provisions for no-fault compensation under Article 41 of the National Health Security Act of 2002. This article enables preliminary compensation for individuals experiencing medical treatment-related injuries, including vaccine-related events, without establishing legal fault (5). The provision is designed to reduce litigation, facilitate trust in health services and strengthen the relationship between patients and the healthcare system.\u003c/p\u003e\n\u003cp\u003eEmpirical data from 2004 to 2020 illustrate the scheme’s effectiveness, with 82.4% of compensation claims successfully resolved (6). In response to COVID-19, Thailand formally extended the NFCS’s principle to cover all vaccine recipients—regardless of insurance scheme—as of 5 April 2021. The system introduced a tiered compensation structure based on severity of injury, thereby ensuring timely and equitable disbursement of funds. As of December 2023, 83.7% of COVID-19 vaccine-related claims filed under the scheme had been approved (7). These developments contributed to high vaccine uptake rates in Thailand despite global trends of vaccine hesitancy.\u003c/p\u003e\n\u003cp\u003eThailand’s NFCS emerged as a key component of its pandemic response—supporting vaccine acceptance, addressing equity concerns and reinforcing the legitimacy of state-led health interventions. However, the expansion of the scheme also introduced fiscal and administrative challenges, raising questions about long-term sustainability and public expectations for future compensation programmes.\u003c/p\u003e\n\u003cp\u003eDespite growing interest in NFCS models, limited research has examined their long-term policy impacts in LMICs or how such policies generate feedback effects across administrative, fiscal and sociopolitical dimensions. Thailand’s experience offers a rare opportunity to explore these dynamics through an empirical case. This study applies Policy Feedback Theory (PFT) to analyse how Thailand’s NFCS shaped public trust, institutional behaviour and financial governance during the COVID-19 vaccination campaign. In doing so, it addresses key knowledge gaps and contributes practical lessons for LMICs seeking to strengthen their health systems in the face of public health emergencies.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study employed a qualitative, multi-method design to examine the policy feedback effects of Thailand’s National No-Fault Compensation Scheme (NFCS) during the COVID-19 vaccination campaign. The study was conducted in accordance with the principles of the Declaration of Helsinki. It was approved by the Institutional Review Board of the Institute for Population and Social Research (IPSR-IRB), Mahidol University (COA. No. 2022/06-138).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStudy design and data sources\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe applied a triangulated qualitative approach to ensure the robustness and credibility of findings. Data sources included: (1) peer-reviewed literature; (2) government policy documents and official NHSO reports; (3) semi-structured interviews and a focus group discussion (FGD) with key stakeholders; and (4) media content analysis of over 100 print and online news reports published between March 2021 and October 2022.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDocumentary and policy analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe first conducted a comprehensive review of policy and legal documents, including the Government Gazette and NHSO administrative guidelines. These sources provided insights into the design, implementation, and governance mechanisms of the NFCS, particularly under Article 41 of the National Health Security Act.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSemi-structured interviews and focus group discussion\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBetween March and September 2022, five semi-structured interviews and one expert focus group discussion were conducted with NHSO policymakers, programme staff and healthcare policy experts. Interviews lasted 45–60 minutes and were recorded and transcribed with informed consent. Discussions explored policy rationale, implementation challenges, procedural efficiency, fiscal management and public engagement strategies. To ensure anonymity and confidentiality, all participant names and identifying details were removed and replaced with role-based descriptors (e.g., “senior NHSO official” “expert group participant”). The semi-structured interview and FGD guides were designed specifically for this study (see Supplementary Files 1 and 2 for English versions).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMedia content analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTo assess public perception and media framing, we reviewed 100+ news articles from major Thai outlets, in both Thai and English (e.g., Bangkok Post and other national news). Inclusion criteria required that articles address vaccine-related adverse events, NFCS implementation, or public commentary on compensation. Using thematic coding, we extracted direct quotes from stakeholders, recurring themes and shifts in public discourse.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAnalytical framework\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study applies Policy Feedback Theory (PFT) to analyse how Thailand’s no-fault compensation scheme (NFCS) for COVID-19 vaccine-related injuries produced effects on administrative governance, fiscal dynamics and public trust. PFT provides a useful lens for understanding how policies, once implemented, not only resolve immediate issues but also reshape political and institutional landscapes through feedback mechanisms (8,9). PFT distinguishes between two main types of feedback effects—self-reinforcing and self-undermining. Self-reinforcing feedback occurs when a policy generates benefits or incentives that bolster political support, institutional legitimacy and societal acceptance. For example, accessible and timely financial compensation may reinforce public trust and reduce litigation, creating stronger public buy-in. In contrast, self-undermining feedback arises when a policy inadvertently creates costs, tensions, or misalignments that reduce its sustainability—such as increasing public expectations beyond fiscal capacity or exposing administrative bottlenecks (10). In the context of this study, PFT was used to guide the analysis of data collected from policy documents, interviews, media coverage and administrative dashboards. Specifically, the theory informed the coding and interpretation of themes related to: 1) The administrative structures and coordination mechanisms created or adjusted in response to NFCS demands; 2) The fiscal implications of rapidly scaling compensation for vaccine-related adverse events; and 3) The sociopolitical consequences, including shifts in public confidence, perceived fairness and expectations of government responsibility.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData triangulation and integration\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFindings were triangulated across all data sources. Media narratives and public statements were cross-referenced with NHSO documents and stakeholder interviews. Quantitative data from the NHSO vaccine compensation dashboard complemented the qualitative findings, enabling a holistic interpretation of feedback effects within Thailand’s health governance system. Integrating diverse data sources provided a nuanced understanding of how the NFCS influences broader governance frameworks and shapes the evolving social contract between the state, healthcare institutions and citizens (11).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eBetween 5 April 2021 and 30 September 2023 (the end of Thailand’s fiscal year), a total of 22,695 claims were filed under the no-fault compensation scheme for COVID-19 vaccinations, with 84.0% (19,057 cases) approved (7,12,13). These figures underscore the policy’s operational reach and the Thai government’s commitment to public reassurance during the vaccine rollout. The results are presented across three key domains: administrative, sociopolitical, and fiscal feedback effects.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAdministrative effects\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe implementation of the NFCS during the COVID-19 pandemic required rapid administrative innovations. The National Health Security Office (NHSO) established multiple access points for claims, including healthcare units, provincial public health offices and its 13 regional branches (14). This decentralised system enabled claims to be resolved within one to two weeks, with payments made within five days (15). Moreover, the eligibility period for filing claims was extended from one year to two years to provide greater accessibility during the pandemic.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInterviews with NHSO officials revealed a strategic emphasis on administrative speed: \u003cem\u003e“Prompt payment is a form of justice. If we pay quickly, patients will be satisfied… so we tried to organise the system to make it fast”\u0026nbsp;\u003c/em\u003e(Interview, NHSO official, March 2022).\u003c/p\u003e\n\u003cp\u003eDespite improvements, challenges persisted. Initial claimants, especially those covered under the Social Health Insurance (SHI) scheme, experienced procedural delays and confusion due to differing administrative protocols between the NHSO and the Social Security Office (16,17). Verification delays and inconsistent guidance on eligibility criteria occasionally undermined the public’s perception of fairness.\u003c/p\u003e\n\u003cp\u003eNevertheless, compensation was issued relatively efficiently. In the first eight months alone (April–December 2021), 72.3% of claims (8,470 out of 11,707) were approved, totalling nearly one billion baht (approximately USD 30 million) (18). As of the end of 2023, over 84.0% of claims had been approved, affirming the system’s effectiveness in responding to grievances (7).\u003c/p\u003e\n\u003cp\u003eAdministrative feedback loops also emerged. Inter-agency coordination, especially among NHSO, the Ministry of Public Health and local health offices, fostered implementation efficiency. For example, provincial sub-committees—including medical and civilian representatives—were tasked with assessing compensation claims, enabling localised decision-making. Meanwhile, the NHSO provided administrative oversight, ensuring adherence to established standards and facilitating the timely disbursement of compensation. Importantly, the scheme was extended beyond UCS beneficiaries to include individuals under the Civil Servant Medical Benefit Scheme (CSMBS) and SHI, promoting administrative equity. UCS beneficiaries represented 41.7% of claims in 2021, rising to 61.1% in 2022, while CSMBS and SHI represented 22.6% and 14.2% respectively in 2022 (12,13).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSociopolitical effects\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDuring early phases of the COVID-19 vaccine rollout, public concern regarding vaccine safety and government transparency posed significant risks to vaccination uptake. Survey data from May 2021 indicated that 67.3% of respondents were concerned about side effects, while 36.4% expressed doubt in the government’s vaccine strategy (19). The NFCS addressed these concerns by enhancing government accountability (20). Expert interviews confirmed that adaptation of Article 41 for vaccine-related compensation was key to securing vaccine supply: \u003cem\u003e“Pharmaceutical companies refused to sell vaccines unless there was guaranteed responsibility towards citizens because companies would not bear any responsibility”\u003c/em\u003e (Expert group participant, April 2022). One expert also noted, “\u003cem\u003eWe adapted the existing Article 41 [NFCS] system, making it more flexible and responsive. We compensated upfront because it directly boosted public confidence in vaccination\u003c/em\u003e” (Expert group participant, April 2022).\u003c/p\u003e\n\u003cp\u003eThe scheme reassured the public and improved perceptions of fairness. Initial reactions were mixed, with concerns regarding transparency, eligibility and adequacy of compensation (21). A public poll found that 56.6% questioned policy effectiveness, and 29.2% had doubts about its fairness (22) However, approval rates increased over time: 5,187 out of 6,571 allergy-related claims were compensated in 2021, followed by 10,865 out of 11,165 claims in 2022 (National Health Security Office, 2023, 2022).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePublic communication mechanisms played a crucial role in trust-building. The NHSO 24-hour hotline (1330) expanded from 300 to 3,000 lines to handle public inquiries, and digital engagement increased through virtual public hearings. Between October 2020 and September 2021, 642,700 out of 2,585,915 inquiries were related to COVID-19 (12). By the following year, COVID-related inquiries surged 5.3 times, reaching 3,461,031, reflecting increased public engagement and improved access to accurate information (13). As one senior NHSO official observed: \u003cem\u003e“Before COVID, only about 20% knew 1330. During the pandemic, it became a lifeline, receiving up to 70,000 calls at peak”\u003c/em\u003e (Interview, NHSO official, March 2022).\u003c/p\u003e\n\u003cp\u003eDespite concerns over vaccine supply and distribution inefficiencies, the campaign achieved notable progress, with 71.2% of the population receiving the first dose and 64.0% receiving the second dose by December 2021. By the following year, coverage increased to 82.7% for the first dose and 77.7% for the second dose (23,24).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFiscal effects\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe NFCS had considerable fiscal implications. From April 2021 to September 2023, the Thai government spent approximately USD 72.2 million on vaccine-related compensation. Compensation was stratified: Level 1 (death or permanent disability) offered up to THB 400,000 (approximately USD 12,121); Level 2 (major disability) THB 240,000 (approximately USD 7,272); and Level 3 (temporary injury) THB 100,000 (approximately USD 3,030) (12).\u003c/p\u003e\n\u003cp\u003eThese expenditures represented 2.1% of the Universal Coverage Scheme (UCS) budget in 2022—exceeding the statutory threshold of 1% stipulated in the National Health Security Act (5). NHSO managed this overrun through reallocation of pandemic response funds (25).\u003c/p\u003e\n\u003cp\u003eAccording to NHSO leadership, efforts to maintain fiscal responsibility included refining eligibility grading and ensuring that claims were not automatically linked to vaccination but described as “possibly associated.” As one official stated: \u003cem\u003e“Not every claim is compensated; there’s a grading system. We never say it is directly from the vaccine; we say it might be associated”\u003c/em\u003e (Interview, May 2022).\u003c/p\u003e\n\u003cp\u003eThe rapid scale-up of NFCS placed pressure on the broader healthcare budget. However, the policy reduced litigation risks, freeing administrative and legal resources. Compared to pre-pandemic years when claims averaged 900–1,000 annually with costs under USD 6.5 million (26), the pandemic saw a fivefold rise in cases and over a tenfold rise in expenditure (13).\u003c/p\u003e\n\u003cp\u003eDespite this, the Thai government maintained fiscal discipline. The policy’s expansion to include all health schemes was viewed as a signal of equity and state accountability, despite mounting financial demands. Future sustainability may require the establishment of reserve funds, enhanced cross-agency cost sharing, or refinements to eligibility thresholds.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study contributes to the growing literature on health systems responsiveness by examining Thailand’s no-fault compensation scheme (NFCS) for COVID-19 vaccine-related injuries through the lens of Policy Feedback Theory (PFT). The implementation of the NFCS highlights the dynamic interactions between public health policy, institutional adaptation and fiscal sustainability. During the COVID-19 vaccination rollout, the policy’s self-reinforcing effects—such as enhanced public trust, administrative efficiency and reduced litigation—contributed to system stability and rapid uptake. However, the policy also generated self-undermining consequences, including heightened public expectations and financial pressures. These dual feedback loops offer important insights for other low- and middle-income countries (LMICs) considering similar approaches.\u003c/p\u003e\n\u003ch3\u003e\u003cem\u003eInstitutional adaptation and reinforcing universal healthcare rights\u003c/em\u003e\u003c/h3\u003e\n\u003cp\u003eA significant early challenge in implementing the NFCS arose from Thailand’s fragmented public health insurance landscape. Differences in eligibility criteria and administrative procedures across the Universal Coverage Scheme (UCS), Social Health Insurance (SHI) and the Civil Servant Medical Benefit Scheme (CSMBS) led to disparities in access to compensation. To address this, the NFCS was expanded to cover beneficiaries under all schemes, thus reinforcing Thailand’s commitment to UHC (27,28). This harmonisation reduced inequities in access to redress, particularly among beneficiaries previously excluded from compensation, such as CSMBS members.\u003c/p\u003e\n\u003cp\u003ePolicymakers noted the uncertainty surrounding the initial implementation of the scheme. As one senior NHSO official explained, \u003cem\u003e“No one could predict COVID-19. We learned as we implemented, but that learning by doing was guided by theory, evidence and existing tools surrounding UHC 20-year implementation”\u003c/em\u003e (Interview, March 2022). This exemplifies the adaptive and responsive nature of institutional decision-making under crisis conditions.\u003c/p\u003e\n\u003ch3\u003e\u003cem\u003eAdministrative innovation and its dual feedback effects\u003c/em\u003e\u003c/h3\u003e\n\u003cp\u003eThailand’s NFCS spurred notable innovations in health system administration. These included the development of a real-time claims review process, decentralised evaluation committees at the regional level, and the extension of the filing period for claims from one to two years. These changes made the scheme more accessible, increased its perceived fairness and contributed to high claim approval rates. Such procedural efficiency reinforced public trust and reduced the likelihood of legal disputes, serving as a self-reinforcing mechanism. These administrative reforms are consistent with literature on institutional learning in health emergencies, where real-time adaptations are critical to sustaining trust (9).\u003c/p\u003e\n\u003cp\u003eHowever, these administrative expansions also led to increased burdens on processing capacity and heightened the risk of fraudulent or exaggerated claims. These issues reflect the self-undermining feedback loops posited by PFT, wherein expanded access and flexibility may jeopardise the sustainability of the very systems they seek to improve. As one participant in an expert consultation remarked, \u003cem\u003e“Few countries worldwide have a no-fault compensation system. Our [Thai] system operated very quickly; we promptly presented it to the [NHSO] Board and issued formal announcements swiftly”\u003c/em\u003e (Expert group participant, April 2022).\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003e\u003cem\u003eStrengthening public trust and institutional legitimacy\u003c/em\u003e\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe NFCS significantly influenced public trust in government health interventions. Key to this was the implementation of a centralised customer relationship management (CRM) system and the substantial expansion of NHSO’s 24-hour hotline (1330). During the pandemic, public awareness of the hotline increased significantly, demonstrating the power of effective communication strategies. Public statements made by NHSO leadership were widely disseminated in the press, further bolstering the credibility of the scheme (29). These communication mechanisms played a pivotal role in countering vaccine hesitancy and reinforcing the social contract between the state and citizens. They also enhanced state legitimacy in crisis management (30). The inclusive scope of the NFCS—extending coverage to all public health beneficiaries—underscored a rights-based, citizen-centric approach that could serve as a model for LMICs aiming to bolster public health system responsiveness.\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eManaging financial risks and public expectations\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eDespite its success in strengthening trust and coverage, the NFCS imposed considerable fiscal demands. Compensation expenditures surpassed the 1% statutory threshold of the UCS budget, reaching 2.1% in 2022 (13). These fiscal pressures prompted NHSO to reallocate funds and eventually led to a temporary suspension of the scheme for review (21). These developments exemplify the self-undermining effects described in PFT, wherein a policy’s success in one dimension (e.g., trust-building) generates sustainability challenges in another (e.g., fiscal management).\u003c/p\u003e\n\u003cp\u003eAn NHSO official noted, \u003cem\u003e“Not every claim is compensated; there’s a grading system. We never say it is directly from the vaccine; we say it might be associated”\u003c/em\u003e (Interview, March 2022). This carefully calibrated language reflects an effort to manage public expectations and maintain the scheme’s integrity. Nonetheless, the growing number of appeals and rising compensation demands demonstrated the need for clearer communication, stronger fiscal planning and more robust verification mechanisms. Unmitigated fiscal strain could undermine the sustainability of Thailand’s broader UHC goals, unless fiscal buffers or reserve funds are institutionalised.\u003c/p\u003e\n\u003cp\u003eTo summarise the dual feedback dynamics observed in the NFCS, Table 1 presents a structured synthesis of both self-reinforcing and self-undermining effects across administrative, sociopolitical, fiscal, legal and policy domains, along with their implications for long-term sustainability.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Feedback effects of the no-fault compensation policy in Thailand\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFeedback Type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNegative Feedback\u0026nbsp;\u003cbr\u003e\u0026nbsp;(Self-Undermining)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePositive Feedback\u0026nbsp;\u003cbr\u003e\u0026nbsp;(Self-Reinforcing)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eImplications for Long-Term Sustainability\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdministrative Effects\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDelays in claims processing lead to administrative inefficiencies and backlogs.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStrengthens healthcare system resilience through efficient claim processing and emergency responsiveness.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSustainability depends on improving administrative capacity, digitising claims management and enhancing inter-agency coordination.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSociopolitical Effects\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRaises public scepticism regarding transparency and fairness of compensation mechanisms.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIncreases public trust, boosts vaccine uptake and fosters confidence in government-led health initiatives.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTransparent governance and effective communication are crucial to sustaining trust and preventing resistance to future policies.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFiscal Effects\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRising compensation expenditures create long-term financial strain and potential budget reallocation.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eReduces litigation costs, allowing reallocation of funds to other healthcare services.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStructured financial planning, budget caps, reserve funds and external funding sources are needed to ensure sustainability.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLegal and Ethical Effects\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMay create unrealistic expectations, leading to demands for similar compensation in other medical scenarios.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStrengthens rights-based approaches to healthcare by ensuring compensation for vaccine-related injuries.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eClear legal frameworks and public education are required to manage expectations and prevent policy overextension.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePolicy Adaptability and Scalability\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVariability in healthcare systems and governance structures may limit direct applicability in other contexts.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eServes as a model for other LMICs seeking to enhance health system resilience.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAdaptability to different national contexts requires flexible implementation strategies.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSource:\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;synthesised by the authors\u003c/strong\u003e\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003e\u003cem\u003eConsiderations and lessons learned for other LMICs\u003c/em\u003e\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThailand’s experience with the NFCS highlights several actionable insights for LMICs:\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003e\u003cem\u003eIntegrated health systems:\u003c/em\u003e Harmonising multiple insurance schemes into a unified compensation framework enhances equity and accessibility.\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eTransparency and engagement:\u003c/em\u003e Public trust can be strengthened through inclusive communication, CRM systems and multi-platform information dissemination.\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eAdministrative capacity:\u003c/em\u003e Decentralised claims processing and real-time digital tools are critical for scalability and efficiency.\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eFlexible fiscal mechanisms:\u003c/em\u003e Budget thresholds should be supplemented with contingency reserves for emergency health spending.\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eCross-sectoral coordination:\u003c/em\u003e Multi-agency collaboration is essential for effective implementation and sustainability.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eAs LMICs prepare for future pandemics and other health-related shocks, Thailand’s experience illustrates the importance of embedding adaptive, equitable and financially sound governance mechanisms into emergency response systems. Thailand’s NFCS demonstrates that no-fault compensation can serve as an effective risk mitigation and trust-building mechanism during public health crises. However, its long-term viability depends on balancing responsiveness with fiscal responsibility, clear communication, and adaptive governance frameworks aligned with Policy Feedback Theory.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThailand’s no-fault compensation scheme (NFCS) for COVID-19 vaccine-related injuries offers a compelling case study of policy responsiveness under crisis conditions. The scheme strengthened vaccine confidence, reduced litigation and reinforced public trust in health institutions—demonstrating critical self-reinforcing feedback effects. However, it also exposed vulnerabilities, including rising fiscal burdens and expanding public expectations, which highlight self-undermining dynamics that could threaten long-term sustainability.\u003c/p\u003e\n\u003cp\u003eThis study contributes to understanding how no-fault compensation schemes function in middle-income settings by applying Policy Feedback Theory to examine their administrative, fiscal and sociopolitical effects. Thailand’s experience underscores the importance of harmonised health financing mechanisms, robust administrative systems, transparent communication, and inter-agency coordination. For low- and middle-income countries (LMICs), these lessons are especially valuable in designing policies that enhance trust and resilience while maintaining fiscal accountability.\u003c/p\u003e\n\u003cp\u003eMoving forward, institutionalising contingency reserves, improving data-sharing systems and establishing clear guidelines for eligibility and appeals will be essential to preserving the legitimacy and sustainability of such compensation schemes. While no-fault compensation is not a panacea, Thailand’s NFCS demonstrates that, when designed with foresight and equity, it can serve as an effective component of pandemic preparedness and broader health systems governance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the principles of the Declaration of Helsinki. It was approved by the Institutional Review Board of the Institute for Population and Social Research (IPSR-IRB), Mahidol University (COA. No. 2022/06-138). All participants in interviews and a focus group discussion provided informed consent prior to participation. Participation was voluntary, and confidentiality and anonymity were assured throughout the research process.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants involved in interviews and focus group discussion provided informed consent for the use of anonymised quotations in this publication. No identifiable personal data are included in the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting the findings of this study are based on publicly available literature, official reports and media sources. Due to the ethical restrictions and confidentiality commitments made to participants, interview and focus group transcripts are not publicly available. However, the semi-structured interview guide and FGD protocol used in this study have been included as supplementary materials (Supplementary Files 1 and 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests. The funder had no role in study design, data collection, data analysis, interpretation, or manuscript preparation. The views expressed in this publication are solely those of the author and do not necessarily reflect the opinions or official positions of the United Nations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was conducted as part of the project “Changes and Policy Feedback Effects of the No-Fault Compensation System in Thailand,” supported by the Office of the Permanent Secretary, Ministry of Higher Education, Science, Research and Innovation, Thailand (Grant No. RGNS 64-144).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;Authors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eAssistant Professor Nucharapon Liangruenrom, Ph.D.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eData collection, Data analysis and interpretation, Drafting the article, Critical revision of the article, Final approval of the version to be submitted\u003c/p\u003e\n\u003col start=\"2\"\u003e\n \u003cli\u003eNattanee Satchanawakul, Ph.D.\u003cbr\u003e\u0026nbsp;Data collection, Data analysis and interpretation, Drafting the article, Critical revision of the article, Final approval of the version to be submitted\u003c/li\u003e\n \u003cli\u003eNapaphat Satchanawakul, Ph.D.\u003cbr\u003e\u0026nbsp;Conception or design of the work, Data analysis and interpretation, Critical revision of the article, Final approval of the version to be submitted\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;Acknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe want to thank the Office of the Permanent Secretary of the Ministry of Higher Education, Science, Research and Innovation of Thailand for providing capacity-building grants to support research of early-career faculty. The authors wish to express their sincere gratitude to Emeritus Professor Churnrurtai Kanchanachitrafor her guidance as the academic advisor to this research project. We are also grateful to the experts for their valuable support and for granting access to critical data and policy documentation. Their insights and cooperation were instrumental to the successful completion of this study. Finally, we acknowledge Mahidol University for supporting the publishing fees of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003cstrong\u003eAuthors’ information (optional)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCrum T, Mooney K, Tiwari BR. Current situation of vaccine injury compensation program and a future perspective in light of COVID-19 and emerging viral diseases. 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Available from: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://ddc.moph.go.th/vaccine-covid19/getFiles/7/1672906417174.pdf\u003c/li\u003e\n\u003cli\u003eSachdev S, Viriyathorn S, Chotchoungchatchai S, Patcharanarumol W, Tangcharoensathien V. Thailand\u0026rsquo;s COVID‐19: How public financial management facilitated effective and accountable health sector responses. Int J Health Plann Manage. 2022 Jul;37(4):1894\u0026ndash;906.\u003c/li\u003e\n\u003cli\u003eNational Health Security Office. NHSO Annual Report 2020. Bangkok: National Health Security Office; 2021.\u003c/li\u003e\n\u003cli\u003eWiig S, Aase K, Billett S, Canfield C, R\u0026oslash;ise O, Nj\u0026aring; O, et al. Defining the boundaries and operational concepts of resilience in the resilience in healthcare research program. BMC Health Serv Res. 2020 Dec;20(1):330.\u003c/li\u003e\n\u003cli\u003eDebie A, Nigusie A, Gedle D, Khatri RB, Assefa Y. Building a resilient health system for universal health coverage and health security: a systematic review. Glob Health Res Policy. 2024 Jan 4;9(1):2.\u003c/li\u003e\n\u003cli\u003eBangkok Post. Vaccine death claims refuted. 2022 Jun 18;\u003c/li\u003e\n\u003cli\u003eLyng HB, Macrae C, Guise V, Haraldseid-Driftland C, Fagerdal B, Schibevaag L, et al. Capacities for resilience in healthcare; a qualitative study across different healthcare contexts. BMC Health Serv Res. 2022 Dec;22(1):474.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Universal Health Coverage, health system resilience, emergency services, health policy, vaccines","lastPublishedDoi":"10.21203/rs.3.rs-6438801/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6438801/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003cbr\u003e\nThailand implemented a no-fault compensation scheme (NFCS) for COVID-19 vaccine-related injuries during the pandemic as part of its Universal Health Coverage (UHC) framework. This policy aimed to promote vaccine confidence, reduce litigation and enhance healthcare system resilience. This study investigates the policy feedback effects of Thailand’s NFCS and its implications for healthcare governance in low- and middle-income countries (LMICs).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003cbr\u003e\nA qualitative multi-method approach was employed. Data sources included government policy documents, peer-reviewed literature, media content, official NHSO reports, five semi-structured interviews with key stakeholders and a focus group discussion with public health experts. Media content analysis included over 100 news reports published between March 2021 and October 2022. The analysis was guided by Policy Feedback Theory to identify self-reinforcing and self-undermining feedback loops.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003cbr\u003e\nBetween April 2021 and September 2023, 22,695 compensation claims were filed, with 84.0% approved. The NFCS reduced litigation risks, built public trust and contributed to high vaccine uptake. Self-reinforcing feedback effects were observed in administrative innovations, public engagement strategies and cross-scheme equity. However, self-undermining effects such as financial strain and increased public expectations emerged. Media narratives and public interviews confirmed the importance of rapid compensation and transparent communication in driving public acceptance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003cbr\u003e\nThailand’s NFCS illustrates how a well-designed compensation mechanism can enhance vaccine confidence and public trust during health emergencies. However, sustained political and financial commitment is necessary to mitigate unintended fiscal and administrative challenges. The findings offer relevant policy lessons for LMICs in designing resilient, inclusive compensation systems during future health crises.\u003c/p\u003e","manuscriptTitle":"Exploring the Policy Feedback Effects of a No-Fault Compensation Scheme for COVID-19 Vaccine Injuries in Thailand: A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-30 14:14:48","doi":"10.21203/rs.3.rs-6438801/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2025-05-28T13:11:49+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-06T13:34:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-18T08:49:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-17T15:22:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-04-17T15:21:18+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6e9dd488-133a-4b3d-a69f-f38c92617981","owner":[],"postedDate":"May 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-05-30T14:14:48+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-30 14:14:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6438801","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6438801","identity":"rs-6438801","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}