Background and objective : Health system governance is a critical determinant of effective elderly care, particularly in rural settings undergoing rapid demographic aging. Despite expanded long-term care coverage in Thailand, persistent challenges—including fragmented service delivery, weak intersectoral coordination, and limited community engagement—continue to constrain system performance. This study examines governance and participation in elderly care in a rural Thai context and develops a participatory governance model to inform scalable policy responses. Methods : A mixed-methods study, informed by Participatory Action Research (PAR), was conducted in Chang Klang District, Southern Thailand, between February and September 2024. Quantitative data from 482 participants were analyzed using one-sample t -tests against predefined performance benchmarks. Qualitative data from interviews, focus group discussions, and observations were analyzed thematically. Iterative PAR cycles were used to co-produce governance strategies and policy recommendations with stakeholders. Results : Community participation exceeded benchmark levels (2.88 ± 0.80, P < 0.001), particularly in care planning and information dissemination, but remained limited in monitoring and evaluation. Elderly care competency was marginally below benchmark (2.34 ± 0.52, P = 0.012), with a small effect size, suggesting limited practical significance . Health care behaviors aligned with expected levels (2.39 ± 0.60, P = 0.711). Qualitative findings revealed systemic governance constraints, including fragmented service integration, weak data systems, and inconsistent cross-sector collaboration, alongside strong community engagement in co-design processes. Integrated analysis informed the development of a participatory governance model based on the six building blocks plus framework. Conclusion : Participatory and decentralized governance approaches are associated with improved system responsiveness and community engagement in elderly care. However, their effectiveness depends on enabling institutional and community-level capacities. The proposed model offers a context-sensitive yet potentially transferable framework for strengthening health system governance in aging rural settings.
Sornkaew et al. (Mon,) studied this question.