Thailand's national strategic plan on antimicrobial resistance: progress and challenges

Abstract Antimicrobial resistance is a serious threat that affects all countries. The Global Action Plan on antimicrobial resistance and the United Nations Political Declaration on antimicrobial resistance set standards for countries to resolve antimicrobial resistance challenges under the One Health approach. We assess progress and challenges in implementing Thailand’s national strategic plan on antimicrobial resistance 2017–2022, discuss interim outcomes and share lessons learnt. Major progress includes: establishing a national governance mechanism that leads high-impact policy on antimicrobial resistance and consolidates actions and multisectoral collaboration; creating a monitoring system and platform to track implementation of the strategic plan; and converting strategies of the strategic plan into actions such as controlling the distribution and use of antimicrobials in humans and animals. Interim results indicate that antimicrobial consumption in animals has nearly halved (exceeding the national goal of a 30% reduction) whereas other goals have not yet reached their targets. We have learnt that elevating antimicrobial resistance to high-level visibility and establishing a national governance mechanism is an important first step, and a monitoring and evaluation system should be developed in parallel with implementation. Securing funds is crucial. Policy coherence is needed to avoid duplication of actions. Highly ambitious goals, although yet to be achieved, can advance actions beyond expectations. Political commitment and collaboration across different sectors will continue to play important roles but might not be sustained without a well-designed governance structure to support long-term actions to address antimicrobial resistance.


Introduction
Antimicrobial resistance is a prominent global threat that jeopardizes the health of humans and animals, and the economy of countries. Antimicrobial resistance also threatens global health security and hampers the achievement of the sustainable development goals (SDGs). 1,2 In 2019, the World Health Organization (WHO) listed antimicrobial resistance in its top-10 global public health threats facing humanity 3 and in 2020 antimicrobial resistance became a new indicator for the SDGs. 4 Addressing antimicrobial resistance requires consolidated multisectoral actions under the One Health approach -a multisectoral and multidisciplinary collaboration that connects human, animal and environmental health sectors to improve the health of all. 5 The 2015 Global Action Plan on antimicrobial resistance 6 and the 2016 United Nations Political Declaration on antimicrobial resistance 7 serve as standards for countries, development partners and relevant stakehold-ers to develop their action plans and align actions in tackling antimicrobial resistance.
Antimicrobial resistance affects every country, 8 including upper-middle-income countries such as Thailand. Thus, in 2016, the government of Thailand endorsed the national strategic plan on antimicrobial resistance 2017-2021, which was recently extended to 2022. The plan takes the Global Action Plan on antimicrobial resistance into account and aligns political declarations with the national context. The plan included a set of ambitious goals together with six strategies for achieving them: (i) antimicrobial resistance surveillance; (ii) regulation of antimicrobial distribution; (iii) antimicrobial resistance containment in humans; (iv) antimicrobial resistance containment in agriculture and animals; (v) public awareness-raising; and (vi) governance mechanisms. 9 At the outset, the government of Thailand established two key strategic foundations for implementing the plan (Box 1). First, a national governance mechanism was created as a political platform to strengthen multisectoral collaboration under the Abstract Antimicrobial resistance is a serious threat that affects all countries. The Global Action Plan on antimicrobial resistance and the United Nations Political Declaration on antimicrobial resistance set standards for countries to resolve antimicrobial resistance challenges under the One Health approach. We assess progress and challenges in implementing Thailand's national strategic plan on antimicrobial resistance 2017-2022, discuss interim outcomes and share lessons learnt. Major progress includes: establishing a national governance mechanism that leads high-impact policy on antimicrobial resistance and consolidates actions and multisectoral collaboration; creating a monitoring system and platform to track implementation of the strategic plan; and converting strategies of the strategic plan into actions such as controlling the distribution and use of antimicrobials in humans and animals. Interim results indicate that antimicrobial consumption in animals has nearly halved (exceeding the national goal of a 30% reduction) whereas other goals have not yet reached their targets. We have learnt that elevating antimicrobial resistance to high-level visibility and establishing a national governance mechanism is an important first step, and a monitoring and evaluation system should be developed in parallel with implementation. Securing funds is crucial. Policy coherence is needed to avoid duplication of actions. Highly ambitious goals, although yet to be achieved, can advance actions beyond expectations. Political commitment and collaboration across different sectors will continue to play important roles but might not be sustained without a well-designed governance structure to support long-term actions to address antimicrobial resistance.
One Health approach. This mechanism aimed to bring technical issues on antimicrobial resistance into the political arena by establishing a national policy committee on antimicrobial resistance. The committee serves to take forward high-impact policy initiatives on antimicrobial resistance in a coordinated manner among the responsible agencies.
Second, a scientific platform was developed to generate evidence to guide policy development, implementation and monitoring. Previously, only fragmented data on antimicrobial resistance and antimicrobial use were available for the human, livestock and food sectors, with limited or no data on the aquaculture, plant, companion animal and environment sectors. 13 During 2017-2021, antimicrobial resistance was listed as a priority area in the WHO country cooperation strategy for Thailand. This cooperation strategy utilizes a pooled funding mechanism and leverages the social and intellectual capital of country cooperation strategy partners in developing the required monitoring and evaluation systems and generating the evidence needed to support the plan. 10,16 We outline here the progress and challenges of implementing Thailand's national strategic plan on antimicrobial resistance from 2017 until the middle of 2021. We also discuss interim outcomes and share lessons learnt.

Progress and challenges
Surveillance system Strategy 1 of the national strategic plan was to establish an antimicrobial resistance surveillance system under the One Health approach (Box 2). Thailand has been able to strengthen its existing antimicrobial resistance surveillance systems (such as in the human, livestock and food sectors) and has developed new surveillance systems, for example, in aquaculture and the environment. A key achievement is the establishment of a national integrated surveillance of antimicrobial resistance network led by the health, agriculture and environment ministries. Our team developed new standard protocols on antimicrobial resistance surveillance to monitor the prevalence and relationship of targeted bacteria across the human, livestock, aquaculture, food and environmental sectors (Fig. 1). Staff from different ministries have provided technical and facility support to overcome the limitations of the microbiology laboratories in the network.
In the human sector, antimicrobial resistance surveillance systems are complex because each existing system has its own organizational mandate. Developing a new system to capture antimicrobial resistance morbidity could have generated additional workload and created another separate system. Instead, we redesigned the data flow of these existing surveillance systems to form a data pool for analysis (Fig. 1).
We learnt that modifying antimicrobial resistance surveillance systems and synchronizing the data is difficult when these systems are established independently by each agency (such as in hospitals). However, data fragmentation can be prevented or mitigated in surveillance systems that are newly developed or have not yet been fully established (such as those in non-human sectors).

Regulation of distribution
Strategy 2 of the national strategic plan was the regulation of antimicrobial distribution (Box 3). Government legislation in Thailand allows antibiotics to be dispensed by a licensed pharmacist without a prescription. 18 Unfortunately, this arrangement cannot safeguard antibiotic use effectively because people can easily gain access to a wide array of antibiotics including critically important antibiotics. 19 Thus, antibiotic reclassification was prioritized as the first step to controlling antibiotic distribution. Antibiotic reclassification aims to ensure access to antibiotics when needed, while preventing excessive use of antibiotics by the general public that may accelerate antimicrobial resistance. 20 Under this principle, several antibiotics should be reclassified as prescription-only drugs, while some would remain as pharmacist-dispensed drugs.
Major challenges to the change were objections from pharmaceutical companies and retailers who feared reduced profits from sales, disagreements among health professionals, and patients' concerns that they might not be able to access antibiotics or need to pay for doctors' fees to obtain access to antibiotics. 20 After examining Thailand's failed attempt to reclassify antibiotics in 2016 and taking into account the scientific, economic and societal concerns, 13 we developed an antibiotic reclassification algorithm to provide clear explanations for relevant stakeholders. Reclassification is still ongoing, with some initial successes.
Meanwhile, we developed the system for surveillance of antimicrobial consumption to monitor trends of antimicrobial consumption in humans and animals. 11 The current system captures data at the national level so it needs to Box 1. Two strategic foundations for implementing Thailand's national strategic plan on antimicrobial resistance 2017-2022

Establishment of a national governance mechanism
Thailand's national policy committee on antimicrobial resistance (chaired by the deputy prime minister) is a high-level, multistakeholder steering panel from government agencies, professional organizations, civil society organizations, private sector and academia aiming to steer and lead high-impact policy on antimicrobial resistance. Five subcommittees under the National Policy Committee on antimicrobial resistance were appointed to supervise and guide the implementation of individual strategies. A strategic coordinating group consisting of secretary teams, experts and relevant partners provides a horizontal mechanism for coordination across the plan.

Development of a scientific platform to generate evidence to guide policy
Antimicrobial resistance is one of six priority programmes in the World Health Organization (WHO) country strategy for Thailand, 2017-2021. The programme pools funds provided by the public health ministry, the Thai Health Promotion Foundation, the National Health Security Office, the Health Systems Research Institute and WHO Thailand. 10 The programme serves as the scientific arm of the National Policy Committee on antimicrobial resistance and is overseen by Thailand's Food and Drug Administration together with the Health Intervention and Technology Assessment Program Foundation mutually. Each year, the programme provides grants for several projects linked to Thailand's national strategic plan on antimicrobial resistance. Key research partners include, but are not limited to, the International Health Policy Program, agencies from the public health ministry, the agriculture and cooperatives ministry and academia. Essential evidence generated through the programme includes baseline data of the national goals; 11,12 the midterm review of implementation of Thailand's national strategic plan on antimicrobial resistance; 13,14 and a study on mapping and prioritizing antimicrobial resistance research. 15 Monitoring and evaluation systems include Thailand's system for surveillance of antimicrobial consumption to monitor consumption and distribution of antimicrobials for human and animal use. 11 National strategic plan on antimicrobial resistance, Thailand Nithima Sumpradit et al.
expand its scope to capture antimicrobial use in hospitals, clinics, pharmacies and farms.

Resistance control in the human sector
Longstanding policy support by the health ministry and two public organizations responsible for universal health coverage and for hospital accreditation 21-23 means that Thailand has been able to reduce the rates of unnecessary use of antibiotics in ambulatory care settings. 23 An important element of these policies was derived from the Antibiotic Smart Use project -an action research initiative to promote rational use of antibiotics introduced in 2007 by Thailand's Food and Drug Administration. 24 However, although antimicrobial resistance in the inpatient setting is more serious and complex, the topic has previously received inadequate policy support. Thus Strategy 3, infection prevention and control and antimicrobial stewardship, was an important component of the national strategic plan (Box 4).
We have created a systems-based, integrated approach to addressing antimicrobial resistance in hospitals (Fig. 2). 25 The initiative requires organizational leadership with a strong governance mechanism to guide strategic, evidence-based actions to reduce antimicrobial resistance-related morbidity across disciplines, focused on infectious disease doctors, infection control nurses, clinical pharmacists and microbiology laboratory staff. Starting in 2018, the initiative has been launched in 121 government hospitals. 13 Along with the development of an assessment tool for the systems-based, integrated antimicrobial management in hospitals, the initiative is currently being scaled up nationwide. However, the rate of roll-out of integrated antimicrobial resistance management has not yet fully matched Box 2. Antimicrobial resistance surveillance system: Strategy 1 of Thailand's national strategic plan on antimicrobial resistance 2017-2022 Strategy Antimicrobial resistance surveillance system using a One Health approach.

Achievements
• Establishing a national integrated surveillance network of antimicrobial resistance under the One Health approach. The process was led by the public health ministry, agriculture and cooperatives ministry and natural resources and environment ministry. The strategy aimed to standardize and harmonize antimicrobial resistance surveillance protocols across the human, animal, food and environmental sectors. The first report on integrated surveillance of antimicrobial resistance under the One Health approach was planned for 2022. • Strengthening the capacity and network of microbiology laboratories in the human, animal (livestock and aquaculture), food and environmental sectors. • Implementing antimicrobial resistance surveillance of extended spectrum β-lactamase Escherichia coli under WHO's Tricycle project. This project encourages countries to build national integrated, multisectoral surveillance systems for antimicrobial resistance using extended β-lactamase producing E. coli as a simple indicator in the human, food (animal) and environmental sectors. • Implementing the WHO global antimicrobial resistance surveillance system in 10 hospitals as sentinel sites representing each health region. • Integrating antimicrobial resistance into surveillance of health-care-associated infections in hospitals.
• Generating a national epidemiological surveillance and response system of antimicrobial resistance, including antimicrobial resistance case reports for five important emerging antimicrobial-resistant pathogens. • Creating an antimicrobial resistance laboratory-based surveillance system as a prototype of a single-portal hospital database on antimicrobial resistance. • Improving the capacity for microbiology laboratory surveillance. • Strengthening epidemiological capacity on surveillance and response to important emerging antimicrobial-resistant pathogens by enhancing the skills of infection control nurses, physicians, pharmacists, laboratory technicians and public health officers. • Advancing Thailand's national antimicrobial resistance surveillance centre system. The aim was to illustrate the national and local patterns and trends of antimicrobial resistance antibiograms across 12 health regions and among hospitals and to allow for local comparisons. • Establishing a national surveillance programme for antimicrobial resistance in food-producing animals (such as broiler chickens and pigs).
Developing a framework for antimicrobial resistance surveillance.

Strengths
• Existence of a national antimicrobial resistance surveillance centre and a national surveillance programme for antimicrobial resistance in foodproducing animals. This structure serves to engage relevant microbiology laboratories to further advance antimicrobial resistance surveillance under the One Health approach. • Strong technical leadership in laboratory surveillance of antimicrobial resistance.

Challenges
• Fragmentation of databases within and across sectors. • Surveillance data on antimicrobial resistance and antimicrobial residues in the non-human sector can sometimes be sensitive as they relate to the economy. There is therefore a need to create mutual understanding across multiple sectors with different interests to facilitate data-sharing and creating an integrated surveillance of antimicrobial resistance under the One Health approach.

Ways forward
• Incorporating surveillance of antimicrobial residues and antimicrobial consumption as an integral part of the national integrated system of antimicrobial resistance surveillance under the One Health approach. • Developing a single portal for surveillance of antimicrobial resistance-associated morbidity in hospitals. WHO

Resistance control in the nonhuman sector
Strategy 4 of the national strategic plan is antimicrobial resistance prevention and control and antimicrobial stewardship (Box 5), which are relatively new areas of focus for the agriculture and animal sectors in Thailand. We have noted improvements in four main sectors: livestock (especially poultry and swine), aquaculture, companion animals and plants. In the livestock development sector, we focused key interventions on regulatory measures (for example, a requirement for a veterinarian to oversee the medicated feed production with antibiotics) and the initiatives under a public-private partnership (such as strengthening biosecurity and implementing the Raised without Antibiotics initiative 26,27 in swine farms). 13,27 These interventions are driven by Thailand's national strategic plan, together with global guidelines and standards. Fishery biologists, aquatic animal health professionals and veterinarians have jointly developed standards for aquatic animal disease control and prevention, and appropriate use of antimicrobials in aquaculture. The recruitment of veterinarians to the government fisheries department in 2018 was a starting point for Thailand to address antimicrobial resistance and antimicrobial use in the aquaculture sector. Containment of antibiotic use in plants shows slow progress since antibiotics are not legally registered for use in citrus or other plants. Thus, the government agriculture department considers that containment of antibiotic use in plants is beyond its authority. The department does however affirm the utilization of a traditional, non-antibiotic approach to address citrus-greening disease. 13 In the companion animal sector, an educational approach is a key intervention for promoting appropriate use of antibiotics by veterinarians.

Raising public awareness
Strategy 5 was to increase public knowledge on antimicrobial resistance and raise awareness of appropriate use of antimicrobials (Box 6). People often have misconceptions about antibiotics and may be unaware of the problem of antimicrobial resistance. 24 Past actions to address this issue were run by the food and drug administration and the drug system monitoring and development centre, a civil society organization funded by an autonomous government agency responsible for health promotion. However, addressing public knowledge requires collaboration among a wider array of stakeholders, especially nongovernment sectors such as civil society organizations. We therefore

Fig. 1. Changes to the antimicrobial resistance surveillance under the One Health approach in Thailand
Note: Before the national strategic plan on antimicrobial resistance, antimicrobial resistance surveillance covered only humans, animals and food, not the environmental sector. It is operated by the health ministry and the agriculture ministry without a coordinating mechanism. After the plan implementation, the health, agriculture and environment ministries successfully established an integrated surveillance network of antimicrobial resistance under the One Health approach. This network not only strengthens the laboratory capacity such as standardizing laboratory protocols, it allows cross-learning and enhances collaboration across different sectors working on antimicrobial resistance under the One Health approach.
National strategic plan on antimicrobial resistance, Thailand Nithima Sumpradit et al.
established a joint coordination mechanism among the health ministry and two autonomous government agencies that are responsible for health promotion and participatory public policy, respectively. Implementation is still at an early stage. Specifically, individual agencies have not yet fully integrated their actions or actively engaged other academic 29, 30 and civil society organization 31 networks to advance public awareness on antimicrobial resistance. Nevertheless, each agency uses their own networks that are distributed nationwide to disseminate antimicrobial resistance key messages to the public. A strong leadership with abilities to connect ideas to formulate innovative processes for solving complex problems is needed to harmonize agency actions.

Governance mechanisms
Strategy 6 involves governance mechanisms to ensure political leadership and concerted efforts are in place to sustain antimicrobial resistance-related actions (Box 7). This strategy serves as a national focal point in several ways. First, fragmented actions across agencies and sectors can be consolidated through the national governance mechanism and multisectoral collaboration (Box 1).
Second, the strategy links global and national policy and actions by working closely with the foreign affairs ministry. Third, the strategy allows progress to be monitored and challenges to be identified in the overall implementation of the national strategic plan and provides essential support and joint action to move specific strategies forward. Finally, by working with the WHO country cooperation strategy we can connect the antimicrobial resistance programme with research institutes and networks to provide technical support for implementation of Thailand's national strategic plan.

Box 3. Regulation of antimicrobial drug distribution: Strategy 2 of Thailand's national strategic plan on antimicrobial resistance 2017-2022
Goal 20% reduction in antimicrobial drug consumption in humans.

Strategy
Regulation of antimicrobial drug distribution.

Achievements
In the human sector: • Withdrawal from the market of inappropriate antibiotics (such as oral colistin and antibiotic lozenges for sore throat).
• Implementing the three-phase antimicrobial reclassification plan. Phase 1 was completed in 2019: antituberculosis drugs and all antibiotics for injection are now prescription drugs. Phase 2 is ongoing in 2021. This phase is the most difficult because it covers all oral antibiotics and affects a wide group of stakeholders such as pharmaceutical companies, pharmacies and patients. We developed a reclassification diagram to help the stakeholders to understand the criteria and procedures used in a reclassification process. The tool is based on local evidence and the World Health Organization Access, Watch and Reserve classification of antibiotics. 17 Phase 3, which covers antibiotics for topical use and external use, will follow in 2023.
In the animal sector: • Reclassifying penicillins, quinolones, cephalosporins, macrolides, polymyxins and medicated premix to be prescription-only drugs, for prescription by a veterinarian. • Resolving an ambiguity of medicated feed regulation. Previously, it was unclear whether production of medicated feed should be regulated under the Drug Act or the Animal Food Quality Control Act. Later, a decision was made that Thailand's Food and Drug Administration regulates medicated premix as a prescription drug under the Drug Act of 1967. The Department of Livestock Development regulates the production of medicated feed from medicated premix under the Animal Food Quality Control Act. • Prohibiting the use of antibiotics as growth promoters and the registration of antibiotics with an indication for growth promotion.
In the human and animal sectors: • Developing a surveillance system to monitor national consumption of antimicrobials for humans and animals. Initially a pilot project, the system is now integrated into the routine Food and Drug Administration system.

Strengths
• Existence of two foundation laws (the Drug Act and the Animal Food Quality Control Act) that enable ancillary laws to be issued to support Strategy 2 interventions. • Joint approach of Thailand's national strategic plan on antimicrobial resistance and the national drug policy. • Strong collaboration between Thailand's Food and Drug Administration and the Department of Livestock Development.

Challenges
• Resistance from opponents who disagree with antibiotic reclassification. • Risk of emergence of a black market to supply illegal antibiotics if new regulations to control antibiotic distribution are enforced while the demand for antibiotics is still high.

Ways forward
• Monitoring law enforcement and linking with Strategy 5 to improve public understanding about antimicrobial resistance and antibiotic use to ensure an effective implementation of the new regulation. • Identifying and monitoring the types and amount of human antibiotics that are used in the non-human sector.
• Extending the scope of Thailand's system for surveillance of antimicrobial consumption to capture antimicrobial use at facility level including hospitals, clinics, pharmacies and farms.
Policy & practice National strategic plan on antimicrobial resistance, Thailand Nithima Sumpradit et al.

Interim results
We have identified five interim results corresponding to the five goals of Thailand's national strategic plan on antimicrobial resistance.

Resistance prevalence
According

Strategy
Infection prevention and control and antimicrobial stewardship in humans.

Achievements
In ambulatory care settings: • Integrating the application of Thailand's Antibiotics Smart Use project for reducing unnecessary use of antibiotics in upper respiratory tract infection, acute diarrhoea and uncomplicated wounds. 24  In acute care settings: • Classifying health-care-associated infections as a communicable disease to be included in surveillance via Thailand's Communicable Disease Act.
• Endorsing the integrated antimicrobial resistance management initiative 25 as a framework to address antimicrobial resistance in hospitals.
• Establishing a national coordinating mechanism for the implementation of integrated antimicrobial resistance management in hospitals, led by the Department of Medical Services and the Office of the Permanent Secretary of Public Health. • Implementing the integrated antimicrobial resistance management initiative in 121 government hospitals. Developing a joint external evaluation tool for integrated antimicrobial resistance management in hospital as a supporting tool for government and nongovernment hospitals to address antimicrobial resistance effectively. • Updating the national guidelines on antimicrobial resistance surveillance and infection prevention and control. Developing an antimicrobial stewardship guideline and an evaluation tool for the integrated antimicrobial resistance management in hospitals initiative. Conducting training for health professionals such as doctors, infection control nurses, clinical pharmacists and microbiological laboratory staff. • Conducting a situation analysis on human resources required for addressing antimicrobial resistance in hospitals to explore the status, distribution and challenges of health professionals in hospitals, especially, infectious disease doctors, infection control nurses, clinical pharmacists, medical technicians and microbiological laboratory staff, and to propose policy recommendations to resolve challenges posed to human resources on antimicrobial resistance.

Strengths
• Existence of a strong health-care system with universal health coverage.
• Existence of strong networks of health professionals (infectious disease doctors, infection control nurses, pharmacists and microbiology laboratory staff ), health professional councils and organizations.

Challenges
• Suboptimal leadership at the national level for effective implementation of integrated antimicrobial resistance management in hospital.
• Delayed implementation of integrated antimicrobial resistance management in hospitals due to the COVID-19 pandemic.
• Insufficiency of health professionals in hospitals to address antimicrobial resistance due to inadequate incentives and career pathways.

Ways forward
• Specifying which antimicrobial-resistant pathogens need priority action.

Antimicrobial use in humans
Data from Thailand's working group on surveillance of antimicrobial consumption 11 indicates that during 2017-2019, antimicrobial consumption in humans increased by 20.9% (from 68.7 to 83.0 defined daily dose per 1000 inhabitants per day), 33 compared with the goal of 20% reduction. Potential explanations are twofold. First, there may be increased antimicrobial use in the human sector as indicated by the increasing trends of carbapenem-resistant Enterobacteriaceae. Second, human antibiotics are widely used in agriculture and companion animals (see Strategy 4) and the volume of their use remains unknown. To reduce antimicrobial consumption in humans, we need to accelerate implementation of the integrated antimicrobial resistance management in hospital strategy. To do this we need to strengthen the infection prevention and control and antimicrobial stewardship (Strategy 3); control antibiotic distribution (Strategy 2); and investigate the situation and ensure appropriate use of human antibiotics in the non-human sector (Strategy 4).

Antimicrobial use in animals
During 2017-2019, antimicrobial consumption in animals decreased by 49% (from 658.73 to 336.25 mg per population correction unit for Thailand), 33 exceeding the target goal of a 30% reduction. The success can be attributed to several factors. First, Strategy 4 focuses on large agricultural food production and processing industries that account for an estimated 70-80% of the market share in Thailand. Second, a new regulation requires a veterinarian to be present at factories to oversee the production of animal feed medicated with antibiotics before the feed is delivered to farms. This ruling prevents farmers from self-preparing medicated feed. Finally, the strategy generates a niche market for the food industry to provide alternative meat products to consumers, for example within the Raised without Antibiotics initiative. 27

Public awareness-raising
Thailand's national health and welfare survey 12 revealed a slight improvement in public awareness of antimicrobial re-sistance and appropriate use of antibiotics in 2017 and 2019 (from 23.7% out of 27 762 respondents 11 versus 24.3% out of 27 900 respondents, respectively). 33 This result reflects the need to accelerate an effective implementation of Strategy 5, especially to widen an array of stakeholders and harmonize their actions to avoid duplication of action and to communicate effectively with the public.

Country capacity
In 2017 we made a baseline assessment on country capacity to address antimicrobial resistance using the joint external evaluation tool for International Health Regulations (2005). 34 The results indicated that Thailand has a demonstrated capacity in antimicrobial resistance detection with laboratory-based surveillance; a developed capacity in infection prevention and control and surveillance of infections caused by antimicrobial resistance; and a limited capacity in antimicrobial stewardship activities including antimicrobial regulation. 35 In 2019, the Global Health Security Index ranked Thailand 22nd globally on antimicrobial resistance management. 36 We hope that the country's capacity on antimicrobial resistance management will reach the

Fig. 2. Integrated antimicrobial resistance management in hospital framework in Thailand
Source: Adapted from the subcommittee on reducing antimicrobial resistance impact in hospitals, 2019. 25 Policy & practice National strategic plan on antimicrobial resistance, Thailand Nithima Sumpradit et al.
national goal in the 2022 joint external evaluation assessment. 37

Lessons learnt
Four key lessons learnt are worth mentioning. First, elevating antimicrobial resistance to high-level visibility and establishing the national governance mechanism should be done at an early stage to galvanize and organize the multisectoral collaborations that lead to effectively consolidate actions under the One Health approach.
Second, the pace of implementation varies across organizations depending on how they prioritize antimicrobial resistance against other issues; how they perceive the relevance and ownership of Thailand's national strategic plan; and how capable they are of convening multipartner, multisectoral collaborations and embedding the strategic plan's actions into their workflow. Missing any of these factors impedes implementation.
Third, investment in building the monitoring and evaluation platform should go in parallel with implementation. Strenuous efforts are needed, especially for countries such as Thailand whose databases are fragmented or not in place. Notably, including the antimicrobial resistance programme within the WHO country cooperation strategy for Thailand makes the establishment of a monitoring and evaluation system possible even when the government fiscal budget is inadequate (and usually prioritized for interventions).
Finally, although Thailand's national goals may be over-ambitious, the

Box 5. Antimicrobial resistance prevention and control in agriculture and animals: Strategy 4 of Thailand's national strategic plan on antimicrobial resistance 2017-2022
Goal 30% reduction in antimicrobial consumption in animals.

Strategy
Antimicrobial resistance prevention and control and antimicrobial stewardship in agriculture and animals.

Achievements
In the livestock sector: • Prohibiting the use of antimicrobials as a growth promoter.
• Strengthening regulation on medicated feeds under the Animal Feed Quality Control Act 2015 that requires veterinarians to oversee the medicated feed production. • Improving the meat-processing systems under the Control of Animal Slaughter and Distribution of Meat Act 2016. • Partnering with farms and retailers on initiatives such as Raised Without Antibiotics 26,27 in 158 swine farms to provide alternative meat products to consumers. 27 In the aquaculture sector: • Promoting appropriate use of aquaculture drugs and chemicals, including antibiotics.
• Conducting a series of trainings for aquaculture farmers and regional staff of the Department of Fisheries to strengthen capacity on antimicrobial resistance containment and relevant regulations. • Investigating the amount of antibiotics used in aquaculture.
In the companion animal sector: • Developing the guideline for antimicrobial use for companion animals by Thailand's veterinary dean network, the veterinary council and the university network of One Health approach. • Investigating the types and amounts of antibiotics used in companion animals.
In crop production: • Conducting a situation analysis and studies on the effectiveness and impact of antimicrobial use in citrus-greening disease. Investigating antimicrobial residues in citrus fruits. • Promoting the implementation of the Good Agriculture Practice 28 in plantations to reduce inappropriate use of antimicrobials in food crop.

Strengths
• As a big production base for meat products, especially chicken, food industries in Thailand need to comply with international standards and guidelines such as those from the United Nations Food and Agriculture Organization, the World Organisation for Animal Health and the Codex Alimentarius Commission for food safety standards, as well as the policies of potential partners such as the European Union. This compliance creates an opportunity for improving the quality of meat production for export as well as for domestic consumption.

Challenges
• Policy and organizational leadership are required to encourage agencies to expand their roles to address antimicrobial resistance. Antimicrobial resistance is new for the non-human sector, especially for aquaculture, crop production and the environmental sector. • Despite not being approved by the Department of Agriculture, antibiotics such as ampicillin and amoxicillin are widely used by farmers to treat citrus-greening disease. Antibiotics provide an easier, quicker and cheaper method than the traditional method recommended by the Department of Agriculture (elimination of infected trees, removal of parts of the infected trees and control of vectors for the disease). This issue has not yet been resolved and potential alternatives for antibiotics have yet to be found for greening disease.

Ways forward
• Establishing national monitoring systems on antimicrobial consumption in aquatic animals, companion animals and crop production.
• Investing in research to find innovations and alternatives to replace or minimize the use of antibiotics in agriculture.
National strategic plan on antimicrobial resistance, Thailand Nithima Sumpradit et al.
goals stimulate actions that go beyond expectations. Indeed, discrepancies between the plan and reality are not unusual as the implementation phase often confronts with dynamic and unpredictable circumstances, not just the goals alone. Thus, we argue that goals that are measurable, despite being highly ambitious, can accelerate action and overcome limitations.

Challenges
Several major challenges can be noted. First, the current political commitment towards tackling antimicrobial resistance in Thailand seems to be weaker than in the development phase of the national strategic plan. The drift could be attributed to several reasons, 38,39 including the COVID-19 pandemic. To maintain political commitment, evidence-based policy communication including evidence of success 40 is essential to keep high-level leaders involved. Additionally, a country's active engagement with the global policy provides mutually positive momentum for global and national actions in addressing antimicrobial resistance. 9 Second, the current governance structure of the action plan on antimicrobial resistance is committee-based and therefore relies heavily on the secretary teams and a group of committed persons to drive the national strategic plan forward. Without a redesigned governance structure, the implementation process could be vulnerable to implementation fatigue or loss of skilful staff due to retirement or moving jobs.
Third, funding is available, but fluctuating. Implementation of the national strategic plan is mainly supported via the government fiscal budget and funding from donors. An example of secured funding from donors is the country cooperation strategy for Thailand for which WHO, the health ministry and three public health agencies agreed to contribute a non-earmarked, pooled fund for the antimicrobial resistance programme. In contrast, despite being a regular source, the government fiscal budget fluctuates annually because the budget allocation to projects depends on an agency's justification in different fiscal years. Thus, securing stable, adequate funds to support long-term efforts to address antimicrobial resistance is important.
Fourth, a problem of data fragmentation makes it difficult to obtain a comprehensive understanding of antimicrobial resistance and antimicrobial use within and across sectors. Progress in synchronizing relevant data has been noted (see Strategies 1 and 2) but long-term investment is still needed to advance and maintain the database alignment.
Fifth, the COVID-19 pandemic has had mixed effects. Large amounts of financial and human capital have been diverted to management of the pandemic, resulting in delayed implementation of Thailand's national strategic plan on antimicrobial resistance. In addition, in some countries the COVID-19 pandemic has increased the use of antibiotics in hospitals. 41 On the other hand, the pandemic strengthens infection prevention and control in hospitals and disease prevention in the community through mask wearing and hand cleaning. Fewer cases of respiratory infections in Thailand have been noted in 2020, 42 possibly leading to lower use of antibiotics. 43 However, further investigation of these findings is needed.
Finally, as a cross-cutting issue, antimicrobial resistance is related to other policies, such as food safety and national drug policy. Duplication of actions sometimes occurs. Policy coherence should be scrutinized to avoid duplication and to increase the efficiency of processes. 44 Additionally, global policy coherence is needed to support national actions. For example, our successful engagement with partners in the environmental sector may not be sustained if global policy in addressing

Strategy
Public knowledge on antimicrobial resistance and awareness of appropriate use of antimicrobials.

Achievements
• Applying a social marketing tactic to encourage the public to avoid taking antibiotics for colds and influenza. The method has been successful in anti-smoking and anti-alcohol campaigns in Thailand. A series of social marketing media developed by the Thai Health Promotion Foundation were broadcast via prime-time television, social media and moving advertisements on transport and reached 9.

Ways forward
• Rethinking and reframing implementation of the strategy to engage a wider array of stakeholders and to ensure actions are integrated.
Policy & practice National strategic plan on antimicrobial resistance, Thailand Nithima Sumpradit et al.
antimicrobial resistance in the environment remains conceptual, without concrete actions.

Ways forward
Thailand's national strategic plan on antimicrobial resistance successfully consolidates actions under the One Health approach. Significant progress can be seen but many challenges remain.
Interim results show success in reduction of antimicrobial consumption in animals. Nevertheless, long-term results need to be monitored. Contributing factors for success include political commitment, multisector collaboration, evidence-based policy guidance and allocated budgets. The impacts of emergent infectious diseases, as highlighted by the COVID-19 pandemic, need to be considered when addressing antimicrobial resistance in the future. In the next stage, we will be discussing the structure of the national governance mechanism, budgeting for the next strategic plan and engaging a wider group of stakeholders to maximize the impact of the plan. ■

Plan estratégico nacional de Tailandia sobre la resistencia a los antimicrobianos: avances y retos
La resistencia a los antimicrobianos es una grave amenaza que afecta a todos los países. El Plan de Acción Mundial sobre la resistencia a los antimicrobianos y la Declaración Política de las Naciones Unidas sobre la resistencia a los antimicrobianos establecen normas para que los países resuelvan los problemas de resistencia a los antimicrobianos en el marco del enfoque «Una única salud». Evaluamos los avances y los desafíos en la aplicación del plan estratégico nacional de Tailandia sobre la resistencia a los antimicrobianos 2017-2022, analizamos los resultados provisionales y compartimos las lecciones aprendidas. Entre los principales avances se encuentran: el establecimiento de un mecanismo de gobernanza nacional que lidera la política de alto impacto sobre la resistencia a los antimicrobianos y consolida las acciones y la colaboración multisectorial; la creación de un sistema de seguimiento y una plataforma para seguir la aplicación del plan estratégico; y la conversión de las estrategias del plan estratégico en acciones como el control de la distribución y el uso de antimicrobianos en humanos y animales. Los resultados provisionales indican que el consumo de antimicrobianos en animales se ha reducido casi a la mitad (superando el objetivo nacional de una reducción del 30 %), mientras que otros objetivos aún no han alcanzado sus metas. Hemos aprendido que elevar la resistencia a los antimicrobianos a una visibilidad de alto nivel y establecer un mecanismo de gobernanza nacional es un primer paso importante, y que debe desarrollarse un sistema de seguimiento y evaluación en paralelo a la implementación. Asegurar los fondos es crucial. La coherencia política es necesaria para evitar la duplicación de acciones. Unos objetivos muy ambiciosos, aunque todavía no se hayan alcanzado, pueden hacer avanzar las acciones más allá de las expectativas. El compromiso político y la colaboración entre los distintos sectores seguirán desempeñando un papel importante, pero podrían no mantenerse sin una estructura de gobernanza bien diseñada que apoye las acciones a largo plazo para hacer frente a la resistencia a los antimicrobianos.