Using evidence from nine countries (Democratic Republic of Congo, Dominica, Egypt, Kazakhstan, Kenya, New Zealand, Thailand, Tunisia, and Uruguay), we analyze the political economy dynamics that emerged during implementation of primary health care (PHC)-oriented reforms. Across these cases, we identify 10 recurring health-system "shifts" toward stronger PHC orientation, which serve as a descriptive framework for examining the political economy challenges reformers faced and the strategies they used to navigate them. Primary data were collected from 356 participants through key informant interviews, focus groups, and expert consultations and were triangulated with document review. Using deductive mapping and inductive thematic analysis, we identify 10 PHC-focused health-system shifts present in some or all of the cases. These entailed shifts from: (i) short-term initiatives with limited scope to long-term, system-wide transformations; (ii) centralized control to devolved multilevel governance; (iii) hospital-centric resource allocation to strategic reallocations favoring primary care; (iv) physician-dominated care to multidisciplinary teams including non-physician providers; (v) siloed disease-focused services to integrated models of comprehensive care; (vi) peripheral, minimally regulated private sectors to their integration and actively state-stewarded participation; (vii) passive input-based budget allocations and provider payments to strategic purchasing; (viii) perceiving citizens as passive recipients of care to building active community engagement; (ix) ad hoc data collection to embedded learning and accountability; and (x) externally driven changes to local ownership for reforms. Reforms routinely triggered political economy dynamics-opposition from physicians, hospitals, specialists, and central bureaucracies; citizen skepticism; and capacity and patronage challenges under devolution. Strategies to address these included: high-level endorsement and passage of legislation; use of political and economic windows of opportunity; local capacity-building; decentralized autonomy; formal engagement with physician associations; regulated private sector participation; strategic purchasing to incentivize a PHC approach; strong data systems and assessments; community engagement; and locally grounded design with domestic capacity and financing. The paper underscores the value of anticipating political economy dynamics for designing and implementing PHC-oriented reforms.

Designing a fit-for-purpose global health architecture requires regional coordination and global alignment.

Objectives Ensuring equity in medical specialist distribution is essential for achieving universal health coverage (UHC). This study explored the changes in the availability and distribution of medical specialists in Thailand from 2015 to 2024 and assessed the equity impacts on workforce.Design A retrospective longitudinal analysis of national administrative workforce data.Setting Public and private hospitals across Thailand, covering 1471 facilities in 77 provinces.Primary outcome and explanatory variables The primary outcomes were specialist-to-population ratios and geographical equity measured using the Gini coefficient (G), where values closer to 0 indicate greater equity. Explanatory variables included specialty type, geographical region and the timing of major workforce policies, including mandatory service and specialty-specific legislative interventions.Results Between 2015 and 2024, the GPs and specialists in Thailand expanded significantly, with improvements in both density and distribution. The Gini coefficient for GPs showed the largest equity improvement (G=0.42 in 2015 and G=0.22 in 2024), reflecting the impact of mandatory service programme and rural recruitment programmes. Among specialists, emergency and family medicine have shown rapid growth and significant reductions in distribution inequity, reflecting the success of legislative policies. Sustainability of workforce policies was challenged by the ‘leaking stock’ phenomenon due to attraction of career opportunities and economic drives.Conclusion Workforce targeted interventions have led to improvements in the availability and equitable distribution of GPs and medical specialists over the past decade. Further policy, such as retention incentives and assisted technology, is needed to achieve equitable distribution across all specialties, particularly in low-density fields. Thailand’s experience offers the lessons for other low- and middle-income countries as the evidence-based and equity-focused workforce policies for UHC advancement.

From the outset of the pandemic there were calls to ensure people with disabilities were included in prevention and response measures, given their increased risk of health consequences from COVID-19 infection. This study sought to explore people with disabilities’ experiences of inclusion in the response to the COVID-19 pandemic, to understand how such responses can be more inclusive in the future. Qualitative interviews were conducted with 372 people with disabilities and their caregivers in Bangladesh, Ghana, India, Peru, Thailand, Türkiye (with Syrian refugees), Viet Nam, and Zimbabwe between 1 December 2020 and 28 February 2023, and analysed using thematic analysis. The study found that people with disabilities demonstrated high levels of knowledge about COVID-19 and were willing to adhere to prevention measures. However, participants noted that countries’ COVID-19 responses were largely not inclusive of people with disabilities; that pandemic information was seldom available in accessible formats; and that adhering to social distancing and other mandates was challenging and incurred personal and economic costs. Consequently, the pandemic compounded existing barriers and inaccessibility experienced by people with disabilities and contributed to inequality.

We examine the significant increase in staffing at the Chinese Center for Disease Control and Prevention (CDC) following the COVID-19 pandemic and compare it to the staffing changes post-2003 SARS outbreak. This analysis views the surge not only as compensation for long-term understaffing, but also as a response to the immediate demands of the COVID-19 crisis. We explore the implications of this increase, addressing the financial burden it imposes on the government, the challenges in maintaining a balanced human resource structure, and the potential long-term effects on public health infrastructure. Additionally, we propose strategic recommendations including reforming the income model for CDC employees, implementing strategic workforce planning, and making infrastructure improvements. These measures aim to support a more effective and resilient public health system in China.

Background: Antimicrobial resistance (AMR) is a pressing global health issue, exacerbated by extensive antimicrobial use across human, animal, and plant sectors. The environment plays a crucial role in AMR emergence and spread due to the contamination from resistant bacteria, resistance genes, and antimicrobial residues from various sources. In Thailand, the regulatory framework that can reinforce AMR mitigation in environmental settings remains underdeveloped. This study aims to analyse the existing regulatory framework for environmental AMR control by identifying regulatory gaps and assessing the challenges of implementing these regulations. Methods: A qualitative approach was employed, combining a literature review and semi-structured interviews with 28 key informants from diverse regulatory sectors, including the ministries of health, agriculture, and environment. This included multi-level stakeholders at national, provincial, and local levels, as well as selected farmers. Content analysis of interview transcripts and regulatory documents was performed to triangulate findings on regulatory gaps and implementation barriers. Results: The study identified five regulatory categories governing water contamination across settings: rivers/canals, hospital wastewater, household wastewater, industrial waste (including pharmaceuticals), and animal farms. While the regulatory frameworks guide pollution standards, regulations lack provisions specific to AMR, highlighting a significant gap in AMR oversight and data on AMR pathogens in environmental wastewater. Key barriers include insufficient incorporation of AMR indicators in routine monitoring, limited enforcement, and inadequate technical and budgetary support. Conclusion: Thailand's current environmental AMR framework lacks comprehensive AMR-specific regulations and robust enforcement mechanisms. Addressing these gaps requires multi-sectoral coordination, enhanced funding, and capacity-building initiatives. By prioritizing indicator development and establishing AMR-focused policies, Thailand can enhance its environmental AMR control measures and contribute to global AMR mitigation efforts.

Purpose:Parental interaction in learning-promoting activities is crucial for supporting early childhood development. This study aimed to assess the level of parental interaction among children aged 2-4 years in Thailand and to identify determinants associated with parental interaction. Patients and Methods:A cross-sectional analysis was conducted using data from the 2022 Multiple Indicator Cluster Survey (MICS), which included a nationally representative sample of 7003 parents of children aged 2-4 years. Parental interaction was assessed through six activities promoting early stimulation and responsive care. Interaction levels were categorized as high (participation in four or more activities) or low (fewer than four activities). Multivariable logistic regression was employed to analyze associations between parental interaction levels and household and participant characteristics. Results:The study found that 88.1% of parents reported high levels of interaction with their children. Children outside Bangkok had lower odds of high interaction, particularly in the Central (AOR=0.33), North (AOR=0.31), Northeast (AOR=0.44), and South (AOR=0.38) regions. Higher odds of high interaction were associated with maternal education above secondary level (AOR=2.00), the highest wealth quintile (AOR=2.48), living with either (AOR=2.14) or both parents (AOR=2.59), being in a non-Thai-speaking household (AOR=1.75), and having three or more books at home (AOR=3.63). Conclusion:Nearly 12% of parents reported low levels of interaction with their children aged 2-4 years, with disparities associated with regional and socioeconomic factors. Policy efforts should prioritize integrating parental support into early childhood education programs and enhancing access to resources, such as children's books and community libraries, particularly for socioeconomically disadvantaged groups.

Introduction Municipalities play a critical role in shaping built environments that support active living, yet little is known about how municipal officials interpret these agendas, implement them or balance them with competing policy demands. This study explores how municipal officials in urban Thailand perceive and implement built environment strategies, manage constraints and identify opportunities to promote active living.Methods We conducted a qualitative study using semistructured interviews with 27 informants: eight elected officials, 15 senior appointed officials and four technical staff from seven municipalities across Thailand. Municipalities were purposively selected to reflect variation in geography across seven regions and administrative levels, including metropolitan, city and town contexts. Thematic analysis combined deductive coding based on policy-related topics such as roles, coordination and governance challenges with inductive coding to identify emergent themes.Results Three themes emerged. First, municipal officials commonly viewed the built environment through a recreational lens, prioritising parks and leisure spaces for their visibility, popularity and alignment with community expectations. Planning was influenced by leadership preferences and external models. Second, implementation was hindered by institutional fragmentation, overlapping mandates, weak cross-sector coordination and contextual factors such as complex land use, unregulated street activity, motorcycle-dominated mobility and political sensitivities. These challenges were more pronounced in smaller municipalities with limited technical capacity. Third, enabling factors included strengthened decentralisation, national incentives (eg, additional floor area near transit hubs), partnerships to repurpose underused spaces, digital tools such as mobile apps for responsive service delivery, adaptive leadership for public communication and leveraging local assets to support inclusive, context-sensitive development.Conclusion In urban Thailand, municipal strategies for active living continue to emphasise recreation over mobility. Implementation remains constrained by institutional and contextual challenges. Advancing more inclusive and responsive environments will require stronger governance, supported by decentralisation, community partnerships, digital tools, local assets and adaptive leadership.

Over the past decade, China has experienced a surge in doctors and beds, along with significant increase in healthcare utilization. This study compares the need-based and demand-based projections with supply of doctors and beds in China from 2021 to 2025. We also evaluate the adequacy and equitable distribution of doctors and beds. By utilizing public data from 2008 to 2018, we employed the health need method, health demand method, and trend projection to estimate the need and demand for and supply of doctors and beds in China. By 2025, the projected need-based, demand-based, and supply of doctors will be 5.93 million, 3.89 million, and 4.40 million, respectively. Correspondingly, bed projections stand at 7.27 million, 6.58 million, and 11.06 million. The study found an inclination toward hospital care, amplified by the need and demand for doctors and beds in hospital sector. Notably, the findings indicate 64.0

Thailand's Rural Doctor Movement (RDM) is a "civic movement" organized by rural doctors who are officials in the Ministry of Public Health (MOPH). RDM's political consciousness and ideologies for social justice were cultivated by their exposures to student activism and repression in October 1973 and 1976 and fostered by the exposure to poverty and ill-health in rural communities while doing compulsory medical service in rural hospitals in the 1970s-1980s, following graduation from medical school. This perspective highlights two major contributions by RDM. First, it fought against the 1998 Drug Scandal and 2009 potential corruption in the MOPH through whistle-blowing role. Second, RDM advocated for legislation from various statutory bodies that support and fill the gap of MOPH. These bodies include the Thai Health Promotion Foundation, the National Health Security Office, and the National Health Commission Office. The legal mandates of these statutory bodies create conflicts with tobacco, alcohol and beverage industries, pharmaceutical industries and MOPH, which led to consistent efforts to roll back the influence of these para-statal health organizations formed and led by RDM advocates. RDM's role as whistle-blowers and advocates for the legislation of statutory bodies provides key lessons for practitioners and policymakers in developing countries. However, they need to adapt to their own policy contexts and policy actors and be agile to grasp the window of opportunity.

Indonesia's National Health Insurance system - the Jaminan Kesehatan Nasional (JKN) - is one of the largest single-payer health insurance schemes in the world, aiming to provide equitable and affordable healthcare to a population of over 280 million. Since its launch in 2014, the JKN has achieved near-universal enrolment, covering 98 % of Indonesians in 2024. However, progress towards universal health coverage - understood as access to the health services people need, when and where they need them, without financial hardship - has been hindered by financing deficits and operational hurdles faced by healthcare providers. In this paper, we examine critical issues affecting the implementation of JKN through the analysis of 20 in-depth interviews and a focus group discussion with government officers and health sector managers at the national and provincial level. Data analysis was guided by a framework combining health systems building blocks and dimensions of access to services. The findings highlight persistent challenges despite the JKN's wide coverage, including difficulties among informal sector workers in paying premiums, regional disparities in service access and health workforce distribution, inefficiencies in provider payment mechanisms, and weak information systems for tracking subsidised members. Interviews also revealed a growing financial and administrative strain on hospitals linked to frequent regulatory changes. To address these issues, we recommend three priority reforms: (1) implement sliding-scale subsidies for informal sector workers; (2) improve provider payment models by introducing cost-sharing for elective services; and (3) adopt participatory policymaking processes to ensure reforms are sustainable and inclusive.

Commercial milk formula (CMF) marketing adversely influences breastfeeding practices globally. Thailand enacted the Control of Marketing Promotion of Infant and Young Child Food Act ('Thai Code') in 2017 to restrict the marketing of CMF for infants aged 0-12 months. This qualitative study aimed to explore mothers' experiences and perspectives of CMF marketing and its regulation by the Thai Code through semistructured interviews with 15 mothers across Thailand between July 2023 and March 2024. Our findings revealed that while traditional advertising and healthcare-setting promotions decreased, CMF marketing strategies evolved toward social media platforms, particularly TikTok and Facebook, and through building relationships with mothers for CMF products for young children. Participants reported varying perceptions toward CMF marketing, with those of lower socioeconomic status appearing to be more susceptible to marketing claims, for example, CMF boosts cognitive development and is equivalent to breast milk. While participants reported receiving strong breastfeeding support from healthcare facilities, subtle CMF promotional practices persisted in private settings through free sample distribution and invitations to join company-sponsored digital platforms. Despite general awareness that some form of CMF marketing regulation exists, participants had limited knowledge of the Thai Code's specific provisions. Therefore, enhanced monitoring of digital marketing and private healthcare settings, alongside improved public communication about the Thai Code, could strengthen its implementation, particularly in lower income settings in which mothers may be more vulnerable to marketing claims.

Objective This qualitative study sought to understand how sufficient economy philosophy (SEP) was applied to cope with and recover from the COVID-19 pandemic.Design A qualitative study conducted through focus group discussions.Participants 19 focus groups, with 161 participants, selected for the diverse backgrounds in gender, profession, education and region (urban/rural) and different levels of impact from the pandemic.Setting Bangkok, the capital city, and the four regions of Thailand: north, northeast, south and central.Findings Participants highlighted the moderation, reasonableness and prudence as key themes that mitigated adverse economic impacts during the pandemic. Communities practising the SEP reported resilience through balanced consumption, prudent planning and social cooperation. Many participants mentioned that the SEP was crucial to their survival and should have been better practised. Though the market structure failed during the pandemic, they still could secure the essential items to maintain livelihood.Conclusion In a society where changes are complicated by multiple factors, crises may occur more frequently, unsuspectedly and in various forms. Tools and a mechanism for resilience are increasingly needed. This study highlights the importance of the SEP, which incorporates five key concepts: moderation, reasonableness, prudence, knowledge and morality. These concepts help affected communities survive and become resilient, which is crucial for achieving several Sustainable Development Goals, such as poverty and hunger reduction, enhanced health and well-being and the sustainability of cities and communities.

BACKGROUND:Indonesia has implemented a series of healthcare reforms including its national health insurance scheme (Jaminan Kesehatan Nasional, JKN) to achieve universal health coverage. However, there is evidence of inequitable healthcare utilization in Indonesia, raising concerns that the poor might not be benefiting fully from government subsidies. This study aims to identify factors affecting healthcare utilization in Indonesia. METHODS:This study analysed cross-sectional survey data collected by the "Equity and Health Care Financing in Indonesia" (ENHANCE) Study. Andersen's behavioural model of health services use was adopted as a framework for understanding healthcare utilization in Indonesia. Sociodemographic variables were categorized into predisposing, enabling and need factors. Outcome measures included the utilization of primary and secondary health services. Multi-level logistic regression models were run to examine factors associated with each type of health service utilization. RESULTS:Of the 31,864 individuals included in the ENHANCE survey, around 14% had used outpatient services in the past month. Fewer than 5% of the study population had visited hospitals for inpatient care and about 23% used maternal and child health services in the past 12 months. Age, gender and self-rated health were key determinants of health services utilization. No significant differences in primary care utilization were found among people with different insurance status, but people who received subsidised premiums under the JKN were more likely to receive primary care from public health facilities and less likely from private health facilities. Compared to people who pay JKN insurance premiums themselves, the uninsured and those whose premiums were subsidised by the government were less likely to visit public and private hospitals when other factors were controlled. CONCLUSION:This study demonstrates that the distribution of healthcare utilization in Indonesia is largely equitable as predisposing factors (age and gender) and health need were found to greatly influence the utilization of different types of health services. However, enabling factors such as health insurance status were also found to be associated with inequity in utilization of hospital services. Further policy actions regarding resource allocation and health service planning are warranted to achieve a more equitable pattern of health service use in Indonesia.

The high volume of antibiotics used for companion animals, off-label use of human-registered antibiotics for veterinary purposes, and close human-animal interactions raises policy concerns related to antimicrobial resistance in companion animals. This study aimed to assess the volume and type of antibiotic usage in companion animals at veterinary teaching hospitals in Thailand. In 2018, we obtained a dataset of visits that occurred between 2015 and 2017 from eight selected veterinary teaching hospitals with a high caseload of companion animals. In total, we included 938,522 dogs and 242,342 cats in our study. Total antibiotic consumption was estimated, and antibiotic usage was standardized by calculating the amount of antibiotic consumed by weight per year (mg/kg/year). The top five antibiotics used include amoxicillin-clavulanic acid, enrofloxacin, cephalexin, doxycycline, and metronidazole, all of which are commonly used to treat bacterial and parasitic infections. Critically important antimicrobials for human medicine, such as amoxicillin-clavulanic acid and enrofloxacin, were among the most used. From 2015 to 2017, total antibiotic usage (kg) markedly decreased (i.e., by 57.0%), with a particularly notable reduction of 78.2% observed for amoxicillin-clavulanic acid. Moreover, veterinarians' overall prescriptions of antibiotics registered for human use decreased by 16% over the same period. However, there was a notable increase in the use of injectable antibiotics registered for human use relative to oral forms. Furthermore, we observed a relatively high usage of third-generation cephalosporins, which may contribute to the emergence of antimicrobial resistance in companion animals. This study emphasizes the need to educate veterinarians and veterinary students on the rational use of antibiotics and highlights the importance of regular monitoring and surveillance of antibiotic use in companion animals.

BACKGROUND:Insufficient physical activity and excessive sedentary behavior are growing public health concerns in rapidly urbanizing Asian cities. Built environment characteristics may influence these behaviors, but region-specific evidence remains limited. This review synthesized associations between built environment characteristics and physical activity or sedentary behavior in urban Asia. METHODS:Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO CRD42023396292), 5 databases (Ovid MEDLINE, Embase, Web of Science, Scopus, and Cochrane Library) were searched for English-language articles published between 2012 and 2024. Articles were included if they examined associations between built environment characteristics and physical activity or sedentary behavior among adults in urban areas of Asia. Statistically significant associations were synthesized descriptively. RESULTS:Of 14,549 records screened, 98 articles from 13 countries met inclusion criteria, most using cross-sectional designs (96.9%). A total of 261 associations were identified, focusing on overall (37.9%), recreational (31.4%), and transport-related (29.9%) physical activity; only 2 associations (0.8%) addressed sedentary behavior. Supportive built environments were more often associated with increased physical activity (n = 208) than with decreased (n = 38). Overall physical activity was commonly associated with recreational facilities and land-use mix; recreational activity with recreational facilities and aesthetics; and transport-related activity with land-use mix and residential density. CONCLUSIONS:In urban Asia, 208 of 261 significant associations showed that supportive built environments were associated with increased physical activity. Land-use mix and access to recreational facilities were most consistently supportive. These findings highlight the need for context-sensitive urban planning and more research on sedentary behavior.

Antimicrobial resistance (AMR) in environmental reservoirs is an emerging global health concern, particularly in urban settings with inadequate wastewater management. This study aimed to investigate the prevalence and resistance profiles of Salmonella spp. in canal water in Bangkok and assess the distribution of key antibiotic resistance genes (ARGs). Between 2016 and 2019, a total of 1381 water samples were collected from 29 canals. Salmonella spp. were isolated using standard microbiological methods and tested for susceptibility to 13 antibiotics. Polymerase chain reaction (PCR) was used to detect extended-spectrum β-lactamase (ESBL) genes and class 1 integron. Salmonella was found in 89.7% of samples. Among these, 62.1% showed resistance to at least one antimicrobial, and 54.8% were multidrug-resistant (MDR). The highest resistance was observed against streptomycin (41.4%). ESBL genes, predominantly blaCTX-M, were detected in 72.2% of tested isolates, while class 1 integrons were found in 67.8%, indicating a strong potential for gene dissemination. The results highlight urban canals as critical environment reservoirs of AMR Salmonella serovars, posing significant public health risks, particularly where canal water is used for agriculture, household, or recreational purposes. Strengthened environmental surveillance and effective wastewater regulation are urgently needed to mitigate AMR bacteria transmission at the human–environment–animal interface.

BACKGROUND:In 2022, 10% of an estimated 560,000 people living with HIV in Thailand were unaware of their HIV status. A well-established HIV program is a solid platform for integrating HIV self-testing (HST) as part of efforts to end AIDS. We analyzed how HST was integrated into the national HIV program and became a benefit package. POLICY ADOPTION OF HST:In 2015, the National AIDS Prevention and Alleviation Committee included HST as a strategy to end HIV/AIDS by 2030. This led to collaboration between the Department of Disease Control (DDC), Food and Drug Administration (FDA), and partner networks, including civil society organizations, to amend policy regulations, allowing HIV testing outside health care facilities and facilitating HST registration. By 2024, 4 HST commercial products were registered by the Thai FDA. PROGRAM PILOTS:In 2020, the DDC launched pilot programs distributing HST kits through private pharmacies in Bangkok and online platforms. Preliminary findings showed feasibility in reaching key populations and adolescents. In 2023, HST was included in the Universal Health Coverage benefit package, providing free access to all citizens. Guidelines, e-learning, public awareness campaigns, and a reimbursement system of HST were developed and implemented. By September 2024, over 166,000 users had received HST kits. LESSONS LEARNED:Leadership, scientific evidence, feasibility testing through pilots, regulatory adjustments, licensing, price negotiations by the National Health Security Office, and stakeholder and community engagement were key to the program's success. A nationwide distribution network through public and private health care facilities, including pharmacies, was a key enabling factor for HST delivery. CONCLUSIONS:HST is an additional intervention to increase awareness of HIV status and a key component in Thailand's effort to end HIV/AIDS.