| 4. In which ways is the initiative creative and innovative?
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The ASU program is innovative in three folds.
First, instead of using a top-down approach by issuing a policy or regulation to curb antibiotic use, ASU uses a bottom-up approach to change prescribing behavior and then uses a top-down approach to sustain behavioral change. As action research, ASU initiates antibiotic prescribing behavioral change through collaborative actions between central partners and local partners.
Second, for ASU, a behavioral change is a process, not a goal. The ultimate goal is to create new social norms, which is new to drug regulators and policy makers. Social norm is a soft law urging individuals to act congruently with societies. Discrepancies between social norms and the legislative laws lead to law violations and ineffective law enforcement.
Third, it is the first time that the complex concept of rational use of medicines is simplified into two steps for action: (1) do not use medicine if not necessary and (2) if necessary to use, use it wisely. This new stance enables the complex problems to be solved in a clear and effective manner. Step 1 is a primary focus of ASU.
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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Program organization: ASU organized on two levels: central partners and local partners. Local partners are a group of health professionals, community leaders and others. They are responsible for ASU implementation in their settings such as hospitals, schools and communities. Central partners are a group of national health authorities, research institutes, civil society organizations (CSO) and others. They are responsible for ASU implementation at national and sub-national levels.
Program administration: The central and local partners are formed the ASU network, which is a decentralize network based on the starfish model, in which management has no hierarchical leadership. The ASU network emphasizes the importance of local ownership and mutual recognition, which have generated pride and commitment. To promote senses of local ownership, the local partners can name their own projects (no need to name it ASU) and design their own methods for improving the use of antibiotics among health profes¬sionals and the public. The central part¬ners play catalytic and supportive roles in two ways. First, they guide and harmonize activities across local partners and disseminate examples of good practice and success stories drawn from local partners (e.g. via newsletters). Second, they provide policy support as well as technical and financial support. The Food and Drug Administration (FDA) is in charge in coordinating across partners.
Size of the population affected/benefited by ASU: The number of people affected and benefited by ASU has increased over time. In 2007, ASU was implemented in one province and then expanded to three provinces and two hospital networks in 2008. In 2010, ASU was expanded to 15 provinces. The first policy support is in 2009 when the National Health Security Office (NHSO), responsible for the Universal Health Coverage (UHC), adopted ASU in to the Pay-for-Performance (P4P) policy. This initial P4P policy was made to cover district hospitals across the country. Since 2011, the P4P policy covers all regional, provincial and district hospitals. As a result, ASU has become a nation-wide program. Additionally, the momentum to adopt ASU in other national policies has continued (see Item 14 for details).
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| 6. How was the strategy implemented and what resources were mobilized?
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ASU has evolved through three phases.
Phase I (2007-2008) is to test the effectiveness of interventions in changing physicians’ behavior in three targeted conditions: URI, acute diarrhea and wound. Based on a quasi-experimental pre-post design with a control group, ASU was piloted in one province (Saraburi) covering 10 district hospitals and 87 sub-district PCUs. Ayutthaya, a matching, neighboring province was the control group. Effectiveness of intervention was as-sessed against the predetermined targeted, i.e., 10% reduction of antibiotic prescriptions, 10% increase in the number of patients who were not prescribed antibiotics; and 70% of the number of patients who were not prescribed antibiotics feel better or full recovery and satisfied with treatment outcome. It used multi-faceted interventions at the individual and organizational levels (see Item 3). The results showed antibiotic prescriptions reduced 18-46%. The number of patients who were not prescribed antibiotics increased 29%. Over 97% of 1,200 patients who were not prescribed antibiotics feel better or fully recovered and over 80% were satisfied with treatment outcome. Successes in Phase I led to Phase II.
Phase II (2008-2009) is to examine feasibility of program scale-up. It was tested in three provinces (large, medium and small provinces) and two hospital networks (public and private hospital networks). It covered 44 hospitals and 627 sub-district PCUs. ASU orga¬nized on two levels: central partners and local partners. It used two strategies. The first strategy applies the interventions from Phase I for changing prescribing behavior. The second strategy aims at scaling-up ASU using the horizontal and vertical scaling-up measures. The horizontal scaling-up measure emphasizes creating a decentralize network (see Item 5) by (1) giving the local partners full autonomy in naming their own ASU projects and designing their own interven¬tions and media materials (see Item 3) and (2) establishing the ‘training for trainers’ program to build local network capacity that can provide technical support to their peers in neighboring areas. The vertical scaling-up measure emphasizes integrating ASU into policy. In 2009, ASU was included in the NHSO’s P4P policy. Key findings are all three provinces and two hospital networks can reduce the rates of antibiotic prescriptions and gain positive patients’ health outcome and satisfaction on treatment outcome as those found in Phase I, and the combination of horizontal and vertical scaling up measure is effective to scale up ASU program. Successes in Phase II led to Phase III.
Phase III (2010-present) is to scale up ASU toward sustainability by creating new social norms. Key strategies include increasing the number of sites, transferring to different settings, and strengthening policy support. Key findings are ASU was expanded to 15 provinces in 2010, by Drug System Monitoring and Development Center (DSMDC), a CSO funded by Thai Health Promotion Foundation. It was adopted by Siriraj hospital (the largest, teaching hospital in Thailand) in 2012, by Queen Sirikit National Institute of Child Health (the largest, children hospital in Thailand) in 2013, by Community Pharmacist Association of Thailand (CPAT) in 2014, and by Antibiotic Awareness Campaign (a sub-national public campaign) in 2013. In 2016, ASU is included in Rational Drug Use (RDU) hospital policy of Ministry of Public Health (MOPH). We also conducted a survey to assess changes of knowledge, attitudes and social norms in various sites of ASU.
Financial support are from WHO (Phase I), from Health Systems Research Institution (HSRI) and NHSO (Phase II) and from DSMDC and HSRI (Phase III) accounting for 33,000; 73,000 and 123,000 USD, respectively. FDA provides subsidiary budget and in-kind contribution of human resources in program management. Technical support for clinical training and program evaluation is from Chulalongkorn University and Srinakharinwirot University, respectively.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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ASU is derived from collective efforts from partners, particularly,
Central partners
Food and Drug Administration is responsible for program planning, management and coordination, mobilizes resources, creates educational materials for patients and generates ASU reports.
Medical professor, Chulalongkorn University trains health professionals, develops educational materials for health professionals and proposes to use white light illuminators.
Pharmacy professors, Srinakharinwirot University conducts program evaluation and provides technical support for local partners for ASU research.
National Health Security Office endorses ASU into P4P policy, supports funding and advances the E-tool program to monitor the rate of antibiotic prescription.
Ministry of Public Health adopted ASU in the RDU hospital policy in 2016.
Drug System Monitoring and Development Center, civil society organization, supports funding, expands ASU sites, initiates the Antibiotic Awareness Campaign by integrating ASU’s key messages in the campaign, and advocates ASU to policy.
Health Systems Research Institute supports funding, advocates ASU to policy and provides a forum for ASU in its national research conference.
Health Accreditation Institute, a public organization, provides a forum for ASU in its national HA forum.
Siriraj Hospital generates evidence enabling NHSO to set the cut-off point at 20% for P4P policy, i.e., the rate of antibiotic prescription for URI and acute diarrhea should not exceed 20%.
Queen Sirikit National Institute of Child Health initiates ASU-Kids project.
Community Pharmacist Association of Thailand, a private sector, initiates ASU-pharmacy project and re-design the ‘Mirror-for-sore-throat-examination tool’ for pharmacies.
Selected local partners
Muaklek District, Saraburi Province is ASU best practice demonstrating sustainability.
Choompae district hospital, Konkean Province develops prototype of E-tool program and then advanced by NHSO to monitor national antibiotic prescription.
International supporter/partners
WHO supports funding and promotes ASU in publication.
ReAct-Action on Antibiotic Resistance, an international civil society organization, promotes ASU as a best practice to other countries and in website, www.reactgroup.org.
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| 8. What were the most successful outputs and why was the initiative effective?
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These are four most successful outputs.
First, the rate of antibiotic prescription in URI and acute diarrhea decrease from 50% to 40% and from 47% to 34%, respectively. Despite yet achieved the 20% target, the trend is promising. This successful reduction is because hospitals regularly receive the feedback data from NHSO regarding their rates of antibiotic prescription, comparing to other hospitals in the same health region. Technical support from FDA and academics to improve use of antibiotics is available for hospitals upon request. This success advances roles of SDG-3 as it reduces risks of AMR and ADRs due to overuse of antibiotics to patients and of SDG-12 as it prolongs the effectiveness of existing antibiotics and therefore promote sustainable consumption of antibiotics.
Second, after 10-year implementation, there is no report that ASU practice jeopardizes patients’ health. In contrast, the follow-up phone calls within 7-10 days after the medical visits in public hospitals found that 97% of 1,200 patients who were affected with the targeted conditions and were not prescribed antibiotics felt better or fully recovered. The similar results were found in private hospitals and pharmacies, i.e., 99% of 917 patients and 92% of 998 patients, respectively. This success is due to the fact that the targeted condition is self-limited diseases and no need for antibiotics. This success advances roles of SDG-3 as this evidence ensures healthy lives and promotes well-being despite receiving antibiotics in these three targeted conditions.
Third, hospitals can cut costs due to unnecessary antibiotic use. For example, Choompae district hospital, in Konkean province started ASU in 2010. They found that the costs of antibiotic use reduce from 25,000 to 6,300 USD during 2008-2014. Additionally, they can maintain the rate of antibiotic use in targeted conditions below 20% till today. The success results from the fact that they use the audit-feedback system to monitor antibiotic use in the hospital with dialogues among physicians. This success advances roles of SDG-1 as AMR negatively impacts on national economy, which could ultimately contribute to slowing down progress towards SDG-1.
Fourth, there is a success in integrating ASU into policy so that it enhances the likelihood of sustainability of ASU implementation. Presently, ASU has been adopted and implemented under two national policies: NHSO’s P4P policy and MOPH’s RDU hospital policy. This success advances roles of SDG 1, 3 and 12 as the policy support is crucial to promote sustainable development.
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| 9. What were the main obstacles encountered and how were they overcome?
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Four obstacles are worth mentioning as follows.
First, although ASU is a well-planned project, it must inevitably be adapted to the local context. For example, physicians in district hospitals have tight schedules as they need to handle hospital and community services. Leaving a hospital to join the training is difficult for them. Thus, an individual training program was delivered on-site in every district hospital to adapt to the tight schedule of district hospital physicians. It took 1.5 months to complete the ‘on-site training’ program for all 10 district hospitals.
Second, physicians fear that patients may get worse without antibiotics. Couple tactics are used to overcome this fear. For example, they may prescribe alternative, herbal medicines listed in Thailand’s National List of Essential Medicines, such as Andrographis paniculata capsules, for patients to relieve symptoms of fever and sore throat from viral infection. Alternatively, they may experiment by cutting down antibiotic use then have nurses/pharmacies to make follow-up calls to monitor clinical outcome of patients who did not receive antibiotics. In one district hospital, the hospital director had physicians, nurses and pharmacists collectively observe his practice of not prescribing antibiotics and co-monitor patients’ clinical outcomes. This can enhance prescribers’ confidence in non-antibiotic therapy.
Third, in district hospitals physicians trained in ASU are often rotated to other settings. Thus, self-governance by hospital’s medical board or pharmacy therapeutic committee to ensure training for incoming physicians is important.
Fourth, resource limitation is a major challenge. Many effective devices, e.g., ‘Mirror-for-sore-throat-examination’ (see Item 10) cannot be reproduced sufficiently due to lack of financial support. In overcoming this difficulty, apart from solving problem on a case basis, we expected multiple, long-term policy commitment to provide sufficient resources so that ASU can achieve creating new social norms on antibiotic use for Thailand.
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