Digital Governance at the Street Level: A Mixed-Methods Study of Systemic Resilience and ‘Human-in-the-Loop’ Telemedicine in Rural Thailand

While telemedicine has proliferated globally, its sustainable implementation in resource-constrained settings remains understudied. This study evaluates the efficacy, determinants of patient satisfaction, and systemic resilience of a “Home Ward” model at a rural Thai community hospital. Employing a convergent mixed-methods design, we surveyed 51 participants and conducted in-depth interviews with service users (n = 5) and a multidisciplinary team (n = 7). Multiple linear regression revealed high patient satisfaction ( = 3.70), explaining 67.3% of the variance (R² = 0.673). Notably, Perceived Usefulness (β = 0.589, p < 0.001) and the Effectiveness of Symptom Monitoring (β = 0.317, p < 0.05) significantly predicted satisfaction. Conversely, Overall System Quality was not a significant predictor (β = 0.142, p > 0.05), highlighting a ‘Low-Tech, High-Touch’ paradox. Qualitative analysis elucidated this through the “Human-in-the-Loop” mechanism, where Village Health Volunteers (VHVs) and healthcare providers bridge the digital divide. However, the study identifies an “invisible workload”—non-formalized discretionary effort—that sustains this resilience. Findings suggest that rural digital health governance should prioritize human intermediaries and pragmatic utility over purely technical upgrades. The study concludes that long-term sustainability requires institutionalizing human support networks while mitigating the exploitation of healthcare personnel’s goodwill.