Bangkok's First Step Toward a Marmot Community

On 5 May 2026, the Urban Studies Institute (USI), together with the Bangkok Metropolitan Administration (BMA), the National Health Security Office Region 13 (NHSO R13), the UCL Institute of Health Equity (IHE), and the China Medical Board (CMB) Foundation, alongside partners including ThaiHealth, HiTAP, NHCO, SHI, WHO Thailand, and Chulalongkorn University, convened a high-level policy meeting at the Ford Community Center and Bangkok 1899. The meeting set out a working structure for advancing health equity in Bangkok under the name Bangkok Social Determinants of Health Equity Initiative (SDHEI). It marks Bangkok's first step toward becoming a Marmot Community, and the first such community to take shape in Thailand and in any middle-income country.

What is a Marmot Community?

A Marmot Community is a network of cities and regions committed to reducing health inequalities by acting on the social determinants of health, using the framework developed by Sir Michael Marmot and the UCL Institute of Health Equity. The network began with Coventry in the United Kingdom in 2013, expanded to Greater Manchester in 2019, and has since grown across other UK cities. At the heart of this concept are the 8 Marmot Principles:

the 8 Marmot Principles:

1. Give every child the best start in life.

2. Enable all children, young people and adults to maximize their capabilities and have control over their lives.

3. Create fair employment and good work for all.

4. Ensure a healthy standard of living for all.

5. Create and develop healthy and sustainable places and communities.

6. Strengthen the role and impact of ill health prevention.

7. Tackle racism, discrimination and their outcomes.

8. Pursue environmental sustainability and health equity together.

These principles are paired with the approach of Proportionate Universalism, which is discussed in detail further on. Bangkok joining the network is therefore not only a milestone for the city itself, but also brings this approach to Thailand and to middle-income country settings for the first time.

The Paradox of Bangkok's Health System

Bangkok has the highest density of health facilities in Thailand, with 358 primary clinics, 112 main contracting units, and 44 referral units. Yet the outpatient utilization rate among Bangkok residents sits at only 2.71 visits per person per year, compared to the national average of 3.75 visits (Thanasak Thumbuntu NHSO, 2026). More concerning still, Bangkok's unmet health need reaches 3.71 percent, nearly three times the 1.34 percent recorded in other regions.

The problem is therefore not the number of facilities, but the "accessibility and usability" of services. This is constrained by several factors: indirect costs, time poverty, a fragmented system, and most critically, populations who remain "invisible" in both BMA and NHSO databases. These are people the system has yet to reach, and who are also bearing multiple compounding challenges.

That some populations are seen by the system but cannot reach services, while others remain unseen altogether, suggests that health inequity in Bangkok is not concentrated only at the bottom of society. It is graded across different levels of vulnerability, varying by group and by area. Responding to a structure of this kind requires a principle that covers the entire population while calibrating the intensity of support to the level of need. This is the essence of Proportionate Universalism. 

In its first phase, the "Development of Indicators and Data Collection Mechanisms to Reduce Urban Health Inequities" project supported by ThaiHealth (Section 9) and the Urban Studies Institute Foundation mapped health disparities across Bangkok. Utilizing the 6-dimensional Social Determinants of Health Equity (SDHE) and the Index of Multiple Deprivation (IMD), the study surveyed 6,523 respondents across all 50 districts and five community types, utilizing public health and tech volunteers. The research focused on four vulnerable groups the elderly, persons with disabilities, informal workers, and the LGBTQ+ community and launched the public Bangkok Health Inequalities Dashboard to visualize the data.

Key Findings: Intersecting and Spatial Disparities

The study reveals deep, overlapping layers of systemic inequity across the metropolitan landscape:

• High-Vulnerability Groups: Persons with disabilities emerged as the most disadvantaged, topping vulnerability metrics in 4 out of 7 dimensions, while the LGBTQ+ community faces a distinct burden from minority stress.

• Intra-Group Inequalities: Vulnerable groups are not monolithic; internal variations in education and income significantly dictate employment opportunities and healthcare access.

• The Neighborhood Gap: Community type directly influences SDHE scores across all dimensions. Slums and informal urban settlements face severe disadvantages compared to gated communities, highlighting a persistent resource gap between Bangkok’s inner core and its outskirts.

The Principle of Proportionate Universalism

The concept emerged from a key finding in Marmot's Fair Society, Healthy Lives report, which showed that health inequality is not confined to the very poorest in society. It runs as a "social gradient" from the top of society to the bottom: at every step down the socio-economic ladder, health is systematically worse than at the step above. Targeting only the most disadvantaged groups is therefore insufficient to reduce inequality across the population, while delivering services on a purely universal basis does nothing to flatten the gradient itself.

Proportionate Universalism resolves this by combining the two principles into one approach: universal public services that cover the entire population, with the intensity of those services scaled to the level of need or vulnerability of each group and place. The aim is to raise overall population health and to flatten the social gradient at the same time, rather than choosing between the two.

This approach is consistent with evidence from the Marmot framework showing that approximately 80 percent of health outcomes are determined by factors outside the clinic, which means the health system alone cannot close the gap. Cross-sectoral action on housing, employment, education, and the urban environment is essential. A clear example comes from Coventry in the United Kingdom, which has applied this approach since 2013 and reduced the male life expectancy gap between its most-deprived and least-deprived areas from 11.2 years to 10.7 years within 6 years.

Beyond the 8 Marmot Principles, the meeting also adopted the Urban Health Ecosystem Framework developed by Dr Wirun Limsawart as a local lens. The framework places the urban social network, comprising individuals, families, social groups, and communities, at the centre, surrounded by three interconnected systems: the health service and welfare system, the social service and welfare system, and the governance and participation system.

6 Pilot Areas

The initiative will pilot across 6 BMA district groups, chosen to span the city's distinct socio-economic, demographic, and environmental contexts:

• Phom Prap Sattru Phai (Central Bangkok Group) is the lead pilot, drawing on the established community base and ongoing work of the Urban Studies Institute (USI) and the Ford Community Center (FCC), which have worked continuously in this dense old-town district on early childhood, elder population, urban environment, and clean air programs.

• Khlong Toei (Southern Bangkok Group) is a high-density informal urban settlement with vulnerable populations, internal migrants, and a heavy burden of NCDs and respiratory disease. The Society and Health Institute (SHI), led by Dr Wirun Limsawart, the originator of the Urban Health Ecosystem Framework, serves as the cluster lead, building on SHI's prior community work in Khlong Toei.

• Bang Khen (Northern Bangkok Group) is a peri-urban transition zone in northern Bangkok with limited BMA hospital infrastructure and notable gaps in access and continuity of care.

• Prawet (Eastern Bangkok Group) is led by Chulalongkorn University, drawing on an existing ageing cohort across 8 communities, an industrial zone with an informal workforce, and Sirindhorn Hospital's role in geriatric and palliative care.

• Khlong San (Northern Thonburi Group) is a riverine old-town along the Chao Phraya, with an ageing population, a heritage urban environment, and community-based care assets.

• Bang Khun Thian (Southern Thonburi Group) is a peri-urban coastal area facing climate vulnerability and rising sea levels, hosting a large migrant workforce from Laos, Myanmar, and Cambodia, and home to BMA's elder hospital.

  
  

Cluster lead organizations for the remaining sites will be matched through joint work with district offices and Public Health Centres in each area, alongside the Partner Data Catalog assessment tool and follow-up convening of extended partners. The process is designed to ensure each cluster is supported by an organization that already holds community trust, existing data, or an active service role in the area.

The Marmot Community Operational Framework

Operating a Marmot Community requires data at the local level as the heart of the system. This is because the framework's headline health outcome indicators, Life Expectancy and Healthy Life Expectancy stratified by area-level deprivation, must be computed at fine spatial resolution. In England, these indicators can be calculated down to the Middle Layer Super Output Area (MLSOA) level, approximately 5,000–15,000 people per unit, roughly equivalent to the khwaeng (sub-district) level in Bangkok. This resolution allows precise targeting of inequality concentrated in "pockets of poverty" that city-wide averages would otherwise obscure.

For Bangkok, the meeting clearly identified two main data gaps. First, limited access to mortality registration based on place of residence, which means that life expectancy cannot yet be directly computed at the district or sub-district level. Second, the gap previously flagged by OECD: Thailand tracks indicators on sex, age, and financial protection well, including catastrophic health spending measured by the Kakwani index, but lacks data disaggregated by socio-economic status on key issues such as chronic illness and health service utilization. Closing these gaps is therefore a central task of Bangkok work, carried out jointly with BMA departments and NHSO Region 13.

Given these constraints, the data architecture is designed in two tiers.

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Tier 1 establishes a city-wide equity baseline standardized across all 6 districts, integrating three data streams: system data from NHSO and BMA, place data covering registered communities and the Index of Multiple Deprivation (IMD), and people data from USI's Phase 1 SDHE survey. Initially, proxy indicators such as premature mortality will stand in for life expectancy. The full set will be filtered down to a headline list of around 10–20 indicators, following the Marmot Place methodology.

Tier 2 translates the Tier 1 baseline into locally specific evidence, with each cluster designing research questions and intervention measures together with partner organizations within a 12–18-month timeline, and results evaluated against Tier 1.

Next Steps

The process of establishing the Marmot Community will begin between May and July 2026, with four priority tasks: formal endorsement of BMA and NHSO Region 13, confirmation of cluster leads for the 3 remaining pilot areas, drafting of the data governance MOU between BMA, NHSO, USI, and other partners, and initiation of the consensus process on the headline indicator set.

The establishment of the Bangkok Social Determinants of Health Equity Initiative (SDHEI) is not a "research project" but a "data governance and policy infrastructure" that takes the existing triangle of people, government, and academia in Bangkok and uses it to redesign Universal Health Coverage and social services so that they work better for those the system has yet to reach. The 6 pilot areas therefore serve as proof of concept for the Marmot Community approach, with the ultimate goal of durable systemic and policy change.