Thailand achieved full population coverage of financial protection for health care in 2002 with successful implementation of the Universal Coverage Scheme (UCS). The three public health insurance schemes covered 98.5% of the population by 2015. Current evidence shows a high level of service coverage and financial risk protection and low level of unmet healthcare need, but the path toward UHC was not straightforward. Applying the Political Economy of UHC Reform Framework and the concept of path dependency, this study reviews how these factors influenced the evolution of the UHC reform in Thailand. We highlight how path dependency both set the groundwork for future insurance expansion and contributed to the persistence of a fragmented insurance pool even as the reform team was able to overcome certain path inefficient institutions and adopt more evidence-based payment schemes in the UCS. We then highlight two critical political economy challenges that can hamper reform, if not managed well, regarding the budgeting processes, which minimized the discretionary power previously exerted by Bureau of Budget, and the purchaser-provider split that created long-term tensions between the Ministry of Public Health and the National Health Security Office. Though resisted, these two changes were key to generating adequate resources to, and good governance of, the UCS. We conclude that although path dependence played a significant role in exerting pressure to resist change, the reform team's capacity to generate and effectively utilize evidence to guide policy decision-making process enabled the reform to be placed on a "good path" that overcame opposition.

Background Currently, various tools exist to evaluate knowledge and awareness of antibiotic use and antimicrobial resistance (AMR) and are applied by various organizations. Previous systematic reviews have focused mainly on study findings such as levels of knowledge and AMR awareness. However, the survey procedures and data instruments used ought to be scrutinized as well, since they are important contributors to credible results. This review aims to assess the study methods and procedures of existing population-based surveys and explore key components which determine the general population's levels of knowledge and awareness of antibiotic use and AMR. Methods We searched existing literature for population-based surveys which sought knowledge and awareness of antibiotic use or AMR in the general population. Databases searched included Ovid, MEDLINE and EMBASE, PsycINFO and Scopus, domestic journals and gray literature sources. Population-based cross-sectional studies published in English or Thai from January 2000 to December 2018 were included in the review. Quality assessment was conducted using the 'Appraisal Tool for Cross-Sectional Studies' (AXIS).

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Problem The challenge of implementing contributory health insurance among populations in the informal sector was a barrier to achieving universal health coverage (UHC) in Thailand. Approach UHC was a political manifesto of the 2001 election campaign. A contributory system was not a feasible option to honour the political commitment. Given Thailand's fiscal capacity and the moderate amount of additional resources required, the government legislated to use general taxation as the sole source of financing for the universal coverage scheme. Local setting Before 2001, four public health insurance schemes covered only 70% (44.5 million) of the 63.5 million population. The health ministry received the budget and provided medical welfare services for low-income households and publicly subsidized voluntary insurance for the informal sector. The budgets for supply-side financing of these schemes were based on historical figures which were inadequate to respond to health needs. The finance ministry used its discretionary power in budget allocation decisions. Relevant changes Tax became the sole source of financing the universal coverage scheme. Transparency, multistakeholder engagement and use of evidence informed budgetary negotiations. Adequate funding for UHC was achieved, providing access to services and financial protection for vulnerable populations. Out-of-pocket expenditure, medical impoverishment and catastrophic health spending among households decreased between 2000 and 2015. Lessons learnt Domestic government health expenditure, strong political commitment and historical precedence of the tax-financed medical welfare scheme were key to achieving UHC in Thailand. Using evidence secures adequate resources, promotes transparency and limits discretionary decision-making in budget allocation.

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