News and Opinions  –  2019

Dr Yoel Lubell, Health Economist, on Thailand, AMR, UCH and cultural factors driving AMR

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Dr Yoel Lubell, heads the Economics and Implementation Research Group (EIRG) at the Mahidol Oxford Tropical Medicine Research Unit in Bangkok, Thailand. EIRG focuses on the evaluation of diagnostics, treatments and vaccines for malaria and other infectious diseases.

Here he speaks to ReAct about the link between AMR and Universal Health Coverage (UHC) and also the cultural and anthropological factors that drive AMR.

Dr. Yoel Lubell, heads the Economics and Implementation Research Group (EIRG) at the Mahidol Oxford Tropical Medicine Research Unit in Bangkok, Thailand.

What is your view of the link between UHC and AMR. Increased access to medicine should increase AMR also, so is there a paradox of sorts at work here. Can implementing UHC boost AMR?

– Thailand has done a lot to get the cost of AMR on the agenda of everyone from the top to the bottom of the health system, through the Antibiotic Smart Use project. They have been very active on that. In the context of UHC however access has to be the priority  and the starting point. That needs to go hand in hand by curbing excess, to get the balance right.

What are the possible entry points in UHC for bringing in AMR concerns? Apart from cost-saving what about the issue of quality of care, which is linked to how seriously a health system takes AMR?

– I am very much of the view that we should also be thinking of AMR in terms of the cost-benefit analysis of UHC. In other words, what are the cost-effective interventions we should be planning in Universal Health Coverage with Antimicrobial Resistance in consideration? There is a study in Vietnam we did recently, which is a  very useful first attempt at estimating the cost of Antimicrobial Resistance per antibiotic consumed. We did that for Thailand also and the US and did it for different antibiotic classes.

– So for example, in the case of a betalactam in Thailand, every time you prescribe it, we assume it is associated with around 10 USD of costs due to Antimicrobial Resistance. In your Universal Health Coverage – if you introduce a test, say the CRP diagnostic test, that costs you less than 1 USD – and can bring down antibiotic prescribing by say 10%, then I can say in terms of the health services, this is a cost-effective intervention. Antibiotic prescription has an associated cost of 10 USD due to AMR, that we were previously not thinking about. If we bring it down by just 10% – the benefit is 1 USD – so using the diagnostic test is worthwhile.

– We find this approach so much more useful, than just saying Antimicrobial Resistance is costing us however many billions of dollars.

As a health economist how would you look at investments in water, sanitation, nutrition, even literacy, as interventions that have an impact on AMR by lowering overall burden of infectious diseases?

– Health economists are very often limited to the framework of cost-effectiveness analysis of medical systems, thinking for example I have a limited budget for healthcare and my concern is how to maximize the output within the health sector. But the broader, cross-sectoral approach, which requires a slightly different framework of cost-benefit analysis could actually lead you to say, OK you can carry on pouring as much money as you want into the health sector, but there are diminishing returns for what you are going to get for that. That fund if put into education, hygiene and similar sectors could have much better health returns. There is however a limited supply of health economists who think like this. Thailand has been very good in making that point about hospitals versus primary care.

– There is no doubt that bringing down infection, both bacterial and non-viral will lower use of antibiotics and bring down levels of Antimicrobial Resistance. We still see clearly correlations between consumption of antibiotics and resistance but it is true that if something can be done to bring down infection as a whole that will have a knock-on effect.

What are the cultural and anthropological factors that affect health-seeking behavior or even the prescribing practices of doctors?

– That’s a huge factor. We know that no matter how good the tests we put out there factors like patients’ expectations to be treated. If patients come demanding  antibiotics from primary health care givers or doctors, if you don’t have good education for patients as well, it is not going to have any effect. We have seen that with the CRP study that was done by our colleagues in Yunnan who showed that at the first point of contact in the primary care clinic, they managed to bring down prescribing by 20%, but a lot of patients went out round the corner and bought an antibiotic in the private sector, because there wasn’t enough of an emphasis on why patients could do without antibiotics. So it is not about having the perfect test, as some of these other factors, behavioral factors are equally important.


Lubell, Yoel & Do, Nga & V. Nguyen, Kinh & T. D. Ta, Ngan & Tran, Ninh & M. Than, Hung & Hoang, Long & Shrestha, Poojan & van Doorn, H. Rogier & Nadjm, Behzad & Wertheim, Heiman. (2018).
C-reactive protein point of care testing in the management of acute respiratory infections in the Vietnamese primary healthcare setting – A cost benefit analysis. Antimicrobial Resistance & Infection Control. 7. 10.1186/s13756-018-0414-1.

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