Currently, various tools exist to evaluate knowledge and awareness of antibiotic use and antimicrobial resistance (AMR) and are applied by various organizations. Previous systematic reviews have focused mainly on study findings such as levels of knowledge and AMR awareness. However, the survey procedures and data instruments used ought to be scrutinized as well, since they are important contributors to credible results. This review aims to assess the study methods and procedures of existing population-based surveys and explore key components which determine the general population’s levels of knowledge and awareness of antibiotic use and AMR. We searched existing literature for population -based surveys which sought knowledge and awareness of antibiotic use or AMR in the general population. Databases searched included Ovid, MEDLINE and EMBASE, PsycINFO and Scopus, domestic journals and gray literature sources. Population-based cross-sectional studies published in English or Thai from January 2000 to December 2018 were included in the review. Quality assessment was conducted using the ‘Appraisal Tool for Cross-Sectional Studies’ (AXIS). All 22 studies included in the analysis had clear objectives focusing on assessing people’s levels of knowledge, awareness, attitudes and behavior relating to antibiotic use and awareness of AMR. These studies had employed appropriate methodologies for population-based cross-sectional surveys relative to research questions. More than half of studies (14 out of 22) had scientifically soundly designed methodologies which captured the representativeness of the population; whereas the remaining studies had unclear sample size estimations, inappropriate sample frames and selection biases. Half of the studies had tested the validity and reliability of the questionnaire. The common questions used by these surveys were categorized into four themes: behavior related to antibiotic use, knowledge and awareness of antibiotic use, knowledge and awareness of AMR and others such as receiving information about antibiotic use and AMR or cross-cutting issues like self-medication. This review identified four key features of good practices in antibiotic use and awareness surveys: a) clear survey objective; b) scientifically sound sampling techniques ensuring representativeness; c) strategies for recruitment of samples and survey administration methods; and d) credible measurement to prevent non-sampling biases. During questionnaire design, the health systems context in terms of access to health services and antibiotics should be taken into account. In conclusion, to maximize the use of surveys, the application of findings in surveys and associated factors related to antibiotic use and AMR should primarily generate public health interventions and target specific groups to make progress in solving AMR problems.

Thailand achieved full population coverage of financial protection for healthcare 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.

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.

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.

Migrant health workers (MHWs) and migrant health volunteers (MHVs) are key health workforce actors who play a substantial role in improving the health of migrants in Thailand. The objective of this study was to explore the factors associated with health literacy in MHWs and MHVs in Thailand. A self-administered questionnaire was conducted from December 2018 to April 2019 in two migrant-populated provinces. A total of 40 MHWs, 78 MHVs, and 116 general migrants were included in the survey. Results showed that a higher education level was associated with a greater health literacy score. MHWs were more likely to have a higher health literacy score (5.59 points difference) than general migrants. The province per se and type of affiliations did not significantly contribute to the difference in the health literacy score of each individual. Most MHWs received health information from health professionals, health staff, and the internet, while MHVs and general migrants received information from health professionals, MHWs/MHVs, family/friends, and posters/leaflets. This study suggests that a higher education level should be used as a criterion for recruitment of MHWs and MHVs. Access to interactive health information like health professionals should be promoted as the main source of information to ensure better health literacy among MHWs and MHVs.

Thailand has become a popular destination for international migrant workers, particularly from Cambodia, Lao PDR, and Myanmar. However, only a fraction of these migrant workers were insured by public health insurance. The objective of this study was to apply systems thinking to explore contextual factors affecting access to public health insurance among cross-border migrants in Thailand. A group model building approach was applied. Participants (n = 20) were encouraged to share ideas about underlying drivers and barriers of migrants’ access to health insurance. The causal loop diagram and stock and flow diagram were synthesised to identify the dynamics of access to migrant health insurance. Results showed that nationality verification is an important mechanism to deal with the precarious citizenship status of undocumented migrants. However, some migrants are still left uninsured. The likely explanations are the semi-voluntary nature of the Health Insurance Card Scheme, administrative delay of the enrollment process, and resistance of some employers to hiring migrants. As a result, findings suggest that effective communication is required to raise acceptance towards insurance among migrants and their employers. A participatory public policy process is needed to create a good balance of migrant policies among diverse authorities.