ICIUM 2011
Antalya, Turkey
A mixed model to
promote rational use of medicines
Nithima Sumpradit (1,2); Pisonthi Chongtrakul (3); Kunyada Anuwong (4); Somying Pumtong (4)
1: Food and Drug Administration; 2: International Health Policy Program, Ministry of Public Health;
3: Faculty of Medicine, Chulalongkorn University; 4: Faculty of Pharmacy, SrinakharinwirotUniversity, Thailand
On behalf of ASU partners and network
ASU partners and network
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Thai Food and Drug Administration
World Health Organization
Health Systems Research Institution
International Health Policy Program, Thailand
National Health Security Office
Drug System Monitoring and Development Center
• Faculty of Medicine at Chulalongkorn University, Konkean
University and Thammasart University
• Faculty of Pharmacy at Srinakarintharawiroj University,
Chulalongkorn University, Maha Sarakram University
• Health professionals and participants from several provinces
• Saraburi, Ayutthaya, Samutsongkhram and Ubonratchathani
• Kantang community hospital network
• Srivichai private hospital network
• many other provinces and settings
Talk outline
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Country’s profile
Antibiotics Smart Use Program
Lessons learned about policy advocacy
Conclusions
Country Profile
• 63.3 millions population
• Universal health care coverage
achieved in 2002
• Drug expenditures: 35% of
health expenditures.
• By law, antibiotics need to be
dispensed by a pharmacist.
• National Antimicrobial
Resistance Surveillance,
Thailand (NARST)
•National plans and strategies
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on AMR are being developed.
Origin of ASU
ASU is an action research to change medicine use behavior.
ASU assumptions
1.RUM is behavioral issue. RUM cannot achieve unless it
creates behavioral change.
2.Bottom-up approaches are needed to change behavior.
Top-down approaches are needed for scaling up and
sustain the behavior changed.
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Objectives
To test the ASU model in promoting RUM
To reduce unnecessary antibiotic uses in upper
respiratory infection (URI), acute diarrhea and
simple wound.
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Individual level
- Correct
misunderstanding
- boost self-efficacy
Hospital level
- Ensure supportive
environment
Network level
- Decentralized Network
National policy level
- Link ASU to policy
Social level
Create a social norm on ASU
Predisposing factors
Attitudes
Subjective
norm
Self-efficacy
Intention
Reinforcing factors
(by level)
e.g., reward and
punishment
Enabling factors
(by level)
e.g., Availability of antibiotics,
tx guidelines, devices etc
Study
framework
Prescribing
behavior
Patients’
health &
satisfaction
Hospital
context
Community context
Phase 1: To test interventions modifying prescribing behavior (2007-8)
Setting: 10 district hospitals and 87 health centers in 1 province
Phase 2: To test feasibility of scaling up program (2008-9)
Setting: 44 hospitals and 627 health centers in 3 provinces (large,
medium and small) and 2 hospital networks (public and private)
Phase 3: Toward sustainability via policy advocacy, network strengthening and
development of new social norms (2010-present)
Interventions
• Multifaceted interventions (i.e., education,
management, incentive and policy/regulation)
via decentralized network between central
and local partners
ASU @ Lumtub community hospital (Krabi province)
Buddhist monk as
ASU health educator
(Saraburi province)
Effects on prescribing behavior
% of patients who were
affected with the
targeted diseases and
did not receive
antibiotics
Source: Kunyada Anuwong & Somying Pumtong
Effects on patients’ health and satisfaction
• Over 80-90% were satisfied with medical services and
treatment outcome and intended to return to this healthcare
setting for the next medical visit.
Source: Kunyada Anuwong & Somying Pumtong
Panuchote Tongyoung et al.
Effects on scaling up
In 2009, National Health Security
Office (NHSO), responsible for
universal care coverage,
announced ASU in an RUM
pay-for-performance policy
2007
2008*
2010
•This number does not included the hospitals that adopted ASU prior the policy announcment.
Lessons learned about policy advocacy
1. Choosing a right policy
Predisposing factors
Attitudes
Subjective
norm
Self-efficacy
Pay-forperformance
criterion
(NHSO)
Intention
Reinforcing factors
(by level)
e.g., reward and
punishment
Enabling factors
(by level)
e.g., Availability of antibiotics,
tx guidelines, devices etc
Prescribing
behavior
Patients’
health &
satisfaction
Hospital
context
Community context
Lessons learned about policy advocacy
2. Multisectoral partners
– Authority (Politic, MOH, Government and Healthcare payer)
– Academia (University and research unit)
– Social movement (NGO and media/social advocator)
Modified from a concept of “triangle that moves the mountain”
Lessons learned about policy advocacy
3. ‘Proof of success’  Evidence-based policy
– Benefits to health
– Cost saving
– Practical to implement and evaluate
4. Critical mass of ASU alliances & Clear directions
– “Climate for change”
5. A window of opportunity
Conclusions
1. ASU is an RUM model that can modify antibiotic
prescribing behaviors.
2. Scaling up the program requires a policy advocacy
via multisectoral partners, decentralized network and
evidence-based program.
3. A bottom up approach (at the individual level) is
needed to change behavior and a top down
approach (and social measures) are needed for
scaling up and sustaining the behavior changed.