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Rational use  –  Examples from the field

Antibiotics Smart Use Thailand

In 2007, an innovative program to promote the rational use of antibiotics and curb antibiotic resistance was launched in Thailand: Antibiotics Smart Use.

Logotype for antibiotic smart use program in Thailand
Figure 1. Antibiotics Smart Use Program logo

In Thailand in 2010, antimicrobial resistance caused at least 3.2 million extra hospitalization days and over 38,000 deaths. In the Thai health care system, there is no divide between prescription and dispensing: both physicians and pharmacists can prescribe and dispense antibiotics. Moreover, incentives to sell antibiotics are misaligned since physicians and pharmacists benefit from selling antibiotics under a fee-for-service system. In addition, the consumer demand for antibiotics is high.

Aim of Antibiotics Smart Use (ASU)

The Antibiotics Smart Use (ASU) program started in 2007 in Thailand as an innovative way to promote the rational use of antibiotics by strengthening human resources, improving health facility infrastructure, and empowering communities in a setting with limited resources and difficulty translating rational use of medicines from theory into practice. The project targeted three conditions not requiring antibiotic treatment: upper respiratory infections, especially the common cold with sore throat, acute diarrhea and simple wounds. For these conditions ASU attempted to reduce unnecessary use of antibiotics.

Implementation in three phases

The ASU program is an implementation research project comprised of three phases: Implementation of behavior change interventions, examination of the feasibility of scale up, and identification of mechanisms for sustainability (see Table 1).

In the beginning, ASU consisted of a network of researchers from Thailand’s Ministry of Public Health and pharmacists and doctors from Srinakharinwirot University and Chulalongkorn University. In phase 1 (2007- 2008) of the ASU program, they piloted educational and training reforms to improve prescribing in 10 hospitals and 87 primary health centers in one province. During this phase antibiotic prescription, provider attitudes of effectiveness and knowledge of antibiotics, non-prescription rates in case of non-bacterial infections and patient health and satisfaction were monitored..

In phase 2 (2008-2009), the same indicators were then used to scale up the program to three provinces and two hospital networks, counting to 44 hospitals and 621 primary health care centres.

The 3rd phase (2010 – Present) focused on long-term sustainability and scaled up ASU – initially to 22 hospital networks in 15 provinces, and then subsequently across the entire country.

Table 1. Characteristics of the ASU program, by programmatic phase, Thailand

Characteristics Phase 1
(Aug 2007-Aug 2008)
Phase 2 (Sep 2008-Dec 2009) Phase 3, transition period
(Mar-Aug 2011)
Goals Test effectiveness of ASU in changing antibiotic prescription behavior Test feasibility of scaling up ASU model Strengthen networks and assess scaling up mechanisms
Target 1 province 3 provinces and 2 networks of public and private hospitals 22 hospital networks in 15 provinces
Funding
agencies
WHO, Thai FDA HSRI, NHSO, Thai FDA DSMDC, Thai FDA
Coordinating
agencies
Thai FDA Thai FDA DSMDC, Thai FDA, IHPP
Budget spending US$ 33 000 US$ 73 000 US$ 123 000
Spillover effect No Yes Yes

Adapted from Sumpradit N, Chongtrakul P, Anuwong K, Pumtong S, Kongsomboon K, Butdeemee P, et al., 2012 

Since its inception, the ASU program has been highlighted as a best practice example of how to curb inappropriate use of antibiotics and limit growing antibiotic resistance in the both hospital and community settings.

Keys for success

Key reasons for the success of ASU, according to project managers, was the championing of the concept at different levels, from community to the national health system. Thanks to this for example in 2009, ASU was first adopted into the Thai healthcare system’s Pay-for-Performance (P4P policy), a major achievement as there was stiff competition from other health priorities vying for the same status. An AMR research program, from Bangkok’s Siriraj Hospital provided significant, domestic evidence for Thailand that the rate of antibiotic use for URI, acute diarrhea and simple wounds should not exceed 20%. This figure was adopted by the P4P policy for ASU implementation.

The participation of numerous partner organisations in bringing about change in practices and social norms regarding antibiotics in the field also played an important role in spreading the ASU initiative and providing ground-level evidence of its impact.

For example, since 2008 the ASU‐Muaklek Project by the Langkhhao primary health center, Muaklek District, Saraburi Province has carried out intensive community education campaigns targeting reduction in antibiotic use. The community is now a model for others in Thailand to visit and learn about different popular communication and mobilization tools for educating the general public on dangers of antibiotic overuse.

Similarly, inspired by the ASU concept, in November 2013, the Queen Sirikit National Institute of Child Health (the largest children hospital in Thailand), launched the Antibiotic Smart Use in Children (ASU‐Kids) Project to reduce unnecessary antibiotic prescriptions for URIs, acute diarrhea and simple wound in children and to empower parents to provide proper care to their kids. The project was launched as a key feature of the Antibiotic Awareness Day 2014.

Integration into national program

The Antibiotic Smart Use program became part of the overall Antimicrobial Resistance Containment Program 2012-2016 in Thailand and its concepts and messages are part of the country’s National Strategic Plan on Antimicrobial Resistance (2017-2021). In 2016, the Thai Ministry of Public Health (MOPH) integrated the ASU concept and its key messages as part of its Rational Drug Use policy package, thus making it a nation-wide program.

Selected Resources

Resource Description
Antibiotic Smart Use – A case study (PDF, 4MB) A write up from ReAct about the Antibiotics Smart Use program.
Antibiotics Smart Use: a workable model for promoting the rational use of medicines in Thailand A WHO Bulletin highlighting the Antibiotics Smart Use program.
Antibiotics Smart Use – Downloads

A selection of promotional materials from the Thai Antibiotics Smart Use program. While all of the materials are in Thai, they can be used to see the different types of awareness-raising and promotional materials that are possible to create.

Antibiotics Smart Use Program: Thailand’s experiences in promoting rational use of antibiotics (PDF) A presentation describing the Antibiotics Smart Use program.
Putting Theory into Practice: Lessons learned from Antibiotics Smart Use Program A PowerPoint presentation. (Putting theory into Practice: Lessons learned from the ASU program).

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