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Antimicrobial resistance (AMR) is a global health concern with significant implications on economies and health security, affecting humans, animals, food, and the environment. To tackle this issue, promoting responsible antimicrobial use in livestock production has emerged as a crucial intervention. In 2018, Thailand introduced the Voluntary Optimization of Antimicrobial Consumption (VOAC) programme, with the objective to encourage responsible antimicrobial use practises. This study aimed to analyse the context, content, process and actors of the VOAC programme. A qualitative method including document reviews and key informant interviews were applied. In-depth interviews were conducted with 18 key informants who are key stakeholders from public and private sectors involved in the policy formulation, design of policy contents and implementation of VOAC: policy makers or officers responsible for animal health (n = 12), animal producers (n = 2), animal product traders or retailers (n = 2), and farm veterinarians (n = 2). Interview transcripts were validated by informants for accuracy, and triangulated with document review findings. Deductive approach was applied for data analysis and interpretation based on Walt and Gilson’s policy analysis framework. The VOAC farm certification comprises of Raised Without Antibiotics (RWA) and Reducing Antibiotic Use (RAU), both aiming to combat AMR in food animals. Global and national factors, including increased public awareness, policy commitments, export requirements from the European Union, and international organisation advocacies, influenced the development of the programme led by the Department of Livestock Development (DLD), under the Ministry of Agriculture and Cooperatives. Collaboration with the private sector facilitated policy clarity, with implementation primarily executed through regional, provincial, and district livestock officers. Integration of the programme with the pre-existing Good Agriculture Practise certification system enabled cost-effective implementation without additional resources. In 2022, DLD official data reported 214 RWA farms (112 pig and 102 broiler), and 230 RAU farms (83 pig and 147 broiler). Incentives for farms to participate in the programme include improving corporate image and demonstrating corporate responsibility addressing AMR in food products. Recommendations include optimising certification strategies, increasing consumer awareness of RWA and RAU products and strengthening monitoring and evaluation systems.

Progressive realization of universal health coverage (UHC) requires health systems capacity to provide quality service and financial risk protection which supports access to services without financial hardship. Government health spending in low-income countries (LICs) has been low and heavily relied on external donor resources and out-ofpocket payment. This has resulted in high prevalence of catastrophic health spending or foregone care by those who cannot afford. Under fiscal constraints posed by pandemic, reforms in LICs should focus on efficiency through health resource waste reduction. Targeting the poor even with low level of health spending can make a significant health gain. Investment in primary healthcare and health workforce is the foundation for realizing UHC which cannot be postponed. Innovative tax on health hazardous products, conditional debt relief can increase fiscal space for health; while international collaboration to accelerate coronavirus disease 2019 (COVID-19) vaccine coverage can bring LICs out of acute phase of pandemic.

Background Non-communicable diseases (NCDs) kill 41 million people a year. The products and services of unhealthy commodity industries (UCIs) such as tobacco, alcohol, ultra-processed foods and beverages and gambling are responsible for much of this health burden. While effective public health policies are available to address this, UCIs have consistently sought to stop governments and global organisations adopting such policies through what is known as corporate political activity (CPA). We aimed to contribute to the study of CPA and development of effective countermeasures by formulating a model and evidence-informed taxonomies of UCI political activity.Methods We used five complementary methods: critical interpretive synthesis of the conceptual CPA literature; brief interviews; expert co-author knowledge; stakeholder workshops; testing against the literature.Results We found 11 original conceptualisations of CPA; four had been used by other researchers and reported in 24 additional review papers. Combining an interpretive synthesis of all these papers and feedback from users, we developed two taxonomies – one on framing strategies and one on action strategies. The former identified three frames (policy actors, problem, and solutions) and the latter six strategies (access and influence policy-making, use the law, manufacture support for industry, shape evidence to manufacture doubt, displace, and usurp public health, manage reputations to industry’s advantage). We also offer an analysis of the strengths and weaknesses of UCI strategies and a model that situates industry CPA in the wider social, political, and economic context.Conclusion Our work confirms the similarity of CPA across UCIs and demonstrates its extensive and multi-faceted nature, the disproportionate power of corporations in policy spaces and the unacceptable conflicts of interest that characterise their engagement with policy-making. We suggest that industry CPA is recognised as a corruption of democracy, not an element of participatory democracy. Our taxonomies and model provide a starting point for developing effective solutions.

BackgroundSince 2020, Thailand has experienced four waves of COVID-19. By 31 January 2022, there were 2.4 million cumulative cases and 22,176 deaths nationwide. This study assessed the governance and policy responses adapted to different sizes of the pandemic outbreaks and other challenges.MethodsA qualitative study was applied, including literature reviews and in-depth interviews with 17 multi-sectoral actors purposively identified from those who were responsible for pandemic control and vaccine rollout. We applied deductive approaches using health systems building blocks, and inductive approaches using analysis of in-depth interview content, where key content formed sub-themes, and different sub-themes formed the themes of the study.FindingsThree themes emerged from this study. First, the large scale of COVID-19 infections, especially the Delta strain in 2021, challenged the functioning of the health system’s capacity to respond to cases and maintain essential health services. The Bangkok local government insufficiently performed due to its limited capacity, ineffective multi-sectoral collaboration, and high levels of vulnerability in the population. However, adequate financing, universal health coverage, and health workforce professionalism and commitment were key enabling factors that supported the health system. Second, the population’s vulnerability exacerbated infection spread, and protracted political conflicts and political interference resulted in the politicization of pandemic control measures and vaccine roll-out; all were key barriers to effective pandemic control. Third, various innovations and adaptive capacities minimized the supply-side gaps, while social capital and civil society engagement boosted community resilience.ConclusionThis study identifies key governance gaps including in public communication, managing infodemics, and inadequate coordination with Bangkok local government, and between public and private sectors on pandemic control and health service provisions. The Bangkok government had limited capacity in light of high levels of population vulnerability. These gaps were widened by political conflicts and interference. Key strengths are universal health coverage with full funding support, and health workforce commitment, innovations, and capacity to adapt interventions to the unfolding emergency. Existing social capital and civil society action increases community resilience and minimizes negative impacts on the population.

Abstract Background Indonesia implemented one of the world’s largest single-payer national health insurance schemes (the Jaminan Kesehatan Nasional or JKN) in 2014. This study aims to assess the incidence of catastrophic health spending (CHS) and its determinants and trends between 2018 and 2019 by which time JKN enrolment coverage exceeded 80%. Methods This study analysed data collected from a two-round cross-sectional household survey conducted in ten provinces of Indonesia in February–April 2018 and August–October 2019. The incidence of CHS was defined as the proportion of households with out-of-pocket (OOP) health spending exceeding 10% of household consumption expenditure. Chi-squared tests were used to compare the incidences of CHS across subgroups for each household characteristic. Logistic regression models were used to investigate factors associated with incurring CHS and the trend over time. Sensitivity analyses assessing the incidence of CHS based on a higher threshold of 25% of total household expenditure were conducted. Results The overall incidence of CHS at the 10% threshold fell from 7.9% to 2018 to 4.4% in 2019. The logistic regression models showed that households with JKN membership experienced significantly lower incidence of CHS compared to households without insurance coverage in both years. The poorest households were more likely to incur CHS compared to households in other wealth quintiles. Other predictors of incurring CHS included living in rural areas and visiting private health facilities. Conclusions This study demonstrated that the overall incidence of CHS decreased in Indonesia between 2018 and 2019. OOP payments for health care and the risk of CHS still loom high among JKN members and among the lowest income households. More needs to be done to further contain OOP payments and further research is needed to investigate whether CHS pushes households below the poverty line.

Background: Healthcare-associated infections (HAIs) pose a grave threat to patient safety, morbidity, and mortality, contributing to antimicrobial resistance. Thus, we estimated the point prevalence, risk factors, types, and pathogens of HAIs in hospitalized pediatric patients. Methods: A point prevalence survey (PPS) of HAIs in hospitalized pediatric patients < 18 years old was conducted from March to May 2021. Outcomes, risk factors, and types of HAIs associated with HAIs in 41 hospitals across Thailand were collected. Results: The prevalence of HAIs was 3.9% (95% CI 2.9–5.0%) (56/1443). By ages < 1 month, 1 month–2 years, 2–12 years, and 12–18 years, the prevalence of HAIs was 4.2%, 3.3%, 4.1%, and 3.0%, respectively (p = 0.80). Significant independent risk factors were extended hospital length of stay (LOS) and central venous catheter (CVC) use. Compared to an LOS of 14 days had adjusted odds ratios (aORs) of 2.65 (95% CI 1.05, 6.68), 5.19 (95% CI 2.00, 13.4), and 9.03 (95% CI 3.97, 20.5), respectively. The use of a CVC had an aOR of 2.45 (95% CI 1.06–5.66). Lower respiratory tract infection (LRTI) was the most common HAI type (46.4%: 26/56). The highest prevalence of HAIs was predominantly observed in LRTI diagnoses, with the highest among these in the

Objectives COVID-19 infection increased nephrology-related risks and mortality rate among end-stage renal disease (ESRD) patients. The pandemic also disrupted essential healthcare services. We aim to explore all-cause excess mortality among ESRD patients who were members of the Universal Coverage Scheme (UCS), the largest public health insurance scheme in Thailand covering citizens who are not employed in the formal sector, including children and older persons.Design A cross-sectional study.Setting We retrieved the dataset from the UCS claims database—electronic health records used for processing healthcare expense claims from medical facilities of all UCS members. This database links mortality outcome to civil registration. We employed the WHO’s excess mortality methodology using pre-pandemic data to estimate expected deaths during the pandemic period (March 2020 to August 2022).Participants This study included ESRD patients from across Thailand, covered by the UCS.Primary outcome measure Excess deaths are the difference between predicted and reported deaths.Results Over a 30-month period of the pandemic, the total number of all-cause excess deaths among ESRD patients was 4966 (male 1284; female 3682). The excess death per 100 000 ESRD patients was 3601 (male 2012; female 4969). The relative excess death was 5.7% of expected deaths (95% CI 1.7%, 10.0%). The excess deaths were highly concentrated among patients aged 65 and older.Conclusion ESRD patients are significantly more vulnerable to pandemic-related mortality than the general population. Health systems’ capacity to contain the pandemic at varying virulence and maintain essential health services for ESRD patients might be related to the size of excess deaths at different periods. The observed excess deaths highlight the importance of established strategies to reduce all-cause mortality such as rapid vaccine rollout for ESRD patients and sustaining dialysis and other essential services for older patients and other high-risk groups.

Orphans, especially those who experience maternal loss at a young age, face significant long-term negative impacts on their lives and psychological well-being, extending beyond the age of 18. As of July 2023, the global death toll of COVID-19 has reached 6.9 million, leaving behind an unknown number of orphans who require immediate attention and support from policymakers. In Thailand, from April 2020 to July 2022, the total number of COVID-19-related deaths reached 42,194, resulting in 4,139 parental orphans. Among them, 452 (10.9%) were children under the age of five, who are particularly vulnerable and necessitate special policy attention and ongoing support. While the provision of 12 years of free education for all and Universal Health Coverage helps alleviate the education and health expenses borne by households supporting these orphans, the monthly government support of 2,000 Baht until the age of 18 is insufficient to cover their living costs and other education-related expenditures. We advocate for adequate financial and social support for COVID-19 orphans, emphasizing the importance of placing them with relatives rather than institutional homes. In the context of post-pandemic recovery, this perspective calls upon governments and global communities to estimate the number of orphans and implement policies to safeguard and support them in the aftermath of COVID-19.

In line with the global trend, the Middle East and North Africa (MENA) region has been growing vulnerable to the direct and indirect health effects of climate change including death tolls due to climatological disasters and diseases sensitive to climate change since the industrial revolution. Regarding the limited capacity of MENA countries to adapt and respond to these effects, and also after relative failures of the previous negotiation in Glasgow, in the upcoming COP27 in Egypt, the heads of the region’s parties are determined to take advantage of the opportunity to host MENA to mitigate and prevent the worst effects of climate change. This would be achieved through mobilizing international partners to support climate resilience, a major economic transformation, and put health policy and management in a strategic position to contribute to thinking and action on these pressing matters, at least to avoid or minimize the future adverse consequences.

Abstract Background Many countries implementing pro-poor reforms to expand subsidized health care, especially for the poor, recognize that high-quality healthcare, and not just access alone, is necessary to meet the Sustainable Development Goals. As the poor are more likely to use low quality health services, measures to improve access to health care need to emphasise quality as the cornerstone to achieving equity goals. Current methods to evaluate health systems financing equity fail to take into account measures of quality. This paper aims to provide a worked example of how to adapt a popular quantitative approach, Benefit Incidence Analysis (BIA), to incorporate a quality weighting into the computation of public subsidies for health care. Methods We used a dataset consisting of a sample of households surveyed in 10 provinces of Indonesia in early-2018. In parallel, a survey of public health facilities was conducted in the same geographical areas, and information about health facility infrastructure and basic equipment was collected. In each facility, an index of service readiness was computed as a measure of quality. Individuals who reported visiting a primary health care facility in the month before the interview were matched to their chosen facility. Standard BIA and an extended BIA that adjusts for service quality were conducted. Results Quality scores were relatively high across all facilities, with an average of 82%. Scores for basic equipment were highest, with an average score of 99% compared to essential medicines with an average score of 60%. Our findings from the quality-weighted BIA show that the distribution of subsidies for public primary health care facilities became less ‘pro-poor’ while private clinics became more ‘pro-rich’ after accounting for quality of care. Overall the distribution of subsidies became significantly pro-rich (CI = 0.037). Conclusions Routine collection of quality indicators that can be linked to individuals is needed to enable a comprehensive understanding of individuals’ pathways of care. From a policy perspective, accounting for quality of care in health financing assessment is crucial in a context where quality of care is a nationwide issue. In such a context, any health financing performance assessment is likely to be biased if quality is not accounted for.

Background: Additional billing is commonly and legally practiced in some countries for patients covered by health insurance. However, knowledge and understanding of the additional billings are limited. This study reviews evidence on additional billing practices including definition, scope of practice, regulations and their effects on insured patients. Methods: A systematic search of the full-text papers that provided the details of balance billing for health services, written in English, and published between 2000 and 2021 was carried out in Scopus, MEDLINE, EMBASE and Web of Science. Articles were screened independently by at least 2 reviewers for eligibility. Thematic analysis was applied. Results: In total, 94 studies were selected for the final analysis. Most of the included articles (83%) reported findings from the United States (US). Numerous terms of additional billings were used across countries such as balance billing, surprise billing, extra billing, supplements and out-of-pocket (OOP) spending. The range of services incurred these additional bills also varied across countries, insurance plans, and healthcare facilities; the frequently reported were emergency services, surgeries, and specialist consultation. There were a few positive though more studies reported negative effects of the substantial additional bills which undermined universal health coverage (UHC) goals by causing financial hardship and reducing access to care. A range of government measures had been applied to mitigate these adverse effects, but some difficulties still exist. Conclusion: Additional billings varied in terms of terminology, definitions, practices, profiles, regulations, and outcomes. There were a set of policy tools aimed to control substantial billing to insured patients despite some limitations and challenges. Governments should apply multiple policy measures to improve financial risk protection to the insured population.

Abstract Background Health, social and economic crises triggered by the Coronavirus disease pandemic (COVID-19) can derail progress and achievement of the Sustainable Development Goals. This commentary analyses the complex nexus of multi-dimensional impacts of the pandemic on people, prosperity, planet, partnership and peace. From our analysis, we generate a causal loop diagram explaining these complex pathways and proposed policy recommendations. Main text Health systems, health and wellbeing of people are directly affected by the pandemic, while impacts on prosperity, education, food security and environment are indirect consequences from pandemic containment, notably social measures, business and school closures and international travel restrictions. The magnitude of impacts is determined by the level of prior vulnerability and inequity in the society, and the effectiveness and timeliness of comprehensive pandemic responses. Conclusions To exit the acute phase of the pandemic, equitable access to COVID-19 vaccines by all countries and continued high coverage of face masks and hand hygiene are critical entry points. During recovery, governments should strengthen preparedness based on the One Health approach, rebuild resilient health systems and an equitable society, ensure universal health coverage and social protection mechanisms for all. Governments should review progress and challenges from the pandemic and sustain a commitment to implementing the Sustainable Development Goals.

BackgroundPhysical inactivity and sedentary behavior are significant risk factors for various non-communicable diseases. Bangkok, Thailand's capital, is one of the fastest-growing metropolitans in Southeast Asia. Few studies have investigated the epidemiology of physical activity and sedentary behavior among Bangkok residents. This study aims to investigate the prevalence of combined physical activity and sedentary behavior patterns among Bangkok residents and examine relationships between participants' characteristics and the combined movement patterns.MethodsWe analyzed data from the nationally representative 2021 Health Behavior Survey conducted by the Thailand National Statistical Office. The Global Physical Activity Questionnaire was used to assess physical activity and sedentary behavior. 'Sufficiently active' was defined as meeting the World Health Organization's guidelines for aerobic physical activity (≥150 minutes of moderate-to-vigorous physical activity per week). 'Low sedentary time' was defined as sitting for ≤7 hours per day. Participants were categorized into one of four movement patterns: highly active/low sedentary, highly active/highly sedentary, low active/low sedentary, and low active/highly sedentary. Multinomial logistic regression was used to identify the factors associated with each group of four movement patterns.ResultsAmong the 3,137 individuals included in the study, the majority were categorized as highly active/highly sedentary (64.8%), followed by highly active/low sedentary (17.9%) and low active/highly sedentary (14.3%). Only a few (3.0%) of participants were categorized as being low active/low sedentary. Compared to males, female participants had a significantly higher likelihood of belonging to the highly active/low sedentary (AOR = 1.69, 95%CI: 1.25, 2.28) or highly active/highly sedentary (AOR = 1.51, 95%CI: 1.19, 1.93) group, rather than the low active/high sedentary group. Compared to unemployed/retired participants, those in labor-intensive occupations had a significantly higher likelihood of being in the highly active/low sedentary group (AOR = 1.89, 95%CI: 1.22, 2.94). Compared to participants with no chronic physical conditions, participants who reported multimorbidity had a significantly lower likelihood of being in the highly active/low sedentary group (AOR = 0.60, 95%CI: 0.37, 0.98).ConclusionThis study provides valuable insights into the patterns of physical activity and sedentary behavior among residents of Bangkok using up-to-date data. The majority belonged to the highly active/highly sedentary group, followed by the highly active/low sedentary group. Correlates such as sex, occupation, and chronic conditions were associated with these patterns. Targeted interventions in recreational activities, workplaces, and urban areas, including screen time control measures, movement breaks and improved built environments, are crucial in reducing sedentary behavior and promoting physical activity.

Antimicrobial resistance (AMR) threatens health security and the economy worldwide. AMR bacteria can spread across humans, animals, food webs and the environment. Excessive use of antimicrobials in food-producing animals has been recognised as one of the main drivers of the emergence of resistant bacteria. This study aims to quantify and identify patterns of antimicrobial consumption in food-producing animals in Thailand in a three-year period (2017-2019). Milligrams of active ingredient from total volume of imported and locally manufactured products minus exports were obtained from Thai FDA. Annual population production of food-producing animals in 2017, 2018 and 2019 was compiled and validated through cooperation between the Department of Livestock Development (DLD), Department of Fisheries (DOF). The total amount of antimicrobial consumption for food-producing animals decreased 49.0% over the three-year period from 658.7 mg/PCUThailand in 2017 to 336.3 mg/PCUThailand in 2019. In 2017, the most common antimicrobials used was macrolides which was replaced by aminopenicillins and pleuromutilins in 2019, while tetracyclines was consistently common over the three-year period. Consumption of the WHO Critically Important Antimicrobials (CIA) group declined significantly over this period, from 259.0 in 2017 to 193.2 mg/PCUThailand in 2019 (a 25.4% reduction). Findings from this study were in line with national policies which curtails prudent use of antimicrobials in food-producing animals. The government should maintain the decreasing trend of consumption, in particular of the CIA category. Improving information systems which captures consumption by specific species contributes to precision of interventions to minimise prudent use in each species.

Private sector plays an import role in health service provision, therefore the engagement of private health facilities is important for ensuring access to health services. In Thailand, two of the three public health insurance schemes, Universal Coverage Scheme and Social Health Insurance, contract with private health facilities to fill gaps of public providers for the provision of health services under Universal Health Coverage. The National Health Security Office (NHSO) and Social Security Office (SSO), which manage the schemes respectively, have designed their own contractual agreements for private facilities. We aim to understand the current situation of contracting private health facilities within UHC of the two purchasing agencies. This qualitative descriptive case study was conducted through document review and in-depth interviews with key informants to understand how they contract private primary care facilities, service types, duration of contract, standard and quality requirement and renewal and termination of contracts. Private providers make a small contribution to the service provision in Thailand as a whole but they are important actors in Bangkok. The current approaches used by two purchasers are not adequate in engaging private sector to fill the gap of public provision in urban cities. One important reason is that large private hospitals do not find public contracts financially attractive. NHSO classifies contracts into 3 categories: main contracting units, primary care units, and referral units; while SSO only contracts main contracting units. Both allows subcontracting by the main contractors. Contractual agreements are effective in ensuring mandatory infrastructure and quality standards. Both purchasers have established technical capacities to enforce quality monitoring and financial compliance although there remains room for improvement especially on identifying fraud and taking legal actions. Contracting private healthcare facilities can fill the gap of public healthcare facilities, especially in urban settings. Purchasers need to balance the right level of incentives and accountability measures to ensure access to quality of care. In contracting private-for-profit providers, strong regulatory enforcement and auditing capacities are necessary. Further studies may explore various aspects contracting outcomes including access, equity, quality and efficiency impacts.

Increased misinformation circulating among the population during the COVID-10 pandemic can trigger rejection to take up vaccines. This study assesses the influence of vaccine information and other factors on vaccine acceptance in the Thai population. Between March and August 2021, six rounds of cross-sectional surveys through village health volunteer networks and online channels were conducted; as well as qualitative interviews with frontline health workers, patients with chronic diseases, and religious believers and leaders. Descriptive and multiple logistic regression with 95% level of confidence were used for survey findings while deductive thematic analysis was used for in-depth interview findings. Among the total 193,744 respondents, the initial COVID-19 vaccine acceptance rate decreased from 60.3% in March 2021 to 44.0% in April 2021, then increased to 88.8% in August 2021. Participants who were able to differentiate true and false statements were 1.2 to 2.4 times more likely to accept vaccine than those who were not. Those who perceived a high risk of infection (Adjusted odds ratio; AOR = 2.6-4.7), perceived vaccine safety (AOR = 1.4-2.4), judged the importance of vaccination (AOR = 2.3-5.1), and had trust in vaccine manufacture (AOR = 1.9-3.2) were also more likely to accept the vaccine. Moreover, higher education (AOR = 1.6-4.1) and living in outbreak areas (AOR = 1.4-3.0) were significantly related to vaccine uptake, except in people with chronic diseases who tended not to accept the vaccine (AOR = 0.7-0.9). This study recommends effective infodemic management and comprehensive public communication, prioritising vulnerable groups such as those with a low level of education and people with chronic conditions. Communication through reliable channels can support higher vaccine acceptance and rapid vaccine rollout. Finally, regular monitoring of misinformation is important such as fact checking support, timely legal actions and specific debunking communication.

This article is part of the Research Topic ‘Health Systems Recovery in the Context of COVID-19 and Protracted Conflict’. The third quarter of 2022 saw COVID-19 cases and deaths in Thailand reduced significantly, and high levels of COVID-19 vaccine coverage. COVID-19 was declared an “endemic” disease, and economic activities resumed. This paper reviews pre-pandemic health systems capacity and identifies pandemic response strengths, weaknesses and lessons that guided resilient and equitable health system recovery. Robust health systems and adaptive strategies drive an effective pandemic response. To support health system recovery Thailand should (1) minimize vulnerability and extend universal health coverage to include migrant workers and dependents; (2) sustain provincial primary healthcare (PHC) capacity and strengthen PHC in greater Bangkok; (3) leverage information technology for telemedicine and teleconsultation; (4) enhance and extend case and event-based surveillance of notifiable diseases, and for public health threats, including pathogens with pandemic potential in wildlife and domesticated animals. This requires policy and financial commitment across successive governments, adequate numbers of committed and competent health workforce at all levels supported by over a million village health volunteers, strong social capital and community resilience. A strengthened global health architecture and international collaboration also have critical roles in establishing local capacities to develop and manufacture pandemic response products through transfer of technology and know-how. Countries should engage in the ongoing Inter-government Negotiating Body to ensure a legally binding instrument to safeguard the world from catastrophic impacts of future pandemics.

Objective This study assesses the role of social capital among people and communities in response to the first wave of the pandemic in 2020.Design Qualitative study using focus group discussions.Setting Capital city (Bangkok) and the four regions (north, northeast, south and central) of Thailand.Participants 161 participants of 19 focus groups with diverse backgrounds in terms of gender, profession, education and geography (urban/rural; regions). They are selected for different levels of impact from the pandemic.Findings The solidarity among the Thai people was a key contributing factor to societal resilience during the pandemic. Findings illustrate how three levels of social capital structure—family, community and local networks—mobilised resources from internal and external social networks to support people affected by the pandemic. The results also highlight different types of resources mobilised from the three levels of social capital, factors that affect resilience, collective action to combat the negative impacts of the pandemic, and the roles of social media and gender.Conclusion Social capital plays significant roles in the resilience of individuals, households and communities to respond to and recover from the impacts of the pandemic. In many instances, social capital is a faster and more efficient response than other kinds of formal support. Social capital can be enhanced by interactions and exchanges in the communities. While face-to-face social contacts are challenged by the need for social distancing and travel restrictions, social media steps in as alternative socialisation to enhance social capital.

Objectives This study assesses effective coverage of diabetes and hypertension in Thailand during 2016–2019.Design Mixed method, analysis of National health insurance database 2016–2019 and in-depth interviews.Setting Beneficiaries of Universal Coverage Scheme residing outside Bangkok.Participants Quantitative analysis was performed by acquiring individual patient data of diabetes and hypertension cases in the Universal Coverage Scheme residing outside bangkok in 2016-2019. Qualitative analysis was conducted by in-depth interview of 85 multi-stakeholder key informants to identify challenges.Outcomes Estimate three indicators: detected need (diagnosed/total estimated cases), crude coverage (received health services/total estimated cases) and effective coverage (controlled/total estimated cases) were compared. Controlled diabetes was defined as haemoglobin A1C (HbA1C) below 7% and controlled hypertension as blood pressure below 140/90 mm Hg.Results Estimated cases were 3.1–3.2 million for diabetes and 8.7–9.2 million for hypertension. For diabetes, all indicators have shown slow improvement between 2016 and 2019 (67.4%, 69.9%, 71.9% and 74.7% for detected need; 38.7%, 43.1%, 45.1% and 49.8% for crude coverage and 8.1%, 10.5%, 11.8% and 11.7% for effective coverage). For hypertension, the performance was poorer for detection (48.9%, 50.3%, 51.8% and 53.3%) and crude coverage (22.3%, 24.7%, 26.5% and 29.2%) but was better for effective coverage (11.3%, 13.2%, 15.1% and 15.7%) than diabetes. Results were better for the women and older age groups in both diseases. Complex interplays between supply and demand side were a key challenge. Database challenges also hamper regular assessment of effective coverage. Sensitivity analysis when using at least three annual visits shows slight improvement of effective coverage.Conclusion Effective coverage was low for both diseases, though improving in 2016–2019, especially among men and ัyounger populations. The increasing rate of effective coverage was significantly smaller than crude coverage. Health information systems limitation is a major barrier to comprehensive measurement. To maximise effective coverage, long-term actions should address primary prevention of non-communicable disease risk factors, while short-term actions focus on improving Chronic Care Model.

The COVID-19 pandemic will not be the last of its kind. As the world charts a way towards an equitable and resilient recovery, Public Health and Social Measures (PHSMs) that were implemented since the beginning of the pandemic need to be made a permanent feature of health systems that can be activated and readily deployed to tackle sudden surges in infections going forward. Although PHSMs aim to blunt the spread of the virus, and in turn protect lives and preserve health system capacity, there are also unintended consequences attributed to them. Importantly, the interactions between PHSMs and their accompanying key indicators that influence the strength and duration of PHSMs are elements that require in-depth exploration. This research employs case studies from six Asian countries, namely Indonesia, Singapore, South Korea, Thailand, the Philippines and Vietnam, to paint a comprehensive picture of PHSMs that protect the lives and livelihoods of populations. Nine typologies of PHSMs that emerged are as follows: (1) physical distancing, (2) border controls, (3) personal protective equipment requirements, (4) transmission monitoring, (5) surge health infrastructure capacity, (6) surge medical supplies, (7) surge human resources, (8) vaccine availability and roll-out and (9) social and economic support measures. The key indicators that influence the strength and duration of PHSMs are as follows: (1) size of community transmission, (2) number of severe cases and mortality, (3) health system capacity, (4) vaccine coverage, (5) fiscal space and (6) technology. Interactions between PHSMs can be synergistic or inhibiting, depending on various contextual factors. Fundamentally, PHSMs do not operate in silos, and a suite of PHSMs that are complementary is required to ensure that lives and livelihoods are safeguarded with an equity lens. For that to be achieved, strong governance structures and community engagement are also required at all levels of the health system.

Abstract Background Extending Universal Health Coverage (UHC) requires identifying and addressing unmet healthcare need and its causes to improve access to essential health services. Unmet need is a useful monitoring indicator to verify if low incidence of catastrophic health spending is not a result of foregone services due to unmet needs. This study assesses the trend, between 2011 and 2019, of prevalence and reasons of unmet healthcare need and identifies population groups who had unmet needs. Method The unmet healthcare need module in the Health and Welfare Survey (HWS) 2011–2019 was used for analysis. HWS is a nationally representative household survey conducted by the National Statistical Office biennially. There are more than 60,000 respondents in each round of survey. The Organisation for Economic Co-operation and Development (OECD) standard questions on unmet need and reasons behind were applied for outpatient (OP), inpatient (IP) and dental services in the past 12 months. Data from samples were weighted to represent the Thai population. Univariate analysis was applied to assess unmet need across socioeconomic profiles. Results The annual prevalence of unmet need between 2011 and 2019 was lower than 3%. The prevalence was 1.3–1.6% for outpatient services, 0.9% - 1.1% for dental services, and lower than 0.2% for inpatient care. A small increasing trend was observed on dental service unmet need, from 0.9% in 2011 to 1.1% in 2019. The poor, the elderly and people living in urban areas had higher unmet needs than their counterparts. Long waiting times was the main reason for unmet need, while cost of treatment was not an issue. Conclusion The low level of unmet need at less than 3% was lower than OECD average (28%), and was the result of UHC since 2002. Regular monitoring using the national representative household survey to estimate annual prevalence and reasons for unmet need can guide policy to sustain and improve access by certain population groups.

Abstract Background In response to an increased health burden from non-communicable diseases (NCDs), primary health care (PHC) is effective platform to support NCDs prevention and control. This study aims to assess Thailand’s PHC capacity in providing NCDs services, identify enabling factors and challenges and provide policy recommendations for improvement. Methods This cross-sectional mixed-method study was conducted between October 2019 and May 2020. Two provinces, one rich and one poor, were randomly selected and then a city and rural district from each province were randomly selected. From these 4 sites in the 2 provinces, all 56 PHC centres responded to a self-administrative questionnaire survey on their capacities and practices related to NCDs. A total of 79 participants from Provincial and District Health Offices, provincial and district hospitals, and PHC centres who are involved with NCDs participated in focus group discussions or in-depth interviews. Results Strong health infrastructure, competent staff (however not with increased workload), essential medicines and secured budget boost PHC capacity to address NCDs prevention, control, case management, referral and rehabilitation. Community engagement through village health volunteers improves NCDs awareness, supports enrolment in screening and raises adherence to interventions. Village health volunteers, the crucial link between the health system and the community, are key in supporting health promotion and NCDs prevention and control. Collaboration between provincial and district hospitals in providing resources and technical support enhance the capacity of PHC centres to provide NCDs services. However, inconsistent national policy directions and uncertainty related to key performance indicators hamper progress in NCDs management at the operational level. The dynamic of urbanization and socialization, especially living in obesogenic environments, is one of the greatest challenges for dealing with NCDs. Conclusion PHC centres play a vital role in NCDs prevention and control. Adequate human and financial resources and policy guidance are required to improve PHC performance in managing NCDs. Implementing best buy measures at national level provides synergies for NCDS control at PHC level.

Abstract Background Lack of knowledge and awareness on antimicrobial resistance (AMR) can result in irrational use of antibiotics, which is one of the major drivers of AMR. One goal of the Thailand National Strategic Plan on AMR (2017-2021) is a 20% increase in public knowledge and awareness of antibiotic use and AMR by 2021. This study assesses antibiotic use, level of knowledge and awareness of antibiotic use and AMR and the factors associated with their knowledge and awareness in the Thai population in 2019. It compares findings with a similar national survey in 2017. Methods An AMR module was integrated into the Health and Welfare Survey, a biennial national household survey conducted by the National Statistical Office since 2017. The 2019 survey took place in March, through face-to-face interviews with 27,900 Thai adults aged 15 years or above who participated in the survey and compares 2019 findings with those from 2017. Results One month prior to the survey, 6.3% of population reported use of antibiotics (reduced from 7.9% to 2017), of which 98.1% received antibiotics through healthcare professionals and almost half (43.2%) for flu symptoms. During the last 12 months, 21.5% of Thai adults received information on the appropriate use of antibiotics and AMR (increased from 17.8% to 2017); mostly through health professionals (82.7%). On knowledge, 24.3% of adults gave correct answers to more than three out of six statements (three true and three false statements) (increased from 23.7% to 2017). The overall mean score of awareness of appropriate antibiotic use and AMR is 3.3 out of total score of 5. Conclusions Although progress was made on knowledge and awareness between 2017 and 2019, certain practices, such as use of antibiotics for flu symptoms and receiving information about antibiotic use and AMR, are inappropriate and inadequate. These findings require significant action, notably strengthening health professionals’ ability to prescribe and dispense antibiotics appropriately and effective communication with patients. The government should promote specific information on rational use of antibiotics and AMR to specific target groups.

Abstract Background Global advocates for breastfeeding were evident since the International Code of Marketing of Breast-Milk Substitutes (BMS Code) was adopted in 1981 and fostered by subsequent relevant World Health Assembly resolutions, using a framework that promotes, supports and protects breastfeeding. Global partners provided comprehensive support for countries to achieve breastfeeding targets while progress was closely monitored. This review identifies breastfeeding policy and implementation gaps in Thailand. Main findings Although Thailand implemented three Thai voluntary BMS Codes, ineffective enforcement results in constant violations by BMS industries. In light of strong resistance by the BMS industries and their proxies, it was not until 2017 that the Code was legislated into national law; however regulatory enforcement is a protracted challenge. A Baby-Friendly Hospital Initiative (BFHI), mostly in public hospitals, was successfully applied and scaled up nationwide in 1992, but it later became inactive due to lack of continued support. Several community-based and workplace programmes, which supported breastfeeding, also faced challenges from competing agendas. Although the Labor Protection Law offers 98 days maternity leave with full pay, the conducive environment for successful six- month exclusive breastfeeding (EBF) needs a significant boost. These gaps in policy were exacerbated by a lack of multi-sectoral collaboration, ineffective implementation of existing interventions, inadequate investment, and lack of political will to legislate six-month maternity leave. As a result, the progress of EBF rate during the first 6 months as measured by previous 24 h was erratic; it increased from 12.3% in 2012 to 23.1% in 2015 and decreased to 14% in 2019. There was a deterioration of early initiation from 49.6% in 2006 to 34% in 2019. These low performances hamper the achievement of global targets by 2030. Conclusions We recommend the following. First, increase financial and human resource investment, and support successful exclusive breastfeeding in BHFI, communities and workplaces through multi-sectoral actions for health. Second, implement the active surveillance of violations and strengthen law enforcement for timely legal sanctions of violators. Third, revitalize the BFHI implementation in public hospitals and extend to private hospitals.

Objective This review assesses interventions and their effectiveness in mitigating psychological consequences from pandemic.Method Published English literatures were searched from four databases (Medline, PubMed, Embase and PsycINFO) from January 2020 and September 2021. A total of 27 papers with 29 studies (one paper reported three studies) met inclusion criteria. Cochrane risk-of-bias tool is applied to assess the quality of all randomised controlled trials (RCT).Results All studies were recently conducted in 2020. Publications were from high-income (13, 44.8%), upper middle-income (12, 41.4%) and lower middle-income countries (3, 10.3%) and global (1, 3.5%). Half of the studies conducted for general population (51.7%). One-third of studies (8, 27.6%) provided interventions to patients with COVID-19 and 20.7% to healthcare workers. Of the 29 studies, 14 (48.3%) were RCT. All RCTs were assessed for risk of biases; five studies (15, 35.7%) had low risk as measured against all six dimensions reflecting high-quality study.Of these 29 studies, 26 diagnostic or screening measures were applied; 8 (30.9%) for anxiety, 7 (26.9%) for depression, 5 (19.2%) for stress, 5 (19.2%) for insomnia and 1 (3.8%) for suicide. Measures used to assess the baseline and outcomes of interventions were standardised and widely applied by other studies with high level of reliability and validity. Of 11 RCT studies, 10 (90.9%) showed that anxiety interventions significantly lowered anxiety in intervention groups. Five of the six RCT studies (83.3%) had significantly reduced the level of depression. Most interventions for anxiety and stress were mindfulness and meditation based.Conclusions Results from RCT studies (11%, 78.6%) were effective in mitigating psychological consequences from COVID-19 pandemic when applied to healthcare workers, patients with COVID-19 and general population. These effective interventions can be applied and scaled up in other country settings through adaptation of modes of delivery suitable to country resources, pandemic and health system context.

Abstract Background At the height of the COVID-19 pandemic, Thailand had almost depleted its critical care resources, particularly intensive care unit (ICU) beds and ventilators. This prompted the necessity to develop a national guideline for resource allocation. This paper describes the development process of a national guideline for critical resource allocation in Thailand during the COVID-19 pandemic. Methods The guideline development process consisted of three steps: (1) rapid review of existing rationing guidelines and literature; (2) interviews of Thai clinicians experienced in caring for COVID-19 cases; and (3) multi-stakeholder consultations. At steps 1 and 2, data was synthesized and categorized using a thematic and content analysis approach, and this guided the formulation of the draft guideline. Within step 3, the draft Thai critical care allocation guideline was debated and finalized before entering the policy-decision stage. Results Three-order prioritization criteria consisting of (1) clinical prognosis using four tools (Charlson Comorbidity Index, Sequential Organ Failure Assessment, frailty assessment and cognitive impairment assessment), (2) number of life-years saved and (3) social usefulness were proposed by the research team based on literature reviews and interviews. At consultations, stakeholders rejected using life-years as a criterion due to potential age and gender discrimination, as well as social utility due to a concern it would foster public distrust, as this judgement can be arbitrary. It was agreed that the attending physician is required to be the decision-maker in the Thai medico-legal context, while a patient review committee would play an advisory role. Allocation decisions are to be documented for transparency, and no appealing mechanism is to be applied. This guideline will be triggered only when demand exceeds supply after the utmost efforts to mobilize surge capacity. Once implemented, it is applicable to all patients, COVID-19 and non-COVID-19, requiring critical care resources prior to ICU admission and during ICU stay. Conclusions The guideline development process for the allocation of critical care resources in the context of the COVID-19 outbreak in Thailand was informed by scientific evidence, medico-legal context, existing norms and societal values to reduce risk of public distrust given the sensitive nature of the issue and ethical dilemmas of the guiding principle, though it was conducted at record speed. Our lessons can provide an insight for the development of similar prioritization guidelines, especially in other low- and middle-income countries.

Summary: Background: In 2014, Indonesia launched a single payer national health insurance scheme with the aim of covering the entire population by 2024. The objective of this paper is to assess the equity with which contributions to the health financing system were distributed in Indonesia over 2015 – 2019. Methods: This study is a secondary analysis of nationally representative data from the National Socioeconomic Survey of Indonesia (2015 – 2019). The relative progressivity of each health financing source and overall health financing was determined using a summary score, the Kakwani index. Findings: Around a third of health financing was sourced from out-of-pocket (OOP) payments each year, with direct taxes, indirect taxes and social health insurance (SHI) each taking up 15 – 20%. Direct taxes and OOP payments were progressive sources of health financing, and indirect tax payments regressive, for all of 2015 – 2019. SHI contributions were regressive except in 2017 and 2018. The overall health financing system was progressive from 2015 to 2018, but this declined year by year and became mildly regressive in 2019. Interpretation: The declining progressivity of the overall health financing system between 2015 – 2019 suggests that Indonesia still has a way to go in developing a fair and equitable health financing system that ensures the poor are financially protected. Funding: This study is supported through the Health Systems Research Initiative in the UK, and is jointly funded by the Department of International Development, the Economic and Social Research Council, the Medical Research Council and the Wellcome Trust.

Abstract Background Antimicrobial resistance (AMR), recognised as a serious and growing threat to global health, is promoted by multiple drivers, including antibiotic use in the livestock sector. Thus, understanding factors influencing antibiotic use in livestock production is essential to the design and implementation of effective interventions to reduce AMR. This qualitative study aimed to explore the experiences and views of the key actors associated with the use of antibiotics for pig farming in Thailand, from local farmers to officers in central government institutions. Methods A total of 31 in-depth interviews were conducted with different categories of actors: pig farmers (n = 13), drug retailers (n = 5), veterinarians (n = 7), government officers (n = 3) and representatives of animal and human health associations (n = 2). Themes emerging from the interviews were identified and explored using thematic analysis. In addition, direct observations were conducted in the pig farms. Results The findings highlight the multi-faceted nature of the views and practices that may contribute to misuse or overuse of antibiotics in the study locations, including misconceptions about the nature of antibiotics and AMR (particularly among smallholders), lack of facilities and financial means to establish an antibiotic-free farm, lack of sufficient training on AMR and antibiotic prescribing for veterinarians, the profit motive of pharmaceutical companies and their ties to farm consultants, and lack of sufficient regulatory oversight. Conclusions Our study indicates a clear need to improve antibiotic use for pig production in Thailand. Farmers need better access to veterinary services and reliable information about animal health needs and antibiotics. Innovative investments in biosecurity could improve farm management and decrease reliance on antibiotics, although the cost of these interventions should be low to ensure wide uptake in the livestock sector. Lastly, further development of professional training and clinical guidelines, and the establishment of a code of conduct, would help improve antibiotic dispensing practices.

Abstract Background Thailand, an upper-middle income country, has demonstrated exemplary outcomes of Universal Health Coverage (UHC). The country achieved full population coverage and a high level of financial risk protection since 2002, through implementing three public health insurance schemes. UHC has two explicit goals of improved access to health services and financial protection where use of these services does not create financial hardship. Prior studies in Thailand do not provide evidence of long-term UHC financial risk protection. This study assessed financial risk protection as measured by the incidence of catastrophic health spending and impoverishment in Thai households prior to and after UHC in 2002. Methods We used data from a 15-year series of annual national household socioeconomic surveys (SES) between 1996 and 2015, which were conducted by the National Statistic Office (NSO). The survey covered about 52,000 nationally representative households in each round. Descriptive statistics were used to assess the incidence of catastrophic payment as measured by the share of out-of-pocket payment (OOP) for health by households exceeding 10 and 25% of household total consumption expenditure, and the incidence of impoverishment as determined by the additional number of non-poor households falling below the national and international poverty lines after making health payments. Results Using the 10% threshold, the incidence of catastrophic spending dropped from 6.0% in 1996 to 2% in 2015. This incidence reduced more significantly when the 25% threshold was applied from 1.8 to 0.4% during the same period. The incidence of impoverishment against the national poverty line reduced considerably from 2.2% in 1996 to approximately 0.3% in 2015. When the international poverty line of US$ 3.1 per capita per day was applied, the incidence of impoverishment was 1.4 and 0.4% in 1996 and 2015 respectively; and when US$ 1.9 per day was applied, the incidence was negligibly low. Conclusion The significant decline in the incidence of catastrophic health spending and impoverishment was attributed to the deliberate design of Thailand’s UHC, which provides a comprehensive benefits package and zero co-payment at point of services. The well-founded healthcare delivery system and favourable benefits package concertedly support the achievement of UHC goals of access and financial risk protection.

Abstract Background Demographic changes in the pattern of disease burden, escalating health expenditures and inequitable access to healthcare are global challenges. Irrespective of their level of development, all countries need to reform their health systems to prepare for the future emerging health needs, in order to meet their commitments of health systems strengthening, universal health coverage (UHC) and explicit targets in the Sustainable Development Goals (SDGs). Summary We propose three core principles for the future health system as described herein. A health system is not simply a ‘cure delivery machine’ but part of a ‘social security system’ that engages all stakeholders through a shared vision and value of health and well-being, not merely an absence of diseases. The future health system shall provide people-centred, affordable care, tailored to the individual’s needs, accessible at any time and any place, and reflect the notion of leaving no one behind through a life course approach — underpinned by the SDGs. Information and communications technology (ICT) offers the potential to facilitate the realisation of these principles by improving the information flow between different parts of the health system through electronic means. We introduce Japan’s new data platform — Person-centred Open PLatform for wellbeing (PeOPLe) — planned to be introduced in 2020 as one example of an ICT-based intervention to realise the three proposed principles. PeOPLe integrates data collected throughout the life course to enable all people to receive affordable, personalised health and social care at any time and any place throughout their lifetime. Furthermore, we discuss the applicability of these principles and PeOPLe to the health systems context of Thailand and the Philippines, including elaborations on ICT transformation challenges. Conclusion Current rising momentum and scale for ICTs in the UHC era offers a great opportunity to make a difference for countries. The PeOPLe concept is not only relevant to resource-rich countries; its applicability to other Asian countries could be feasible though it will need to be adapted to the various country contexts. We hope that this paper contributes to wider discussion around policy choices of ICT application for future health systems strengthening and UHC in order to achieve the SDGs.

Benefit package is crucial for implementing universal health coverage (UHC). This editorial analyses how the benefit package of the Thai Universal Coverage Scheme (UC Scheme) evolved from an implicit comprehensive package which covered all conditions and interventions (with a few exceptions), to additional explicit positive lists. In 2002 when the Thai UC Scheme was launched; the comprehensive benefit package, including medicines in the national essential list of medicines, formerly offered by the previous schemes were pragmatically adopted. Later, when capacities of producing evidence on health technology assessment (HTA) increased, rigorous assessment of cost effectiveness is mandatorily required for inclusion of new interventions into the Thai UC Scheme benefit package. This contributed to evidence-informed policy decisions. To prevent emptied promises, whichever policy choices are made about the benefit package, either using a negative or a positive list, developing country governments need to make quality health services available and accessible by the entire population. Political decision on benefit package should be informed by evidence on cost effectiveness, equity dimension and health system capacity to deliver equitable services. Low- and middle-income countries need to strengthen HTA capacity to generate evidence and inform policies.

BackgroundAn infodemic is an overflow of information of varying quality that surges across digital and physical environments during an acute public health event. It leads to confusion, risk-taking, and behaviors that can harm health and lead to erosion of trust in health authorities and public health responses. Owing to the global scale and high stakes of the health emergency, responding to the infodemic related to the pandemic is particularly urgent. Building on diverse research disciplines and expanding the discipline of infodemiology, more evidence-based interventions are needed to design infodemic management interventions and tools and implement them by health emergency responders. ObjectiveThe World Health Organization organized the first global infodemiology conference, entirely online, during June and July 2020, with a follow-up process from August to October 2020, to review current multidisciplinary evidence, interventions, and practices that can be applied to the COVID-19 infodemic response. This resulted in the creation of a public health research agenda for managing infodemics. MethodsAs part of the conference, a structured expert judgment synthesis method was used to formulate a public health research agenda. A total of 110 participants represented diverse scientific disciplines from over 35 countries and global public health implementing partners. The conference used a laddered discussion sprint methodology by rotating participant teams, and a managed follow-up process was used to assemble a research agenda based on the discussion and structured expert feedback. This resulted in a five-workstream frame of the research agenda for infodemic management and 166 suggested research questions. The participants then ranked the questions for feasibility and expected public health impact. The expert consensus was summarized in a public health research agenda that included a list of priority research questions. ResultsThe public health research agenda for infodemic management has five workstreams: (1) measuring and continuously monitoring the impact of infodemics during health emergencies; (2) detecting signals and understanding the spread and risk of infodemics; (3) responding and deploying interventions that mitigate and protect against infodemics and their harmful effects; (4) evaluating infodemic interventions and strengthening the resilience of individuals and communities to infodemics; and (5) promoting the development, adaptation, and application of interventions and toolkits for infodemic management. Each workstream identifies research questions and highlights 49 high priority research questions. ConclusionsPublic health authorities need to develop, validate, implement, and adapt tools and interventions for managing infodemics in acute public health events in ways that are appropriate for their countries and contexts. Infodemiology provides a scientific foundation to make this possible. This research agenda proposes a structured framework for targeted investment for the scientific community, policy makers, implementing organizations, and other stakeholders to consider.

Thailand’s first wave of COVID-19 in March 2020 was triggered from boxing events and nightclubs in Bangkok, which spread to 68 provinces. The nation responded rapidly with strong public health and social measures on 26 March 2020. Contact tracing was performed by over 1000 surveillance and rapid response teams with support from 1.1 million village health volunteers to identify, isolate and quarantine cases.Thailand implemented social measures in April 2020 including a full-scale national lockdown, curfews and 14-day mandatory quarantine for international travellers. With a strong health system infrastructure, people’s adherence to social measures and a whole-of-government approach, the first wave recorded only 3042 cases and 57 deaths with 1.46% case fatality rate. Economic activities were resumed on 1 May 2020 until the end of the year. On 17 December 2020, a second wave was carried by undocumented migrants who were not captured by the quarantine system. As the total lockdown earlier led to serious negative economic impact, the government employed a targeted strategy, locking down specific areas and employing active case finding. Essential resources including case finding teams, clinicians and medicine were mobilised.With synergistic multisectoral efforts involving health, non-health and private sector, the outbreak was contained in February 2021. Total cases were seven times higher than the first wave, however, early admission and treatment resulted in 0.11% case fatality rate. In conclusion, experiences of responding to the first wave informed the second wave response with targeted locking down of affected localities and active case findings in affected sites.

Participatory and responsive governance in universal health coverage (UHC) systems synergistically ensure the needs of citizens are protected and met. In Thailand, UHC constitutes of three public insurance schemes: Civil Servant Medical Benefit Scheme, Social Health Insurance and Universal Coverage Scheme. Each scheme is governed through individual laws. This study aimed to identify, analyse and compare the legislative provisions related to participatory and responsive governance within the three public health insurance schemes and draw lessons that can be useful for other low-income and middle-income countries in their legislative process for UHC. The legislative provisions in each policy document were analysed using a conceptual framework derived from key literature. The results found that overall the UHC legislative provisions promote citizen representation and involvement in UHC governance, implementation and management, support citizens’ ability to voice concerns and improve UHC, protect citizens’ access to information as well as ensure access to and provision of quality care. Participatory governance is legislated in 33 sections, of which 23 are in the Universal Coverage Scheme, 4 in the Social Health Insurance and none in the Civil Servant Medical Benefit Scheme. Responsive governance is legislated in 24 sections, of which 18 are in the Universal Coverage Scheme, 2 in the Social Health Insurance and 4 in the Civil Servant Medical Benefit Scheme. Therefore, while several legislative provisions on both participatory and responsive governance exist in the Thai UHC, not all schemes equally bolster citizen participation and government responsiveness. In addition, as legislations are merely enabling factors, adequate implementation capacity and commitment to the legislative provisions are equally important.

Thailand achieved full population coverage of financial protection for health care in 2002 with successful implementation of the Universal Coverage Scheme (UCS). The three public health insurance schemes covered 98.5% of the population by 2015. Current evidence shows a high level of service coverage and financial risk protection and low level of unmet healthcare need, but the path toward UHC was not straightforward. Applying the Political Economy of UHC Reform Framework and the concept of path dependency, this study reviews how these factors influenced the evolution of the UHC reform in Thailand. We highlight how path dependency both set the groundwork for future insurance expansion and contributed to the persistence of a fragmented insurance pool even as the reform team was able to overcome certain path inefficient institutions and adopt more evidence-based payment schemes in the UCS. We then highlight two critical political economy challenges that can hamper reform, if not managed well, regarding the budgeting processes, which minimized the discretionary power previously exerted by Bureau of Budget, and the purchaser–provider split that created long-term tensions between the Ministry of Public Health and the National Health Security Office. Though resisted, these two changes were key to generating adequate resources to, and good governance of, the UCS. We conclude that although path dependence played a significant role in exerting pressure to resist change, the reform team’s capacity to generate and effectively utilize evidence to guide policy decision-making process enabled the reform to be placed on a “good path” that overcame opposition.

Abstract Background Despite substantial positive impacts of Thailand’s tobacco control policies on reducing the prevalence of smoking, current trends suggest that further reductions are needed to ensure that WHO’s 2025 voluntary global target of a 30% relative reduction in tobacco use is met. In order to confirm this hypothesis, we aim to estimate the effect of tobacco control policies in Thailand on the prevalence of smoking and attributed deaths and assess the possibilities of achieving WHO’s 2025 global target. This paper addresses this knowledge gap which will contribute to policy control measures on tobacco control. Results of this study can help guide policy makers in implementing further interventions to reduce the prevalence of smoking in Thailand. Method A Markov chain model was developed to examine the effect of tobacco control policies, such as accessibility restrictions for youths, increased tobacco taxes and promotion of smoking cessation programs, from 2015 to 2025. Outcomes included smoking prevalence and the number of smoking-attributable deaths. Due to the very low prevalence of female smokers in 2014, this study applied the model to estimate the smoking prevalence and attributable mortality among males only. Results Given that the baseline prevalence of smoking in 2010 was 41.7% in males, the target of a 30% relative reduction requires that the prevalence be reduced to 29.2% by 2025. Under a baseline scenario where smoking initiation and cessation rates among males are attained by 2015, smoking prevalence rates will reduce to 37.8% in 2025. The combined tobacco control policies would further reduce the prevalence to 33.7% in 2025 and 89,600 deaths would be averted. Conclusion Current tobacco control policies will substantially reduce the smoking prevalence and smoking-attributable deaths. The combined interventions can reduce the smoking prevalence by 19% relative to the 2010 level. These projected reductions are insufficient to achieve the committed target of a 30% relative reduction in smoking by 2025. Increased efforts to control tobacco use will be essential for reducing the burden of non-communicable diseases in Thailand.

Addressing the determinants of non-communicable diseases (NCDs) is challenged by aggressive market promotion by tobacco, alcohol and unhealthy food industries in emerging countries with fast economic development; and interference by these industries in government policies aimed at containing consumption of unhealthy products. This editorial reviews market promotion and industry interference and classifies them into four groups of tactics: (a) interfering with the legislative process; (b) using front groups to act on their behalf; (c) questioning the evidence of tobacco harm and the effectiveness of harm-reduction interventions; and (d) appearing responsible in the eyes of the public, journalists and policy-makers. Despite active implementation of the Framework Convention on Tobacco Control (FCTC), the tobacco, alcohol and unhealthy food industries use similar tactics to aggressively interfere in policies, with the tobacco industry being the most aggressive. Policy interference by industries are effective in the context of poor governance, rampant corruption, conflict of interest among political and government actors, and regulatory capture in all levels of countries from low- to high-income. In addressing these interferences, government requires the practice of good governance, effective mechanisms to counteract conflict of interests among political and policy actors, and prevention of regulatory capture. The World Health Organization (WHO) Framework of Engagement with non-State Actors can be applied to the country context when engaging private entities in the prevention and control of NCDs.

Abstract Background The vital registration system is universally recognized as the main source of mortality data which is essential for policy formulation, proper interventions and resource allocation to address priority health challenges. To improve availability and quality of mortality statistics by strengthening the vital registration system, understanding the current vital registration system is essential. This study identified challenges in generating reliable mortality statistics in the vital registration system of Myanmar. Methods Qualitative methods were used to collect data in two selected townships of Mandalay Region. Grey literature related to the management of mortality registration was reviewed; in-depth interviews of sixteen key informants and fourteen focus group discussions were conducted with those involved in death registration at the local level, such as healthcare providers, local administrators and knowledgeable adults in households where deaths occurred during the past three years. Thematic analysis was performed to identify system barriers in the death registration process. Results Weaknesses in the death registration system are classified in three areas: a) administrative which includes the lack of enforcement of mandatory death registration, limited issuance of death certificates and no formal mandatory notification of death events by households and; b) technical which includes absence of proper and regular on-the-job trainings, ineffective cause-of-death certification practice for deaths in the communities and the absence of routine data plausibility checks at the local level; and c) societal which includes poor community awareness and inadequate participation in death registration. Conclusion The study highlighted challenges in the death registration system at the operational level, which undermines the achievement of a satisfactory level of completeness and accuracy of mortality data. We recommend establishing a strong legal framework, improving technical capacities and raising public awareness and cooperation to strengthen the system that can generate reliable mortality statistics.

Abstract Objective To review the publicly available policies and commitments of selected food companies in Thailand relating to obesity and non-communicable diseases (NCDs) prevention, and to assess these stated policies and commitments against global recommendations. Methods Nineteen food and beverage companies, including 13 packaged food, three non-alcoholic beverage, two food retailer, and one fast food company were selected, based on their market share by sector and food category. A review of publicly available policies and commitments related to four domains (product reformulation, food marketing, nutrition information and food accessibility) was carried out for each company. Content analysis of all data was conducted, including a comparison of policy content against global recommendations in each domain. Results Eleven companies (58%) reported at least one policy or commitment across the four domains. The packaged food companies reported policies in all four domains while the beverage companies committed to implement policies in all except the accessibility domain. The food retailers and fast food company only had policies in the reformulation and nutrition information domains. Very few of the policies and commitments covered all of the recommended components in each domain, and most lacked sufficient specificity to allow detailed monitoring and evaluation. Conclusion A small number of the most prominent food companies in Thailand have several nutrition-related policies in place. However, these policies do not sufficiently cover recommended areas for NCD and obesity prevention. Moreover, the extent to which policy statements translate to implementation has yet to be evaluated. Successful implementation of nutrition-related policies by the food industry in Thailand will likely require concrete, measurable indicators to guide both corporate policy making as well as public monitoring. The Thailand Government requires greater capacity to establish effective multi-sector platforms for NCD prevention, and to evaluate food companies’ policies and enforce compliance both with regulations and voluntary commitments.

Abstract Background Childhood stunting, defined as the height-for-age standardized score lower than minus two, is one of the key indicators for assessing well-being and health of a child; and can be used for monitoring child health inequalities. Thailand has been successful in improving health and providing financial protection for its population. A better understanding of the determinants of stunting will help fill both knowledge and policy gaps which promote children’s health and well-being. This study assesses the factors contributing to stunting among Thai children aged less than five years. Methods This study obtained data from the Multiple Indicator Cluster Survey Round 4 (MICS4), conducted in Thailand in 2012. Data analysis consisted of three steps. First, descriptive statistics provided an overview of data. Second, a Chi-square test determined the association between each covariate and stunting. Finally, multivariable logistic regression assessed the likelihood of stunting from all independent variables. Interaction effects between breastfeeding and household economy were added in the multivariable logistic regression. Results In the analysis without interaction effects, while the perceived size of children at birth as ‘small’ were positively associated with stunting, children in the well-off households were less likely to experience stunting. The analysis of the interactions between ‘duration of breastfeeding’ and ‘household’s economic level’ found that the odds of stunting in children who were breastfed longer than 12 months in the poorest household quintile were 1.8 fold (95% Confidence interval: 1.3–2.6) higher than the odds found in mothers from the same poorest quintiles, but without prolonged breastfeeding. However prolonged breastfeeding in most well-off households (those between the second quintile and the fifth wealth quintile) did not show a tendency towards stunting. Conclusions Childhood stunting was significantly associated with several factors. Prolonged breastfeeding beyond 12 months when interacting with poor economic status of a household potentiated stunting. Children living in the least well-off households were more prone to stunting than others. We recommend that the MICS survey questionnaire be amended to capture details on quantity, quality and practices of supplementary feeding. Multi-sectoral nutrition policies targeting poor households are required to address stunting challenges.

Abstract Background The food industry can influence individual and population level food consumption behaviours, shape public preferences and interfere with government policy on obesity prevention and NCDs. This paper identifies the Corporate Political Activity (CPA) of major food companies in Thailand which relate to obesity and NCDs. Methods Using the INFORMAS framework to classify CPA, we reviewed publicly available information by 12 food companies between August 2011 and July 2016 in order to identify, analyse and classify the CPA contents. Semi-structured interviews with 17 key stakeholders who are experts in this field supplemented evidence from the document review. Data analysis applied a thematic approach. Results Food industry in Thailand applied a variety of CPA strategies and practices. The two most common strategies were constituency building and information and messaging. Conclusion The diverse range of CPA strategies which influence government policy and public opinion can undermine efforts to prevent obesity and diet-related NCDs. We recommend systematic monitoring of their CPA, strengthening mechanisms to hold the food industry accountable for their role in protecting and promoting the nutrition and health of the population, introducing mandatory registration of lobbyists, mandatory disclosure of political donations, and stronger oversight of conflicts of interest among the government actors.

Abstract Background Many low and middle income countries are implementing reforms to support Universal Health Coverage (UHC). Perhaps one of the most ambitious examples of this is Indonesia’s national health scheme known as the JKN which is designed to make health care available to its entire population of 255 million by end of 2019. If successful, the JKN will be the biggest single payer system in the world. While Indonesia has made steady progress, around a third of its population remains without cover and out of pocket payments for health are widespread even among JKN members. To help close these gaps, especially among the poor, the Indonesian government is currently implementing a set of UHC policy reforms that include the integration of remaining government insurance schemes into the JKN, expansion of provider networks, restructuring of provider payments systems, accreditation of all contracted health facilities and a range of demand side initiatives to increase insurance uptake, especially in the informal sector. This study evaluates the equity impact of this latest set of UHC reforms. Methods Using a before and after design, we will evaluate the combined effects of the national UHC reforms at baseline (early 2018) and target of JKN full implementation (end 2019) on: progressivity of the health care financing system; pro-poorness of the health care delivery system; levels of catastrophic and impoverishing health expenditure; and self-reported health outcomes. In-depth interviews with stakeholders to document the context and the process of implementing these reforms, will also be undertaken. Discussion As countries like Indonesia focus on increasing coverage, it is critically important to ensure that the poor and vulnerable - who are often the most difficult to reach – are not excluded. The results of this study will not only help track Indonesia’s progress to universalism but also reveal what the UHC-reforms mean to the poor.

BackgroundRising global concern about antimicrobial resistance has drawn attention to the use of antibiotics in livestock. Understanding the current usage of antibiotics in these animals is essential for effective interventions on the optimisation of antibiotic use. However, to date few studies have been conducted in low- and middle-income countries. This study aimed to explore the use of antibiotics and estimate the total amount of antibiotics used in pig production in Thailand.MethodsThis was a mixed-methods study including a cross-sectional questionnaire-based survey of 84 pig farmers, secondary analysis of data from a survey of 31 feed mills to estimate the amount of antibiotics mixed in pig feed and interviews with five veterinarians involved in the feed mill industry to gain an understanding of medicated feed production.FindingsHalf of the farmers reported using antibiotics for disease prevention. Use was significantly associated with farmers’ experience in raising pigs, farm income, having received advice on animal health and belonging to a farm cooperative. The estimated total amount of active ingredients mixed into medicated feed for pigs for the whole country was 843 tonnes in 2017. Amoxicillin was the most commonly used antibiotic reported by both pig farms and feed mills. The use of Critically Important Antimicrobials including colistin was common, with one-third of farmers reporting their use as oral or as injectable medication, and accounting for nearly two-thirds of antibiotics contained in medicated feed.ConclusionA majority of antibiotics used in Thai pig farms belonged to the category of Critically Important Antimicrobials. Progressive restriction in the use of antibiotics in pigs is recommended through using prescriptions to control the distribution of certain antibiotics. The government should strengthen veterinary services to improve access of farmers to animal health advice and explore alternative interventions.