Global health governance: a case study of interactions ...

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GLOBAL HEALTH GOVERNANCE: A CASE STUDY OF INTERACTIONS BETWEEN

INTERNATIONAL ORGANIZATIONS, PUBLIC AND PRIVATE SECTORS, TOWARDS ADDRESSING

ANTIBIOTICS RESISTANCE IN THAILAND (2014 - 2017)

BY

MR. PUTTINANT RUNGSUNLOHAKUL

AN INDEPENDENT STUDY SUBMITTED IN PARTIAL

FULFILLMENT OF THE REQUIREMENTS FOR

THE DEGREE OF MASTER OF POLITICAL SCIENCE

IN INTERNATIONAL RELATIONS

FACULTY OF POLITICAL SCIENCE

THAMMASAT UNIVERSITY

ACADEMIC YEAR 2016

COPYRIGHT OF THAMMASAT UNIVERSITY

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Independent Study Title GLOBAL HEALTH GOVERNANCE:

A CASE STUDY OF INTERACTIONS

BETWEEN INTERNATIONAL

ORGANIZATIONS, PUBLIC AND PRIVATE

SECTOR TOWARDS ADDRESSING

ANTIBIOTICS RESISTANCE IN THAILAND

(2014 - 2017)

Author MR. PUTTINANT RUNGSUNLOHAKUL

Degree Master of Political Science

Major Field/Faculty/University International Relations

Faculty of Political Science

Thammasat University

Thesis Advisor DR. CHARLIE THAME, Ph.D.

Academic Years 2016

ABSTRACT

Antimicrobial Resistance (AMR) causes domestic health governance

challenges for Thailand in both the public health and agriculture sectors. The world is

moving toward a “Post Antibiotic Era” where a little infection can cause death.

Although we cannot eradicate AMR, the Global Action Plan on Antimicrobial

Resistance (GAP), launched by the WHO, FAO, and OIE, calls for “multisectoral

collaboration” in decreasing AMR rates and encourages states to develop and

implement their own national strategic plans. This study focused on cooperation

between domestic public and private sectors in the implementation of the GAP on

AMR in the agricultural industry in Thailand. Semi-structured interviews with high

ranking key informants and farmers were conducted to explore issues of cooperation

between the public and private sectors and the challenges posed in the domestic

implementation of the GAP. The results indicate that in Thailand the GAP has been

ineffective in the past because of inadequate knowledge of the consequences of

inappropriate use of antimicrobials and antibiotics in the private sector and among

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local farmers. The legislative system was in place but enforcement was ineffective in

the private sector, which sometimes cheated domestic law through intentional

misinterpretation of the law, and at times, bribing. This allowed them to use

antimicrobials and antibiotics more freely. Domestic law could be better enforced for

some particular actors, like some leading agro-industrial companies and their contract

farms. The role of the Thai state is to ensure that all stakeholders follow the National

Strategic Plan on AMR in domestic implementation to achieve a sustainable way to

reduce AMR in Thailand. This study suggests that the Ministry of Public Health

should engage more on countering AMR in the agriculture sector with private

agricultural industries, stakeholders, and farmers. Encouragement of Public and

Private Partnerships, strengthening domestic law to cover all AMR players, and

raising awareness of AMR in agriculture to local farmers, may pave the way to a

sustainable reduction of AMR from farms to forks.

Keywords: Global Health Governance, Antimicrobial Resistance, Antibiotic

Resistance, Domestic Implementation, Legislative System in Thailand

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ACKNOWLEDGEMENTS

This Independent Study became a reality with the assistance of many

individuals whom I would like to thank: Professor Dr. Chirayu Auewarakul, Deputy

Dean for International Relations, Faculty of Medicine Siriraj Hospital, Mahidol

University, for her great support in giving me an opportunity to further my study here

at the Faculty of Political Science, Thammasat University. I am deeply grateful for the

supervision, helpful support, and kind attention of Dr. Charlie Thame throughout my

dissertation. I would also like to express my special thanks to all key informants in

Antimicrobial and Antibiotic Resistance professions: Dr. Richard Brown; Program

Officer of Antimicrobial Resistance, World Health Organization (WHO) Country

Office; Dr. Wantanee Kalpravidh, Regional Manager, Food and Agriculture

Organization of the United Nations; Professor Chanwit Tribuddharat, Vice President,

International Collaboration National Science and Technology Development Agency

(NSTDA); Professor Visanu Thamlikitkul, Chairman of Clinical Epidemiology Unit,

Faculty of Medicine Siriraj Hospital, Mahidol University; and Dr. Damnoen

Chaturavittawong, Senior Vice President of Veterinary Service Department, Charoen

Pokphand Foods (CPF) Public Company Limited; and two CPF shrimp farmers and

two poultry farmers from Betagro for giving me very productive and insightful

information towards my research questions in the study. My study was supported by

the Siriraj Development Scholarship, Faculty of Medicine Siriraj Hospital, Mahidol

University, Thailand.

Last but not least, I am deeply appreciative of my family, friends, and

colleagues who always supported and encouraged me throughout my study at

Thammasat University. Foremost, I would like to dedicate my study to His Royal

Highness Prince Mahidol of Songkla who taught me through his motto that “True

success is not in the learning, but in its application to the benefit of mankind.”

Mr. Puttinant Rungsunlohakul

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TABLE OF CONTENTS

Page

ABSTRACT (1)

ACKNOWLEDGEMENTS (3)

LIST OF FIGURES (6)

CHAPTER 1 INTRODUCTION 1

1.1 Antibiotics Resistance 1

1.2 Antibiotic Resistance in Thailand: Why does it matter? 2

1.3 International & National Response to Tackling AMR

in Thailand: What have we done so far? 4

1.4 Significance of the Study 9

1.5 Research Objectives 10

1.6 Research Questions

1.6.1 Main Research Question 10

1.6.2 Sub Research Question 10

1.7 Hypothesis 11

1.8 Scope of Study 11

1.9 Analytical Framework 12

CHAPTER 2 REVIEW OF LITERATURE 15

CHAPTER 3 RESEARCH METHODOLOGY 20

CHAPTER 4 RESULTS 25

4.1 Global Action Plan (GAP) to Domestic Implementation 25

4.2 WHO’s Role on Antibiotics Resistance in Thailand 27

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4.3 FAO’s Role on Antibiotic Resistance in Thailand 29

4.4 OIE’s Role on Antibiotic Resistance in Thailand 32

4.5 Thai Public Sector’s Product: The National Strategic Plan on

Antimicrobial Resistance 34

4.6 Private Sector’s Role on Antibiotic Resistance in Thailand 38

4.7 Drugs Residues in Thai Shrimp: Voice from Farmers 43

4.8 Legislative System on AMR in Thailand 46

CHAPTER 5 DISCUSSION 49

5.1 Challenges faced in Countering AMR in Thailand 49

5.2 Discussion of the Refined Analytical Framework 55

CHAPTER 6 CONCLUSIONS AND RECOMMENDATIONS 59

6.1 Conclusions 59

6.2 Recommendations 61

6.2.1 Pay more Attention to the AMR from the Agriculture Side 62

6.2.2 Encourage Best Practices through Public and Private Partnerships

(PPPs) 62

6.2.3 Strengthen the Domestic Law to Cover all AMR Players 63

6.2.4 Improve AMR Awareness in Farmers 63

REFERENCES 65

APPENDICES 72

APPENDIX A 72

APPENDIX B 74

BIOGRAPHY 75

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LIST OF FIGURES

Figures Page

1.1 Antimicrobial Resistance Global Report on Surveillance 2014 9

1.2 Process of Global Health Governance and International Standard 12

of Domestic Implementation

4.1 National Strategic Plan on Antimicrobial Resistance 2017-2022, Thailand 36

5.1 Antimicrobials Distribution in Stakeholders Value Chain 50

5.2 Joint Pre-Assessment of the Public Health 53

5.3 Impact of Antibiotic Use in Food-Producing Animals 54

5.4 The Multisectoral Framework of Global Health Governance in

Antimicrobial Resistance: the case of Thailand 56

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CHAPTER 1

INTRODUCTION

1.1 Antibiotics Resistance

Antibiotics are a type of antimicrobial medicine used to stop and treat bacterial

infections. Antibiotics were accidentally discovered when “penicillin” was identified

by Sir Alexander Fleming on September 3, 1928. The antibiotic was mass produced

and utilized during World War II. It was able to eliminate all infections from bacteria

that were triggered among the troops. At that time, penicillin was called a “wonder

drug” and in the same year, Fleming and his colleagues, Howard Florey and Ernst

Chain, were awarded the Nobel Prize for Medicine. Post-1945 was the era of

antibiotics.

Antibiotics became popular and were used by people around the world after

the so called “Pre Antibiotics Era”. However, over consumption or improper use of

antibiotic medicine can cause harm to patients. If a bacterial infection becomes

resistant to antibiotics it will lead to illness complexity and make the germs harder to

kill or lead to Antimicrobial Resistance (AMR). When a particular antibiotic does not

cure newly emerged diseases, patients necessarily revisit a hospital to find a stronger

more expensive antibiotic medicine to kill the germ. This leads to longer treatments

and costlier bills for both patients and governments, who support medical coverage

for patients. According to the World Health Organization (2016), “microorganisms

that develop antimicrobial resistance against stronger medicine and become difficult

to kill can be called “superbugs”. As a result, this leads to higher treatment fees,

longer stays in a hospital, and higher mortality rates. The antibiotic resistance problem

is becoming international concern because it causes an economic burden and

decreases life expectancy in affected countries. The world is now entering a so called

“Post Antibiotics Era” - a period when a number of infectious diseases become

stronger, unresponsive and difficult to kill by using antibiotic drugs. The term Post

Antibiotics Era was firstly coined by Dr. Keiji Fukuda (WHO, 2014), WHO’s

Assistant Director-General for Health Security, explaining that the globe will be

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moving towards the Post Antibiotics Era if there is no urgent and collective action

from stakeholders. In addition, according to Professor Timothy Walsh from the

University of Cardiff, when the resistance spreads from key antibiotics producers like

China to other countries in Asia, a new mutation of the resistance can emerge, such as

when E. coli meets Pseudomonas aeruginosa (Gallagher, 2015). Professor Walsh

ended his interview with BBC (Gallagher, 2015) by contending that: "At that point if

a patient is seriously ill, say with E. coli, then there is virtually nothing you can do."

This happened because of the imbalance between the production of new invented

antibiotics and the emergence of new diseases, such as a new type of Tuberculosis

(MDR-TB) or the famous mobilized colistin resistance (mcr-1). Moreover, in many

countries, people can buy antibiotics without a prescription by the doctor. This often

leads to incorrect or unnecessary antibiotic use and this makes it easy for bacteria to

develop into multidrug-resistance. Antibiotic resistance is much worse outside

Europe. The antibiotics used in developing countries are often substandard or even

fake. To save money, many patients do not take the full course of antibiotics. As a

result, the bacteria causing their infection are not completely killed. The surviving

bacteria adapt and become resistant to the antibiotic.

1.2 Antibiotic Resistance in Thailand: Why does it matter?

In Thailand, Fredrickson (2017) reported, that there are 100 people dying

every day from antibiotic resistance, worse than all of Europe and up to 38,000 Thais

could be dying from antibiotic resistance bacteria because of overuse, dismissing

prescriptions and the prevalence of the drugs in food and the water supply. Moreover,

the stronger medicine which is needed is more expensive. For example, 15 grams of

Carbapenems cost around 30,000 TH Baht, more expensive that 1 Baht of gold in

today’s market. According to the study by Assistant Professor Direk

Limmathurotsakul, Head of Microbiology at Mahidol Oxford Research Unit (MORU)

(Lim, n.d.), national spending for treating AMR patients is increasing and “the

proportion of multidrug-resistant bacteria found in patients is increasing and that the

burden of antibiotic resistance in Thailand is deteriorating over time”. Professor

Limmathurotsakul also highlighted that Antibiotic Resistance is not only a national

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problem anymore, but it impacts the population on a global scale in terms of national

prosperity, world economics, and world life expectancy.

Thailand is the world’s fourth ranked broiler meat (poultry) exporter.

According to the United States Department of Agriculture, over 710 Metric Ton of

broilers have been exported in 2017, with a positive continuing growth rate of 5.97 %

(Indexmundi.com, 2017). In order to export such a mass production of broilers,

Thailand reasonably relies heavily on private agricultural firms. One way or another,

antibiotic medicine has been used as a “growth promoter” in feed supplements to

accelerate the growth of chickens, cattle, and swine, to maintain the number of

exports. As a result, the private sector gains a lot of profit every year. Another reason

many private industries continue to give antibiotic medicine to food-producing

animals is because they want to keep their animals healthy before selling. For

instance, the Pew Campaign on Human Health and Industrial Farming (2016)

explained that “antibiotics and other antimicrobials (drugs that kill microorganisms

like bacteria) often are routinely given to food animals in the U.S. in order to grow

animals faster and to compensate for unsanitary conditions on many industrial farms.

Bacteria exposed to antibiotics at low doses for prolonged periods can develop

antibiotic-resistance—a dangerous trait enabling bacteria to survive and grow instead

of being inhibited or destroyed by therapeutic doses of a drug.” Therefore it can be

seen that antibiotic medicines have been injected into healthy animals in order to

prevent illnesses rather than to treat the illnesses. Research has (Boonyasiri et al.,

2014) found that the prevalence of AMR in daily life is in limbo. The study showed

that Escherichia coli (E. coli), one of the most dangerous and difficult germs to kill

and one which can cause intestinal infection in humans and lead to severe diarrhea

and kidney failure, was detected among healthy food-animals, pigs (76.7%) and

poultry (40%).

Apart from the Thai poultry industry, there are also a number of antibiotics

used in seafood and fresh water animals for selling. Most recently, (Yee, 2017) it was

shown that seafood products from Thailand have been banned by neighboring

countries as it was contaminated with antibiotics. Moreover, more than one hundred

catfish farms were found to be using antibiotics as a Growth Promoter (AGP),

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according to a report in Tuoi Tre News portal “One of the antibiotics detected

included colistin, which can damage kidneys.” (Yee, 2017). In June, 2016, one of the

Thai aquatic firms, Narong Seafood, was put on the U.S. alert list for having

detectable antibiotic strains in their shrimp.

Those pigs, poultry, and aquatic animals were processed by private agriculture

industries as food products and distributed to many convenient stores, creating a

contaminated food chain for consumers. For instance, in Thai society, people typically

buy fresh chicken from supermarkets near their home, thus, the contaminated meat

from farms spread easily throughout the community and people developed antibiotic

resistance without knowing it. Antibiotic Resistance deriving from animals used as

food has become a silent killer impacting Thai meat consumers.

1.3 International & National Response to Tackling AMR in Thailand: What have we done so far?

The World Health Organization (WHO) was founded in 1948 in Geneva (HQ)

with six regional offices, responsible for leadership, coordination, partnership,

research & development, knowledge & information sharing, standards setting,

institutional support, monitoring and evaluating state practices on public health issues

worldwide. Dr. Maureen Birmingham, WHO Representative to Thailand and

Professor Dr. Samlee Plianbangchang, Regional Director, WHO Regional Office for

South-East Asia (SEARO), highlighted the consequences of antimicrobial germs in

mitigating mortality, morbidity and misery produced by communicable diseases.

WHO/SEARO, with the intention of reducing AMR at the country level, has come up

with a strategic plan, which is simple to put into practice and to scale up. At the 63rd

session of the SEARO Committee meeting, a strategic solution was adopted which

focuses on prevention and containment of the AMR. In the “Jaipur Declaration on

Prevention Antimicrobial Resistance”, SEARO’s Director declared progress must be

made and requested that all participants thoughtfully generate a mechanism for the

containment of AMR, at the country level, and the implementation must be effective

and efficient. The ultimate goal is to reduce morbidity and mortality rates from AMR

infections and to preserve the effectiveness of antimicrobial agents. Later, on May

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(Global Action Plan on Antimicrobial Resistance, 2016)

• To improve awareness and understanding of AMR;

• To strengthen knowledge through surveillance and research;

• To reduce the incidence of infection;

• To optimize the use of antimicrobial agents; and

• To develop the economic case for sustainable investment that takes account of the

needs of all countries, and increase investment in new medicines, diagnosis tools,

vaccines and other interventions.

25th, 2015, the World Health Assembly agreed with all members concerning the

global action on handling the AMR problem and antibiotic resistance.

The five tactical objectives were given by the WHO (Global Action Plan on

Antimicrobial Resistance, 2016) as below:

The World Health Organization, the World Organization for Animal Health

(OIE) and the Food and Agricultural Organization (FAO) are intergovernmental

organizations that are tackling the problem of antibiotic resistance in agriculture,

environment, and livestock. The OIE (Finishers, 2016) commented that antibiotics are

given to animals in Thailand freely and it is not an important issue for veterinarians,

who control and prescribe them to farmers. According to a report by David Burch,

Former President of the United Kingdom’s Pig Veterinary Society on the

Antimicrobial Resistance in Asia (2016), “antibiotics in feed are used widely in

Thailand as an AGP.” He continued to say that antibiotics in Thailand are simply

accessible, affordable, and available. The private sectors are also considering the costs

and benefits of using antibiotics in the treating and prevention of infections and

increasing yields. The livestock raised by the private sector, which uses antibiotic

growth promoters (AGPs), becomes resistant to antibiotics in two ways (Vegad,

2016): first from the mutation of the genes, and second from the antibiotic resistance

of other germs. Dr. Vegad (2016), from the Department of Veterinary Pathology at

Jawaharlal Nehru Agricultural University, Jabalpur, India claimed that there are many

studies revealing the significant prevalence of superbugs coming from the routine

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utilization of growth promoters in private farming industries. As a result, humans are

at risk because they are consuming the resistant strains contaminating meat and

poultry that can be easily bought from stores.

In response, the OIE and FAO launched a plan to counter Antibiotic

Resistance in Asia, including Thailand. Their plan of action includes:

The solution of this problem seems simple; just tell the private sector to stop

adding Antibiotic Growth Promoters (AGP) to their animal feed. However, that is

easier said than done. Even though the private sector has been told by public

authorities, such as the Ministry of Public Health, the Ministry of Agriculture and

Cooperatives, the Department of Livestock, and the Department of Fisheries, acting

on the orders and action plans from the OIE and FAO, we are not seeing any

decreases in antibiotic contamination in meat and poultry. Antibiotic use in food-

animals by the farming industry rose by one percent from 2014 to 2015 (Lozanova,

2017). In 2001, almost thirty million pounds of antibiotics were used in livestock,

while around eight million pounds were used in humans. Therefore, there must be a

breakdown somewhere among three actors: International Organizations, the public

sector, or the private sector.

The prevalence of antibiotic resistance in livestock in ASEAN has caused a

huge negative consequence to the ASEAN economy and to human health security.

The study from the Faculty of Veterinary Medicine, Kasetsart University, Thailand

(Finishers, 2016)

• Improve awareness and advocacy on AMR and related threats

• Develop capacity for surveillance and monitoring of AMR and AMU

(antimicrobial use) in food and agriculture

• Strengthen governance related to AMU in food and agriculture

• Promote good practices in food and agricultural systems and

the prudent use of antimicrobials.

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(Archawakulathep et al., 2017) revealed that public health systems dealing with

monitoring and controlling in ASEAN countries are still highly diverse and require a

unifying action. National monitoring and control programs for AMR have not been

successfully established in most ASEAN countries and a regional-cooperative

program has yet to be set in place. The multi-drug resistance microorganisms in

animal-food products have risen dramatically in Thailand and in other ASEAN

member countries.

In Thailand the resolution of the superbug problem was initially launched by a

group of prime movers who have the motive, academic and social credit, and

leadership in dealing with AMR in 2011. The so called Thailand Antimicrobial

Resistance (AMR) Containment Program aimed to contain and prevent the emergence

and spreading of common or important AMR bacterial infections in Thailand. The

Thailand AMR containment program has been supported by the Thai Health

Promotion Foundation, Health Systems Research Institute (Thailand), Faculty of

Medicine Siriraj Hospital, Government Pharmaceutical Organization, and

International Development Research Center (Canada) since 2012. However, the root

cause of the antibiotic resistance infection is not only a lack of social awareness, but

also from food and feed given to food-animals processed by private industries. The

food chain, which starts from animal feed to people’s mouths, directly and indirectly,

is transmitting the antibiotic resistance from industries to people. The actions taking

place in Thailand have been primarily focused on creating social awareness and

educating people about the use of antibiotics while visiting hospitals, not the foods

they are consuming every day.

Furthermore, it has been found that Thai public authorities have made little

effort to counter this cause (agricultural cause) in comparison to the first cause of

antibiotics (medicinal cause). According to Yee, (2016), “Thailand's Food and Drug

Administration, as well as the Department of Livestock Development, have not

responded to requests for interviews on antibiotics in livestock and aquatics animals.”

An effort to control the use of antibiotics in animal feed has been introduced by the

Ministry of Agriculture and Cooperatives of Thailand since 1999, under the Animal

Feed Quality Control Act B.E. 1982, banning several antimicrobial medicines, such as

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avoparcin, niltrovin, furazolidone, and more. Later on, the Department of Livestock

Development amended the old Act to be the Animal Feed Quality Control Act B.E.

2558 (2015), clarifying terms of animal feed, more regulations on special controlled

animal feed, requisitions for quality certificates, and restrictions on Antibiotics as

Growth Promoters (AGP). Nevertheless, the prohibition of antibiotics/antimicrobial

substances used in animals did not start in the updated Act, creating an opportunity

for private agricultural industries to exploit this gap of unclear and vague laws to

utilize antibiotics in animals for the prevention of illness. Although, there are some

farmers in Thailand who have acknowledged the banning of the use of antibiotics as

growth promoters (AGP), there are still gaps of knowledge on where and how AGP

can be utilized correctly on their farms. This problem is also associated with social

awareness, which the Food and Agriculture Organization (FAO) and Thai Public

Authorities are taking on. Moreover, the Review of Evidence on Antimicrobial

Resistance and Animal Agriculture in Developing Countries (Grace, 2015) revealed

that “Antimicrobial-resistant infections currently claim at least 50,000 lives each year

in Europe and the US (Laxminarayan et al., 2013) and some estimate that drug

resistant infections will cause 10 million extra deaths a year and cost the global

economy up to $100 trillion by 2050 (Review on Antimicrobial Resistance, 2014),

with most of the impact stemming from E. coli, malaria and tuberculosis (of these,

only E. coli resistance could be linked to agricultural use).” In Thailand, based on

data from 2010 (Phumart, et al., 2012), national spending on patients who get ill from

superbugs is approximately $200 million from antibiotic resistance treatment and

around another $1 billion from indirect costs due to superbug infections. The

Antimicrobial Resistance Global Report on Surveillance (2014) done by the WHO

also explained that the threat of antibiotic resistance can shrink consumer income,

employment, and their savings. Moreover, it increases the national burden on research

investment and healthcare delivery, i.e. universal health coverage in Thailand, and

lastly it decreased the nation’s Gross Domestic Product (GDP) from 3.6 to 3 percent.

The danger of antibiotic resistance from animal meat has become a silent

killer, in which many people have never noticed. It has become a huge national

economic burden nowadays.

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1.4 Significance of the Study

Antimicrobial Resistance (AMR) Infections are becoming a global threat. The

acceleration of globalization has brought infections from one country to another. The

review (King, 2014) on AMR done by Jim O’Neill revealed that there will be 300

million premature casualties and at least a $100 trillion loss to the world economy in

2050. Actions by an individual or a single country alone cannot diminish mortality

rate, eradicate infections, or bring back the overall wellbeing of a population.

Therefore, international cooperation and positive action between the public and

private sectors are essential. In Thailand, the plan tackling the superbug has already

been implemented. However, the Thailand Antimicrobial Resistance (AMR)

Containment Program, launched in 2011, was inadequate. It only focused on building

social awareness of proper medical usage of antibiotics, and neglected the fact that

the ultimate cause of the infection came from animal feed and animal medicine,

which have been utilized in livestock and then sold to people as food products by

the private sector within the food chain. The AMR problem in Thailand is no

longer only a problem for medical doctors or researchers trying to solve the issue, but

has now become a problem for policy makers, governments, and for students of

international relations to ponder. One of the root causes comes from a lack of

Figure 1.1: Antimicrobial Resistance Global Report on Surveillance 2014, (WHO, 2014)

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cooperation between the Thai public authorities and many private agricultural

industries. Thailand, as a developing country, has insufficient means to afford

necessary stronger antibiotic medicines and has started to further collaborate and

abide with orders from the WHO, OIE, and FAO. Thailand has committed to do all it

can to reduce and contain antibiotic resistant infections. However, when it comes to

domestic implementation, the cooperation between Thai authorities and private

agricultural industries is dysfunctional. This raises the question, what is wrong with

the cooperation between the Thai public sector and the private agricultural industry

within the architecture of the global action plan launched by the International

Organizations? 1.5 Research Objectives

The main objectives of this research are:

1. To study the relationship between the Thai public authorities and the private

sector on countering the Antibiotic Resistance problem in Thailand

2. To bring about possible and sustainable ways of making the private sector

cooperate with the Thai public authorities in order to decrease the Antibiotic

Resistance problem in Thailand

3. To contribute this research’s outcome to the Faculty of Medicine Siriraj

Hospital for healthcare development in Thailand, as a scholarship

commitment, and for the benefits of mankind

1.6 Research Questions

1.6.1 Main Research Question Why was the Global Action Plan to counter Antibiotic Resistance

launched by International Organizations ineffective in the case of Thailand?

1.6.2 Sub Research Questions

What challenges were faced in the implementation of the Global Action

Plan and in the coordination between the public and private sectors during the plan?

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1.7 Hypothesis

The lack of cooperation between the Thai public and private sectors made the

global action plan ineffective and this is because of the weak agricultural legislative

system in Thailand.

1.8 Scope of Study

According to the given introduction mentioned by the author, there are two

main causes of Antibiotic Resistance Infection. Firstly, the medicinal cause is made

by humans themselves, i.e. unnecessary and improper use of antibiotics. This problem

has already received much attention by the main global health institutions, like the

WHO and in the media. It has also been discussed thoroughly in many international

multilateral meetings concerning the best way to implement global action. Secondly,

the agricultural cause tends to receive less attention and it leads to the dilemma of

cooperation between the public and private sectors. Therefore, it would be better to

focus only on the agricultural cause and find a way to achieve effective cooperation

between the Thai public sectors and private agricultural industries.

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1.9 Analytical Framework

To explore the above hypothesis, the author developed an analytical

framework called “the Process of Global Health Governance and International

Standard of Domestic Implementation”. The author studied the case of Thailand,

starting from interactions between international organizations, to public and private

sectors, by looking at how the Global Action Plan to Counter Antibiotic Resistance,

launched by International Institutions, is implemented by member states through

domestic policy and law. The successful outcome of actions related to the plan would

be enhancing the wellbeing of the population.

Starting from the beginning, Antibiotic Resistance is a global threat. It can

spread to people directly, from the improper use of antibiotics, and indirectly, which

Figure 1.2: “the Process of Global Health Governance and International Standard

of Domestic Implementation”

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is the focus of the author, agriculture, livestock, and animal feed. When it becomes a

global threat, within the anarchic state system, there is no world government to tackle

this problem unilaterally. Neoliberal institutionalism points out that International

Institutions were established for states to use as a “platform” for collaboration,

cooperation, and coordination with each other to achieve their national interests. In

this case, the national interest is the protection of people and the reduction of infection

rates. International Organizations like the WHO, OIE, and FAO are formal

international organizations involved in human health dealing with antibiotic resistance

infection worldwide. The three involved institutions have led health agenda by

addressing the problem of resistance, coming up with the so called “Global Action

Plan to Counter Antibiotic Resistance” and encouraging states to perform a significant

role in tackling this problem domestically. The Global Action Plan was set up as an

“international standard” in which states needed to achieve in order to meet national

interests and maintain peace and security through the wellbeing of their populations.

States implement the plan domestically by prescribing a policy or law to be

enforced involving stakeholders. In this research, the author focused only on

antibiotics coming from livestock. The prevalence of antibiotic resistance strains in

poultry, cattle, and pork, stemming from animal feed being infused with antibiotics as

growth promoters (AGP), ensuring fast growth, more weight, and increased

productivity in the private sector. What the private sector has been doing is

reproducing a “silent killer”. It harms people’s health and will lead to a vulnerable

population, which will create an economic burden for the country. The longer

treatment, longer hospital stays, and higher costs of stronger antibiotics, will put strain

on the governmental universal healthcare.

Domestic implementation to achieve international standards has proved

successful in many countries. Denmark is the most successful country. With a strong

legislative system, all stakeholders agreed to ban Antibiotics as Growth Promoters for

food animals, e.g. swine, poultry, and fresh water fish. The term successful can be

defined as a decreasing rate of antibiotics in food animals and consumers with stable

productivity from the private sector. However, when the Global Action Plan was

implemented in Thailand, who is the world 4th broiler meat poultry exporter, the

domestic implementation went dysfunctional. Therefore, in this research, the author

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will try to use this analytical framework to identify what is wrong with Thailand’s

domestic implementation. This will include the relationship between the public and

private sectors and how well the outcome meets the international standards set by

international institutions.

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CHAPTER 2

REVIEW OF LITERATURE

The term Post Antibiotic Era, first coined by Dr. Fukuda from the World

Health Organization in 2014, reflects the notion that Antibiotic Resistance is not a

small problem that states can handle anymore. When antibiotic resistance reaches a

certain stage, a small infection during a simple minor surgery can cause death to the

patient. Nowadays, many people around the world have been infected by superbugs

directly and indirectly. Medical institutions are doing their job on research &

development, creating new antibiotic drugs to cure the antibiotic resistant ailments.

However, it is important to say ,“to prevent is better than curing”, thus, although

AMR is quite a new issue, there are a number of experts who try to find the linkage

between AMR and global health governance and come up with sustainable ways to

contain and decrease the infection numbers in their countries. The author’s angle

therefore focuses on the agricultural side in this study. In this review of the literature,

the author has elaborated more on the terms mentioned in the analytical framework to

assist readers to know how the terms have been related to the problem of antibiotic

resistance in Thailand.

Neoliberal institutionalism has been used to analyze the antibiotic resistance

from the starting point. Neoliberal institutionalism points out that the international

system is anarchic, just like neorealism. However, cooperation between states are

possible when there is no central government. States remain the key actors and act in

rational ways to pursue their own interests. However, institutionalist also emphasize

the role of non-state actors, e.g. international organizations, non-intergovernmental

organizations, multinational corporations, and the private sector. They cannot be

ignored, as they influence the state decision making process and the compliancy of the

state’s orders and norms. The State, as a public sector, still needs other actors to

contribute to state interest, thus the need for good collaboration with influential actors,

like the private sector, to achieve goals. In this context, the goal is meeting the

international standard set by international organizations. As globalization accelerates,

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so does the spreading of antibiotic resistance. States and other actors are in an

interdependent relationship in which they need collective action to counter the

problem. The process of cooperation and coordination is facilitated through key

International Regimes and Institutions. According to Professor Robert Keohane

(Keohane & Martin, 1995, p.45), institutions offer a coordinating mechanism to help

states capture potential gains from cooperation. Specific institutions also provide an

arbitrary body that is able to provide states with information preventing states from

cheating. Neorealism argues that anarchy leads to competition and conflict, but the

institutionalists make a counter argument, that the problems can be managed through

institutions as institutions play an assistant role for states in overcoming obstacles to

cooperation as states provide cooperative engagement with incentives (public goods)

or learn how to cooperate with each other (reciprocity). What institutionalists are

concerned with is non-compliance and cheating by states. Those are the greatest

obstacles to cooperation. Institutions encourage states to cooperate through

multilateralism and cooperation for securing national interests in order to manage the

globalization process and fix common problems.

Domestic implementation by states is a core component to achieving the world

health order launched by the Institution. Neoliberal Institutionalists’ Antibiotic

Resistance goal is to see coordination and cooperation between involved International

Organizations, the spearhead of the health agenda, state authority, and other partners,

like the private sector, to decrease the number of infections and to eradicate the root

causes of how people get infected by superbugs. Nowadays, there are more than 30

key institutions working on antimicrobial regimes under the umbrella of the United

Nations. However, achieving the world health order on Antibiotic Resistance is easier

said than done. There are many challenges. Global Health Governance does not

function well in many countries. It is difficult to convince the private sector to

comply. Public authorities of the state and other sectors are still concerned with the

benefits they are receiving from antibiotics, but are not concerned about how it will

impact human health in the long run. The potential gains from the interdependent

cooperation between public authorities and the private sector in relation to the Global

Action Plan on Antimicrobial Resistance (GAP), co-launched by three international

organizations, the WHO, FAO, and OIE, can be the well-being of people and the

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significant reduction of AMR. We can call this a win-win situation, where public

authorities can secure national health security for the state and gain recognition by the

international community on the state’s achieving of the international standard.

Furthermore, the private sector can regain positive images for companies, e.g. food

safety or bio-security, as well as international positive recognition. However,

cheating and non-compliance of stakeholders down the line on domestic

implementation can occur when they think they are not receiving appropriate or a

disproportionate amount of attention or benefits from the public sector. Moreover, the

policies launched by the world health order are focused too much on only one cause

of Antibiotic Resistance, causing insufficient knowledge and a lack of effort to

encourage governments to encounter the problem at the other cause, which is located

in agricultural industries and lies heavily in the private sector. Therefore, Neoliberal

Institutionalism helps us understand the problem and challenges we are facing right

now in the Antibiotic Resistance Era. Global Health Governance reminds all

involving key players to come up with a “real” effective and collective action to this

problem and aim for well coordination and cooperation between the antimicrobial

regime, public authority, and private sectors.

When Neoliberal Institutionalism is applied to the context of Global Health

Governance, health institutions, like the World Health Organization (WHO), play a

key role as a platform to coordinate and monitor new threats and any health concerns

for the global population. Other institutions, like the Food and Agriculture

Organization (FAO) and World Organization for Animal Health (the Office

International des Epizooties) (OIE) also have significant roles in pursuing the well-

being of a population. Health, for Neoliberal Institutionalism, can mean many things.

Health often links to development, economic reform, and the role of a state’s financial

institution. The WHO aims to establish peace through the wellbeing of populations. In

order to acquire a healthy population, a state must cooperate bilaterally or

multilaterally with another states or non-state actor, such as an IGO, NGO, or private

sector by having the Global Health Institution as a platform and follow the so called

“world health order”. The World Health Assembly, held by the WHO, is an example

where states cooperate with each other. They can promote and bring about a better

health system, budget allocation, and prevent the spread of diseases around the world.

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The members of the WHO must abide by the 1978 Alma Ata Declaration, which

states that urgent actions must be executed by governments, all health institutions,

health development companies, private sectors, and the world community to promote

wellbeing and protect health for all people. This became the so called “Health for All”

concept by the WHO later on.

In this review of the literature, the author has chosen two case studies on how

institutions responded to the problem. The two following case studies are different in

terms of the analytical framework, but they share one goal in common, which is

finding possible ways to reduce Antibiotic Resistance Infection caused by livestock.

Lastly, the review will end with a breakdown on how the analytical framework of the

author can help the author understand the research problem mentioned at the

beginning of the dissertation.

The first article, “Strategies for achieving global collective action on

antimicrobial resistance”, is by Professor Vegad from the Department of Veterinary

Pathology, Jawaharlal Nehru Agricultural University, India. Vegad (2016) highlights

that the overuse of antibiotics as a growth promoter (AGP) is a major threat to Public

Health and the wellbeing of a population because the resistant genes are

contaminating poultry and meat. That poultry and meat are consumed by humans and

resistance is transmitted to them. Vegad (2016) mentions numerous reports revealing

routine use of antibiotics by many private farms that promote antibiotic resistance.

AGP is routinely used even if the livestock is not sick to ensure fast growth and

increase the production. The reason they put AGP into the meat and poultry is it

increases the weight and makes production cheaper. As a result, people are at risk

from both treatment, when they are taking antibiotic medicines, and when they are

consuming meat and poultry. In the end of his research, Vegad concludes that the

remedy for this problem is quite simply to stop adding AGP to animal feed and

banning the use of AGP in the countries with high rates of Antibiotic Resistance

infections. He is convinced that the banning is quite effective as it has been successful

in the EU, who totally banned all antibiotic use in animals in 2006.

A second study, “Strategies for achieving global collective action on

antimicrobial resistance” by Steven Hoffman et al. (2015), points out that the problem

in achieving collective action on Antimicrobial Resistance (AMR) is the insufficient

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coordination, in terms of leadership and funding, between institutions and initiatives.

He describes how numerous institutions are pointing out the threat of AMR with

many strategies and initiatives, but all mandates launched by the institutions are not

aligned. Hoffman and his colleagues (2015) demonstrated that Antibiotics as a

Growth Promoter (AGP) is supported by state governments to maintain productivity

and increase exports. Moreover it can advance FAO objectives by improving weight

gain in farm animals, but the consequence is the AGP will indirectly harm human

health because it will contaminate meat and poultry. Hoffman concluded that the

solution of this problem is strengthening institutions and reforming three sets of

institutional functions: the decision making process, operational mechanisms in

finance, and to encourage the commitment of the members for compliance. Unilateral

options are also a solution suggested by Hoffman, which can be direct financing,

import / export bans, and sanctions as a penalty to a state that lacks specific policies

or fails to achieve certain goals.

These two articles have similarities and differences. They share the common

goal of reducing antibiotic misuse and pointing out the ultimate cause of the antibiotic

resistance comes from livestock production by the private sector. However, they are

also different in terms of framework and how they address the problem. There is no

existing study on the cooperation between the public sector and the private

agricultural industry under the global action plan launched by International

Organizations, like the WHO, OIE, and FAO. To fill the gap in the literature, this

dissertation will apply the analytical framework called “the Process of Global Health

Governance and International Standard of Domestic Implementation” to approach

Antibiotic Resistance in Thailand and try to find possible solutions to the problem and

answer the research questions.

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CHAPTER 3

RESEARCH METHODOLOGY

The research employed a qualitative method. The author analyzed the

relationship between Thai public authorities, namely, the Ministry of Health, Ministry

of Agriculture and Cooperative, Department of Livestock, and Department of

Fisheries and private agro-industrial companies, i.e. Charoen Pokphan Food Public

Company Limited, Betagro, and Narong Seafood, in order to understand their

interaction and coordination among them on countering the Antibiotic Resistance

problem in Thailand. Identify challenges facing them during the implementation of

the Global Action Plan (GAP) co-launched by WHO, FAO, and OIE was also

analyzed. Using the qualitative method allowed the author to broaden the network of

collaboration between players according to the author’s analytical framework, and

discover obstacles and challenges in each strand of the network causing ineffective

implementation. The author defined ineffectiveness of the GAP on AMR in Thailand

as when there is non-compliance or any cheating by stakeholders, i.e. the private

sector being non-compliant with the public authority by increasing the number of

AMR used in agriculture.

The author conducted fieldwork in May, 2017. The interview questions were

drafted by the author and approved by his advisor, Dr. Charlie Thame from the

Faculty of Political Science, Thammasat University in April. Being a semi-structured

interview, it allowed for flexibility and open-ended questions. The author circulated

the interview questions beforehand to allow key informants time to be well-prepared

for the questions. The interviews were systematically guided and conducted in the

language that the informants were comfortable with. The interviewees were asked

their permission for voice recordings, note taking, and to include their names in the

appendix of the report. All key informants signed the consent form provided by the

author before conducting the interviews. Emphasizing more on the informants, in the

AMR case, the author selected informants that had significant roles in organizations

related to the AMR scheme. Most of the key informants had high ranking positions

and were spearheads of AMR in Thailand. The author also conducted interviews of

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other key informants during the fieldwork, i.e. farmers and CP workers. Conducting

interviews of high ranking positions allowed the author to understand the overall

picture, policy, and system from the top to bottom. More importantly, conducting

interviews of farmers and fieldwork officers allowed the author to understand the

challenges and the effectiveness of the policy in practical terms.

In the elite interviews, the author contacted 5 important leaders in the AMR

scheme in Thailand. The semi-structured interview questions, which were sent to the

five beforehand, are discussed below:

1. How effective has the implementation of the Global Action Plan to

Counter AMR been in Thailand’s agricultural sector?

2. Can you explain the role of your organization in domestic implementation

of the Global Action Plan to Counter AMR here in Thailand?

3. Apart from your organization, have any other International Organizations

played significant roles in the reduction of AMR in Thailand?

4. As a matter of fact, the number of AMR patients in Thailand, as well as

the national spending on AMR treatment, are increasing according to the

WHO Global Report on Surveillance. Do you think the Global Action Plan

in functioning well in Thailand? If so, why? If not, why not?

5. Do you think domestic implementation efforts regarding on the eradication

of Antibiotic strain in food-animal such as poultry, swine, and aquaculture

of Thai public sectors are sufficient?

6. Who should be held responsible on the contamination of antibiotics

resistance in food-animals in Thailand and why?

7. In your point of view, what are the main challenges faced by Thailand

countering AMR?

8. What is your opinion of the capacity of Thailand’s legislative system to

effectively prevent stakeholders from using antibiotic drugs in food-

animals?

The first respondent is Dr. Richard Brown, Program Officer of Antimicrobial

Resistance, WHO Country Office, Thailand, who has been involved in AMR in

Thailand for over 15 years. The information from Dr. Brown supported the author in

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understanding the overall picture and working mechanism of AMR management in

Thailand, especially in the Global Action Plan and the effort Thailand is coming up

with concerning the National Strategic Plan on AMR. Dr. Brown focused heavily in

Medicine and Public Health. Interviewing Dr. Brown also paved the way to the main

focus of this dissertation, which is AMR being caused by the agricultural sectors. Dr.

Wantanee Kalpravidh, the Regional Manager of FAO country office, was interviewed

by the author after Dr. Brown’s recommendation. Dr. Kalpravidh has been playing a

leading role on countering AMR in agriculture since 2004. The scope of the FAO

covers three factors of AMR in Thailand, i.e. food animals, feed, and environment.

The interview provided a great source of information on both the main and sub-

research questions for the author. Regarding the public sector, the author conducted

an elite interview with Professor Chanwit Tribuddharat, Vice President of

International Collaboration National Science and Technology Development Agency

(NSTDA). Prof. Tribuddharat is a former Assistant Dean for International Relations at

the Faculty of Medicine Siriraj Hospital and he has worked as a microbiologist

involved in AMR in Thailand, focusing on antibiotic resistance contamination in

animal meats, i.e. poultry and shrimp for over 10 years. Another key public sector

interviewee, who spearheads the combating of AMR in Thailand, is Professor Dr.

Visanu Thamlikitkul, Chair of the R&D Committee on Anti-microbial Resistance

Prevention & Control System under the Steering Committee on Drug System R&D,

Health Systems Research Institute (HSRI), and the Ministry of Public Health.

Interviewing Prof. Thamlikitkul allowed the author to learn about and understand the

progress of the so called National Strategic Plan on Antimicrobial Resistance (NSP-

AMR), which is the core domestic implementation plan aligned with the Global

Action Plan launched by the WHO, FAO, and OIE. Prof. Thamlikitkul also gave the

author helpful information regarding the cooperation dilemma between the public and

private sectors and the role of the legislative system in constraining the private

sector’s compliance with the NSP-AMR. For the private sector, the author conducted

an elite interview with Dr. Damnoen Chaturavittawong, Senior Vice President,

Veterinary Service Department of Charoen Pokphand Foods Public Company Limited

(CPF) to understand the big picture of the role of the influential private sector on

domestic implementation related to AMR in agriculture. The interview also

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highlighted challenges posed during implementation as well as to what effort is being

made to follow the plan requested by the public authorities. All elite interviews were

conducted mannerly in a very formal setting.

Apart from elite interviews, the author conducted interviews with working

people in the field in order to understand the practical reality of implementation. Two

CPF shrimp farmers and two poultry farmers from Betragro were interviewed to

understand operations inside the farms; both company farming and contract farming.

Moreover, two local farmers were interviewed to understand the basic knowledge

they have on antibiotic resistance in agriculture. The interview questions for working

people and local farmers are listed below:

1. Can you tell me about your role in this organization and what companies

this organization conducts business with?

2. Have you used antibiotic medicine on shrimp here? Why ?

3. To what extent is the feeding procedure controlled by the companies you

contract with?

4. What are the consequences of feeding antibiotic medicine or any growth

promoters to the shrimp? Are you aware that it can cause antibiotic

resistance and will spread to consumers?

5. Are you aware of the ACT of Animal Feed Quality Control law 2015?

6. Do you think is it possible to feed animals and maintain productivity of the

business without using antibiotics?

In addition, primary sources were also collected by the author: two of the

important primary resources were the Global Action Plan launched by the WHO,

FAO, and OIE, and the National Strategic Plan on Antimicrobial Resistance by the

Ministry of Public Health, Thailand. The first two primary sources were very

important to the author because it allowed the author to know and understand the

global effort of combating AMR and how it aligned with the national strategic plan by

the Thai MOPH. The author also collected information from the WHO, FAO, and

OIE official websites, spectrums suggested by the author’s advisor on the drug

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residue crisis between the private sector and the United States Foods and Drugs

Administration (USFDA), and a fact sheet of current export trends in Thailand from

reliable media.

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CHAPTER 4

RESULTS

4.1 Global Action Plan (GAP) to Domestic Implementation

The Global Action Plan is a project initiated by a tripartite collaboration

between the World Health Organization (WHO), Food and Agriculture Organization

of the United Nations (FAO), and the World Organization for Animal Health (OIE),

published in 2015. The GAP is a framework for member states to implement their

own domestic implementation. It could be forming new policies towards AMR, new

legislative systems, or even an adaptation to a state’s national plan. The GAP is

ensured to cover both medical and agricultural causes of AMR as five core objectives

were set to be followed. The GAP strongly recommends an action for member states

to follow. States might implement the following actions according to the plan: take

urgent action to address acute AMR problems like infection control in hospitals,

increase education and prevention of infection as a priority, develop national policies

or plan and set standard practices for every stakeholder to follow, and strengthen the

animal health and agricultural practices through the guidelines of the OIE (OIE

Terrestrial and Aquatic Animal Health Codes) and FAO/WHO (Codex Alimentarius

Code of Practice to Minimize and Contain Antimicrobial Resistance). The WHO

strongly stressed the 21st point of the GAP to Thailand, which urged Thailand to come

up with a national plan conforming with the GAP (Global Action Plan on

Antimicrobial Resistance, 2015).

In the author’s point of view, the GAP is not functioning well in Thailand.

There continues to be increasing national spending by the government in AMR

treatment as well as an increase in the number of AMR infections in Thailand.

However, this might not be totally correct. The World Health Organization Country

Office argued that it is too early to claim that the GAP plan is ineffective. The country

office has said that Thailand now has good AMR surveillance system technology.

This allows the Ministry of Public Health of Thailand access the facts and figures of

AMR data. In countries that do not have a good AMR surveillance system there may

be an absence of data and they will report that they have no AMR infections. “When

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some countries start to look for it and take it seriously, they therefore improve the

surveillance system like Thailand and they will find it and realize it’s a big problem!”

(Brown, personal communication, March 22, 2017). Therefore, trending facts on

AMR must be carefully interpreted. The increase might be genuine, but some of it

might be just having a better surveillance system. Another reason for the increase in

national spending on AMR might reflect the prescription behavior in hospitals, not

only the expenditure effort to reduce AMR.

Dr. Richard Brown, the Program Manager of Antimicrobial Resistance and the

expert in Public Health Emergency in Thailand has been working in the AMR field

for over 15 years in Thailand. Brown explained the current situation of AMR has both

good and bad news. The good news is that nowadays partners are working toward the

new “National Strategic Plan on Antimicrobial Resistance” (NSP-AMR). In the past,

there were several plans being carried out, but they were it scattered and focused on

specific sides and there remained a gap to be filled. The Food and Agriculture

Organization (FAO) filled the gap of with the WHO by adding agricultural awareness

in the Global Action Plan as the 16th point of GAP, (Global Action Plan on

Antimicrobial Resistance, 2015). It indicated “the loss of effective antimicrobial

agents to treat sick animals damages food production and family livelihoods”. Brown

(personal communication, March 22, 2017) pointed out that AMR burdens humans

both physically and mentally and in the past there was no global guideline for a state’s

health policy. Today we have one and we need to support states in every possible way

to be compliant to the health policy.

Turning the attention to the bad news, interesting research on the use of

Antibiotics as Growth Promoters, funded by the WHO and USAID, has revealed new

threats for people. The research revealed (Boonyasiri et al., 2014) a new way of using

antibiotic pills in fruits by direct injection. In Chiang Mai, a local farmer injected

AGP into orange trees to increase citrus production. The farmer was caught by the

researcher and confessed that the antibiotic can increase their productivity and can be

easily bought from pharmaceutical companies. This also posed a new problem for

people working in AMR because they are not aware of it. Therefore, it is necessary

for Thailand to have its own national plan as requested by the WHO.

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4.2 WHO’s Role on Antibiotics Resistance in Thailand

Nowadays, the World Health Organization faces many obstacles and

challenges in their mission to sustain Global Health Security. Antibiotic Resistance is

an urgent problem that the WHO needs to address and implement its plan of action in

member states. According to Irwin, (2010) the WHO’s role is not only to offer

technical assistance for member states but also to make sure that states comply with

the health agenda made by the World Health Assembly (WHA). In order to do this,

the Global Action Plan needs to be transformed into a National Action Plan for

domestic implementation by member states.

Brown also explained Global Health Governance in Thailand. The WHO has

assigned the WHO Country Office in Thailand to set up specialized working group in

Antimicrobial Resistance. The country office is working closely with the Ministry of

Public Health, International Health Policy Program, Food and Agriculture

Organization (FAO), and USAID to come up with the sustainable reduction of AMR

in Thailand caused by both medical and agricultural misuse of antibiotics (Brown,

personal communication, March 22, 2017). The parties joined together to aid Thailand

by focusing on the generation of knowledge in Antimicrobial Resistance in terms of

medical, agriculture, and aquaculture. The WHO Country Office’s role in domestic

implementation of the GAP to counter AMR in Thailand can be characterized by the

Country Cooperation Strategy (CCS) framework – normally, a brand new framework

that covers 5 years starting from 2017 – 2022, working together with the Thai

Government to solve issues by focusing on priority areas (Brown, personal

communication, March 22, 2017). In order to define what the priorities are,

comparative advantage and access to expertise needs to be considered. The WHO can

bring partners together and provide factors that the Thai Government is lacking. The

Thai Government hopes that the CSS leverages social and intellectual capital in the

Thai population. Antimicrobial Resistance is one of the priority areas that was stated

in the CCS. In practice, the CCS’s governance mechanism operates via a program

steering committee which is a discussion panel that involves stakeholders and Thai

institutions (Brown, personal communication, March 22, 2017). However, it is still

not a complete mechanism because key players like the FAO, Ministry of Agriculture

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and Cooperatives, and individuals who suffer from AMR are not involved as

stakeholders. In 2016, CCS held a number of dialogue meetings to come up with a

rule based mechanism and a financial system called “pooled funds”, financial support

from all stakeholders and institutions that are aggregated for tackling AMR problem

in Thailand. The Thai institutions, such as the International Health Policy Program,

Health Systems Research Institute, Thai Health, and the National Health Security

Office are involved in the support of these pooled funds. Brown (personal

communication, March 22, 2017) explained that the pooled funds work by being

common money, which will be spent by involved stakeholders and institutions to fund

programs tackling AMR. How the funds are implemented is done by the CCS steering

committee. This CCS mechanism is unique to Thailand. The WHO has never done

this in other countries. The CCS of Thailand has attracted interest from the Director

General of the World Health Organization because of the uniqueness and how the

CCS brings partners, including Thai institutions, together to cooperate and fund many

important programs. However, the CCS is just a beginning phase and the pooled

funds only cover some particular areas of AMR, i.e. evaluation, knowledge

generation, and information dissemination, but not infection control and medical

treatment in hospitals.

Apart from this, the WHO has its own source of financial support for the

AMR program in Thailand. Although the funding is much smaller than the CCS, it is

more flexible and can be utilized in many areas of tackling AMR, such as design and

printing, holding several meetings, and research in some areas. The funding by the

WHO can also be beneficial for funding in the so called “orphan area” – the area that

has been overlooked or is not interesting (Brown, personal communication, March 22,

2017). In the medical sciences and research, the WHO has established the WHO

Collaborating Center (WHOCC) for AMR at the Faculty of Medicine Siriraj Hospital

and has been supervised by Professor Dr. Visanu Thamlikitkul, Chair of the R&D

Committee on Anti-microbial Resistance Prevention & Control System, under the

Steering Committee on Drug System R&D, Health Systems Research Institute

(HSRI), Ministry of Public Health. More importantly, the WHO plays a significant

role in supporting and facilitating the Thai experts’ work, such as research to go

beyond the Thai border. The antibiotic best practices in the hospital has been carried

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out and illustrated to other countries in the region. The WHO has been successful in

creating awareness of AMR in Southeast Asia. Thai experts are helping the WHO by

sharing best practices, holding workshops and meetings with neighborhood countries

to counter this problem together.

4.3 FAO’s Role on Antibiotic Resistance in Thailand

The Food and Agriculture Organization of the United Nations (FAO) plays a

significant role in dealing with Antimicrobial Resistance in Thailand. Antibiotic

resistance is one of the riskiest problems threatening global food security and it comes

from both terrestrial and aquatic food-animals. (WHO, 2014). The strategic objective

of the FAO is therefore to achieve global food security for all and to ensure that

people have an access to adequate quality and clean food to maintain healthy lives

(FAO, 2017). Starting from regional to national, the FAO has played a significant role

in addressing AMR in the livestock industry in Southeast Asia since 2015 and the

initial plan will last for 5 years (2015 - 2019). In the beginning, the main job of the

FAO was to develop the Global Action Plan and to gather information from

stakeholders in Thailand, as well as gaining support from Thai authorities and

implementing a National Strategic Plan. After the National Strategic Plan has been

finalized, the FAO will further expand the job in Thailand by being involved in public

hearings in particular fields: medical, livestock, fishery, and agriculture. In AMR, the

work of the FAO covered the majority areas of causes of AMR, which is agriculture,

food, and environment, while the WHO focuses on public health and human

medicine. The OIE focuses on animal health and welfare. This factor makes the FAO

dominant and a key player in helping agricultural-based countries like Thailand.

Dr. Wantanee Kalpravidh, the Regional Manager of the FAO country office

explained about FAO’s effort in helping Thailand enhance national capacities for

AMR risk management in food-animals. “AMR is also one of the priority areas for

FAO because food and agriculture are involving in the AMR supply chain” said

Kalpravidh (personal communication, May 22, 2017), “FAO’s job in Thailand is to

support agricultural sectors to produce food for human consumption, prevent and

diminish AMR, and to ensure the Global Action Plan has been implemented or

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adapted in Thailand.” According to Dr. Wantanee Kalpravidh, Regional Manager of

FAO (personal communication, May 22, 2017), “as AMR plays a critical role in food-

animal health or even in fruits and plants, we are trying to address this food security

problem in Thailand for the well-being of people and animals.” FAO, therefore, plays

a key role in supporting the Thai government, stakeholders involving the private

sectors, food producers, or even merchants and farmers to acknowledge this problem.

On May, 2017, the FAO declared their objective of countering AMR to the

international community. They aim to assist member states to develop and implement

multisectoral national action plans to counter AMR under the concept of “One

Health”, which was addressed by the World Health Organization. The GAP plan for

Thailand is still too broad to be covered, FAO therefore works flexibly with the key

players in the public sectors, i.e. the Royal Thai Government, Ministry of Public

Health, Ministry of Agriculture and Cooperatives to make a national plan for Thailand

to be conformed and aligned with the GAP as much as possible. One thing that is

compulsory for the national plan is to use the concept of “One Health” and to

implement it in Thailand.

FAO is the organization that has confirmed that it is impossible to eradicate

AMR. Dr. Wantanee (personal communication, May 22, 2017) explained that AMR is

both a natural phenomenon in humans and a man-made one. The natural phenomenon

of AMR occurs when microbes adapt to survive in humans or animals, but the man-

made phenomenon comes from unnecessary and inappropriate use of antimicrobial or

antibiotic medicines. FAO has categorized AMR infection in agricultural in Thailand

into 4 factors: first from a lack of regulation of antibiotic use, second is poor treatment

obedience, third is from non-therapeutic use, and fourth is from simple access to

antibiotic medicine for stakeholders. Antibiotic use in agriculture is also essential in

the AMR problem. It has been used widely for two purposes in terrestrial and aquatic

food-animals. Firstly, antibiotics have been used for animal treatment (therapeutic

utilization). Secondly, it has also been used for non-therapeutic purposes, such as

AGP. “The accessible and availability of antibiotic medicine in agricultural sectors

have both pros and cons”, said Dr. Wantanee. She continued to explain that “the

advantage is it is a life-saving drug for animals suffering from severe bacterial

infections, but the bad side is that people buy it and use it improperly or without

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having correct knowledge of its benefits.” I was surprised when Dr. Visanu revealed

that AGP was directly injected into orange trees for citrus production by the farmers

in Chiang Mai. In Thailand, the organization realized that the AMR issue is not only a

problem for individuals, but for all stakeholders involved in the supply chain.

Therefore, the FAO is demanding for multisectoral cooperation by adhering to the

“One Health” approach to encompass the linkage between humans, animals, and

environment for the well-being of the population.

The framework of the FAO is quite similar to the WHO’s Country

Cooperation Strategy (CCS), but the name is the “Country Program Framework

(CPF)”. It uses the same mechanism as the WHO but the angle is focused on food and

agriculture by working closely with the Ministry of Agriculture and Cooperatives, the

Department of Livestock Development, Department of Fisheries, and several Thai

institutions. In practice, the tripartite cooperation of the WHO/FAO/OIE leads the

agenda in combatting AMR in Thailand within the public and private sectors. “We

have tried to be a part of many projects launched by both the government and private

sectors”, and “we support them in order to adopt measures to reduce the use of

antibiotics and the resistance.” said Dr. Kalpravidh (personal communication, May

22, 2017). The strengths of the FAO is that they have a lot of expertise in

multidisciplinary areas, e.g. animal welfare and reproduction, terrestrial and aquatic

veterinarians, food and feed safeness, crop production and protection, legislative in

agriculture and so on. For example in private sectors, the FAO coordinates with the

Ministry of Livestock to send inspectors to private sector farms and monitor the use of

antibiotic medicines in both company farms and contract farming. However, the FAO

still admits that the surveillance system in Thailand for agriculture needs to be

developed. Apart from private sectors, there are a number of farms owned by local

farmers and most of them do not have knowledge about the AMR in their raised food-

animals (Kalpravidh, personal communication, May 22, 2017). In this case, the best

practice among the leading agricultural private sectors can be a part of this by setting

up the AMR awareness program for local farmers. Dr. Katinka de Balogh (personal

communication, May 22, 2017), Senior Officer- Animal Health and Production at

FAO Regional Office for Asia and the Pacific firmly explained, “sharing information

on good practices is very important to reduce the AMR infection in agricultural

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sectors, they need to acknowledge that the improper use of antibiotic medicine can be

devastating and we need the best practices from private sectors”. For this project, the

FAO can play a leading role in providing integrated technical and advisory support as

well as some funding support for the campaign together with the private sectors to

educate local farmers. This project turns positive among the leading agro-industrial

company like Charoen Pokphand Foods PLC., “we are willingly to be a part of

sustainable solution to reduce AMR in our country, and make sure that our foods from

us and local farmers will be safe and hygienic for consumers”, said Mr. Payungsak

Tanagul, Vice President of Charoen Pokphand Foods PLC. Finally, although there are

many challenges ahead, the FAO encouraged that working multilaterally with all

involved parties with the support from the organization under the scope of the Global

Action Plan as the National Strategic Plan of Thailand will pave the way to the

achievement of international standards and sustainable solutions of AMR mitigation.

4.4 OIE’s Role on Antibiotic Resistance in Thailand

The Office International des Epizooties (OIE) or the World Organization for

Animal Health is one of the tripartite collaborators that launched the Global Action

Plan into the Global Health Security and Global Food Security schemes. The OIE

started an intense study on AMR in 2010. The approach called “One Health” was also

mutually agreed on by the OIE in order to combat AMR as well as other emerging

threats to all life forms. To use the “One Health” approach in response to AMR, the

OIE argued that everyone needs to be a part of it, “to accomplish this together,

multisectoral cooperation between the public health and veterinary sectors is very

important in order to lead member states mutually implemented actions and long term

commitments against AMR,” said Hirofumi Kugita, OIE Regional Representative for

Asia and the Pacific, (OIE, 2016). The OIE tackled the AMR problem by working

closely with member states under 5 principles: first, forming a network called “focal

points” for states to collaborate with the OIE, second, recommend harmonization of

risk management in member states, third, ensure animal health surveillance, fourth,

setting the international standard to improve veterinary education for member states,

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and fifth, setting an international standard on the design and functioning of national

and regional veterinary legislative bodies (OIE, 2016).

The OIE objective on the AMR problem in Thailand is to emphasize on

awareness and the impact of AMR infections on animals, people, and environment

(OIE, 2016). The organization focused mainly on the encouragement of education on

animal health and animal welfare, such as holding a meeting and seminar for

stakeholder s on the promotion of proper antibiotic prescriptions in the industries. In

2012, the OIE (2016) started a pilot program in Thailand called “Focal Points for

Veterinary Products”, consisting of three cycles categorized by continent and

Thailand is in the second cycle (Asia-Pacific). The pilot program aimed to educate the

members in each cycle on the prudent use of antibiotics and antimicrobials in

terrestrial and aquatic food-animals. The program also included a tracking system to

identify counterfeit antibiotic medicine, and the educational program on the

responsible use of antibiotics in veterinary medicine. In the seminar, all 180 countries

in the three cycles needed to report and give feedback on their achievements related to

antibiotic use (OIE, 2016).

The job of three organizations, the WHO, FAO, and OIE are quite similar and

overlapping. The organizations support the government and enhance several Thai

universities’ research and development in AMR, e.g. AMR in veterinary medicine,

livestock, aquaculture, and food-animals. For the local farms, OIE, sometimes,

approaches and conducts research for them and supports them by vaccinating their

food-animals. The OIE is unique from the two organizations as it keeps records on

antibiotic or antimicrobial usage in member states by keeping “the global database on

AMR”. They have received very positive feedback from members as seventy percent

of the members have submitted the information to the OIE, (Finishers, 2016).

The OIE (2016) pointed out that in Thailand AMR affects competition for

Thai products versus the international market because when there are AMR strains

left in Thai export products at higher levels than the rate set by an import country’s

authority, i.e. Food and Drugs Administration, the products will be returned and put

on high alert due to the drug residues. For this reason, the trust deficit of importing

food products from Thailand declines as it contains the AMR strains, which are not

safe for consumption. The AMR strains in food animals are also being championed by

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veterinary services and the livestock farming management in Thailand. The OIE

(2016) explained at the 84th General Session of the World Assembly of OIE that “the

implementation of international standards and recommendations requires substantial

effort at the national level, especially in Asia, where the actual situation on the ground

is sometimes restrictive, due often to the absence of adapted legislation, underfunded

veterinary services and the existence of parallel markets which are outside the control

of health authorities.” This made domestic implementation difficult to achieve

because there was a cooperation dilemma on trade. The institutions like the WHO,

FAO, and OIE, are here helping Thailand to develop a better legislative system and

enhance the food-animal production to be able to compete within the international

market. Therefore, this might be the reason why the Thai government has supported

the OIE, WHO, and FAO intervention so far. The speech given by Dr. Bernard Vallat,

Director General of the World Organisation for Animal Health (OIE) pinpointed the

vulnerability of underdeveloped and developing countries on the access of

antimicrobial and antibiotic medicine. This is quite true for Thailand in the point that

antimicrobial and antibiotic medicines are freely available to anyone without

restriction. Moreover, farmers are undereducated about the use of antibiotic medicine,

but “the use of antimicrobials in animals by untrained personnel is not confined to

developing and emerging countries”, said Dr. Vallat (2015). Dr. Vallat took it

seriously in his closing speech to remind the member states to comply with the Global

Action Plan when he said, “although some countries and regions are already very

cautious, the adoption of effective provisions by the rest of the world is likely to be

long, difficult and controversial, not to say illusory”, said Dr. Vallat (2015).

4.5 Thai Public Sector’s Product: The National Strategic Plan on Antimicrobial Resistance

The author had a valuable opportunity to conduct the interview with Professor

Visanu Thamlikitkul as recommended by Dr. Brown. Professor Thamlikitkul has

explained the progress of the finalization on the National Strategic Plan. In 2014, the

working group on AMR realized that although Thailand is having an outstanding

practice on AMR reduction, the working groups and programs carried out were quite

scattered and lacked unity. The government did not have a concrete national plan on

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AMR. In 2015, the government tried to come up with a state plan to counter AMR

together with all stakeholders. The effort was supported and advised by the World

Health Organization Country Office and funded by the Country Cooperation Strategy

(CCS) pooled funded mechanism.

The National Strategic Plan on Antimicrobial Resistance (NSP-AMR) was

first drafted in the middle of 2015 and, finally, finalized in December, 2015. Later on

the final draft was endorsed by the cabinet in August, 2016. The parties involved in

the creation of the National Strategic Plan are the Ministry of Public Health, Ministry

of Agriculture and Cooperatives, the National Health Commission Office of Thailand

(NHCO), National Health Security Office (NHSO), Thai Health Promotion

Foundation, Health Systems Research Institute (HSRI), International Health Policy

Program (IHPP), the Drug System Monitoring and Development Program (DSMDP),

the Food and Agriculture Organization of the United Nations (FAO), and the World

Health Organization (WHO). The characteristics of NSP-AMR can be defined by two

concepts. Firstly, the term “One Health”, the approach that requires a collaborative

effort to work toward the well-being of humanity locally, nationally, and globally.

Human health is interconnected with animals and the environment (USCDC, 2017)

Secondly, is by the term “Triangle that Moves the Mountain”, which highlights the

importance of issues involving multisectoral players through policy engagement and

social movement driven by evidence from knowledge generation (Ministry of Public

Health, 2017). The NSP-AMR was made to conform to the GAP which was declared

by the WHO at the 68th World Health Assembly. The NSP-AMR was established with

three core principles: action oriented strategy, synergetic and orchestrated strategy,

and the stimulation of political commitment of the nation for sustainability of the

implementation. Although the Global Action Plan is too broad for Thailand to be

covered completely, the National Strategic Plan is in alignment with the GAP,

focusing on the main problems by adhering to the concept of “One Health” and

“Triangles that Move the Mountain”. The goals the national plan set are quite high

and are aimed to be achieved in 5 years (2017-2022). In order to achieve the goals, the

6 core strategies will be carried out to the domestic implementation.

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The NSP-AMR has involved all influential and appropriated players to address

the AMR risks in Thailand, especially in knowledge generation which has already

been taking place in the national plan. There is one question that has been asked and

argued all the time in the AMR working group and even from the people who do not

have any background about the AMR, which is “who should be held responsible on

1. Creation of Relevant Knowledge

3. Political Involvement 2. Social Involvement

Figure 3: National Strategic Plan on Antimicrobial Resistance 2017-2022, Thailand, (Ministry of Public Health, 2017)

Triangle that Moves the Mountain Source: (Wasi, 2000)

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the contamination of antibiotic resistance in food and animal?” There are many

debates between domestic antibiotic experts and academics on the responsibility on

AMR. It seems that the victims from AMR are quite obvious, human and animals.

However, it is difficult to search for those who should be held responsible for the

issue of AMR because it is a fact of nature. Dr. Brown (personal communication,

March 22, 2017) firmly stated that “AMR is a natural process in humans and animals

and it has always been there as a fact of life”, therefore, we cannot eradicate the AMR

but should instead minimize the infections. The reason why AMR infection is

increasing right now is from human activities accelerating the prevalence of AMR

across the globe. For example, medical doctors might argue that veterinarians should

be responsible for the prevalence of AMR in agricultural because they dismiss the

legislative system by feeding AGP to animals. In contrast, the veterinarians might

counter their arguments by saying that the doctor and healthcare providers should be

held responsible for the prevalence of AMR because of the majority number of AMR

infections come from the infections in the hospital, e.g. the non-stop usage of the

drugs in the operation room. Ordinary citizens like us might argue that the private

sector should be held responsible for this because they inject AGP into animals and

there is drug residue in the food we eat nowadays. Therefore, instead of finding a

scapegoat for this problem, it is better to bring all parties together to share and

identify the problem in each field to assign the specific problems to the related fields

and control as well as try to reduce the prevalence of AMR. In other words, we can

say that players who are involved in the antimicrobial resistance issue should be held

responsible and do the best on their own to control and minimalize the prevalence of

AMR.

In the discussion of the effectiveness of the Global Action Plan on the

domestic implementation in Thailand, Professor Vitsanu also agreed that it is too

early to claim that the Global Action Plan is not functioning well in Thailand because

the National Strategic Plan on Antimicrobial Resistance (NSP-AMR) has just been

finalized and implemented in some areas in 2017. In the past, it might have been true

that the GAP was dysfunctional because the work on AMR had no direction and was

scattered around, but claiming that GAP is dysfunctional now would be a bit bias

because the National Strategic Plan just started this year. The study of the

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effectiveness of the GAP to NSP-AMR in Thailand should be further studied in the

next 4-5 years following the NSP-AMR roadmap and timeline.

4.6 Private Sector’s Role on Antibiotic Resistance in Thailand

The image of the private sector in regards to AMR in Thailand is quite

negative among consumers when they realize that there is drug residue in both

terrestrial and aquaculture animal meats. There were several studies revealing the

prevalence of antibiotics and antimicrobials strains in animal meat, which is available

for consumers. Professor Chanwit Tribuddharat (personal communication, May 22,

2017), the Vice Chairman of National Science and Technology Development Agency

(NSTDA) and a microbiologist of Faculty of Medicine Siriraj Hospital, revealed the

prevalence of bacteria contaminated in animal meat. “We assessed contamination by

antibiotic-resistant bacteria in chicken meat obtained from supermarkets in Bangkok,

Thailand. The prevalence of Salmonella enterica and Escherichia coli was 18.7z

(14/75) and 53z (106/200), respectively. Most probable number (MPN) analysis

showed that 56.7z of the samples (34/60) were in violation of the limit of allowable

coliform bacteria in chicken meat, for which the maximum is 46,000 MPN/g.

Multidrug-resistant phenotypes of both S. enterica and E. coli were found”, (Chaisatit

et al., 2012). Other evidence (Pisuthipan, 2017) revealed that the use of colistin, one

type of antibiotic medicine for raising animals at farms, is becoming a risk for

people’s health in Thailand. Several farms were found to have used colistin to prevent

bacterial infections in swine. The colistin strain was left in animal intestines and lead

to resistance called MCR-1 and MCL-1, which has been found in humans in over 40

countries. Although the news headlines on the prevalence of AMR creates awareness

among consumers, the downside of that is it also creates a negative image of the

private sector.

However, if we study the role of the privates sector in cooperating with the

public authorities and also with the international organization towards the Global

Action Plan as an international standard, it can be seen that there are some leading

private sectors that are following the recommendations of the GAP plan. Senior Vice

President in Veterinary Service Department of Charoen Pokphand Foods (CPF) PLC,

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Dr. Damnoen Chaturavittawong (personal communication, May 20, 2017), explained

the framework and how they take care of their terrestrial and aquaculture food-

animals before arriving at a consumer’s mouth. Dr. Chaturavittawong (personal

communication, May 20, 2017) explained that the level of necessary use of antibiotic

medicine in food animals can be ranked according to the animal welfare legislation

and regulations of the Food and Agricultural Organization (FAO) under the Thai

Agricultural Standard (Domestic legislation) created by the National Bureau of

Agricultural Commodity and Food Standards Ministry of Agriculture and

Cooperatives (Agricultural Standards Act B.E. 2551, 2008). The stated six principles

of the freedom of animals can be seen below in the diagram:

Therefore, in this antibiotic issue, point 3 of the Act must be applied to make

animals recover from the illness. Dr. Damnoen clarified that antibiotic medicine is

just an option to maintain an animal’s health. He illustrated that when food animals,

like swine, are ill, a diagnosis must be done before giving any medication. The level

prescribed will fit what is necessary. What is quite unique for CPF is the level of the

prescriptions by the senior veterinarians as indicated by two levels of antibiotic

prescriptions: first, the antibiotic drugs which can be used for animals only, and

second, the antibiotic drugs which can be both utilized for humans and can be applied

to animals as well. If the illness of an animal can be treated with the 1st level of

1. Freedom from hunger and thirst – by ready access to fresh water and a diet designed

to maintain full health and vigor;

2. Freedom from discomfort – by the provision of an appropriate environment including

shelter and a comfortable resting area;

3. Freedom from pain, injury or disease – by prevention or through rapid diagnosis and

treatment;

4. Freedom to express normal behavior – by the provision of sufficient space, proper

facilities and company of the animal's own kind; and

5. Freedom from fear and distress – by the assurance of conditions that avoid mental

suffering

(The Agricultural Standard Act. B.E. 2551, 2008)

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antibiotic drugs, the drugs will be used first, but if the disease of an animal cannot be

cured by using the 1st level of animal used only antibiotics, the 2nd level drugs will be

applied. The benefit for using the 1st level is that it will not leave the strain in an

animal’s intestinal system. The antibiotic medicine that can be used by humans will

not be utilized for curing animals without a prescription from the company’s

veterinarians. Both terrestrial and aquatic food animals will not receive antibiotic

treatment for 3 days before going to the slaughterhouse to ensure that nearly all of the

antibiotic residues are out of the meat.

In the past, the company (Chaturavittawong, personal communication, May

20, 2017) admitted that there was no research on the consequence of AMR from the

beginning to the end of the food supply chain. In 2016, the company started to realize

this problem, as acknowledged by the Food Agricultural Organization, regarding the

Global Action Plan. The study of AMR in all types of food animals produced by the

company has been established. The so called “sensitivity test” was implemented to

terrestrial and aquatic food-animals like swine, poultry, fresh water fish, and shrimp

to identify the best proper antibiotic medicine for the treatment of food-animals in

each case of illness. The sensitivity test has a benefit that it allows the veterinarian to

know the proper prescription which will bring about 0% of the antibiotic strain to be

left in the food-animal intestinal system.

Focusing on the cooperation between the private sector and other key players,

CP was invited to meetings with the World Bank, WHO, and FAO to discuss the

emergence of the GAP in 2016. In the end of 2016 the company was working with the

FAO and Chulalongkorn University on a two year project called the AMR

surveillance system. The company had the FAO as an advisor and Chulalongkorn

University helped with technical and research assistance. There was also a

cooperative project with Chiang Mai University and the FAO in dealing with AMR in

the field of awareness generation in agriculture. The company has been working

closely with the FAO and following the GAP as they try to adapt their food-animal

policy with the GAP. “Awareness and surveillance are the most concerning factors in

the AMR in agricultural sectors,” said Chaturavittawong (personal communication,

May 20, 2017). According to Chaturavittawong, “at the beginning, the FAO did not

believe that [CP] were adhering to the GAP until the veterinarians from FAO visited

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our farm.” Nowadays, CP has declared that the company does not misuse antibiotic

medicines in all types of animals. “We are having the same standards for our farms

and other contract farming. The value that we give local farmers, who do our contract

farming, is only marketing in order to generate profits for them.” Hygiene is one of

the most concerning objectives in both company farms and contract farming.

Nowadays CP uses the Evaporative Air Cooling System (EVAP) in all of their farms

and also encourages the local farmers to have it as well by giving loans for setting up

local EVAP farms. The benefit of EVAP farming is that it can control the cleanliness

in a farm, unlike outdoor farming. It also helps with preventing disease carriers to

access farms whereas outdoor farms are very vulnerable. However, the company is

quite worried and has commented about it. When AMR occurs, “we are working

multisectorally and they put this issue in meetings held by the Ministry of Health,

who sit as a chairman, and many key players are arguing on “who should be

responsible for an incident” said Chaturavittawong (personal communication, May

20, 2017). “I think that the platform was built in order to address the problem and

assign each stakeholder to do their own job to achieve it, not arguing who should be

blamed for making this phenomenon happen. If it is going on like this it is difficult to

see progress on countering this issue,” he continued. For example, one Thai institution

blamed the company for the drug residue in chicken meat and demanded the company

to reduce the antibiotic medicine in chicken. Dr. Damnoen argued, “we did not

dismiss this blame but we need to be sure that in what extent it should be reduced and

our productivity and animal welfare will not be impacted.” The reduction of antibiotic

medicine in animals means that the company needs to expand the area of the farm,

increasing investment, and other consequences, like the food-animals suffering and

dying, which is wrong according to the Agricultural Standard Act. 2008. Another

example is that there are many studies in European countries, such as Denmark,

which proved as the first European country who permanently banned Avoparcin in

humans and animal use. They were still able to maintain the swine productivity and

healthiness (Levy, 2014). The study of the best practices in Denmark, somehow,

cannot be compared to Thailand, Chaturavittawong (personal communication, May

20, 2017) strongly argued:

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“Comparing Denmark and Thailand seems irrational in some sense, first thing you cannot compare is the weather, bacteria can incubate and grow faster in the warmer temperature. In Denmark the average temperature for the whole year is between 7.7 – 15 Celsius while Thailand is between 29 – 31 Celsius. second, the legislative system in the European country can enforce effectively on the antibiotic users, e.g. the farmers who bought Avaparcin without prescriptions will be punished according to the European Union on Veterinary Medicines (EU Press Release, 2016), and what about the enforcement on the legislation in Thailand ? Where bribery is widespread and the authority pushes less effort to enforce the law, or even if they did enforce it, how would the punishment look like? Is paying 1,000 – 20,000 TH Baht going to make the reckless stakeholders stop using antibiotic on their products?.”

Therefore, the private sector can choose to agree on only acceptable demands

from the involved parties that will not affect their businesses. It is the fact that the

reduction of antibiotic medicine in food animals is still possible, but needs time to be

studied in a multidisciplinary manner and analyze the pros and cons.

As the new National Strategic Plan on Antimicrobial Resistance was finalized

in 2017, leading agro-industrial companies, like CPF, see it as a good sign that

developments to counter AMR locally, nationally and globally with the government is

taking place. “It is better to have a plan rather than having nothing” said

Chaturavittawong (personal communication, May 20, 2017). The company feels that

the goals for the reduction rate of AMR in animals according to the NSP-AMR set at

30% in 2022 is convincing, but needs more commitment from all stakeholders to

make sure they adhere with the plan and do the best job on their own.

In the end, the leading agro-industrial company confirmed that the AMR

problem needs a collective action from multi-sectors. “Everyone involved in the use

of antimicrobials should be held responsible,” claimed Chaturavittawong (personal

communication, May 20, 2017). For violations of the domestic law, “it is our vision

from our CEO, Mr. Dhanin Chearavanont that our company will never violate the law

to make a profit,” Chaturavittawong (personal communication, May 20, 2017),

assured. In addition, the Senior Vice President of CFP (Chaturavittawong, personal

communication, May 20, 2017) also added:

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“We are very open for everyone who wants to know what is going on in the AMR context because the company wants to eradicate the negative belief about the AGP created by some consumers, for example like the belief that some parents always teach their children to not eat chicken too much because it will make you overgrow.” What the company is worried about is a lack of awareness in the farmers who

still are not adequately educated about the consequences of the misuse of antibiotic

medicines without a veterinarian’s prescription. As the NSP-AMR has been produced,

the company thinks that the cooperation between multisectoral stakeholders will be

more intense, comprehensive, and committed in order to reduce AMR in Thailand.

Today, the leading agro-industrial company has stopped using Colistin in food-

animals and are trying to shift to a new way of feeding by giving alternative feed,

which is high in nutrition, such as pro and pre-biotic feeds. The new alternative feed

can enhance an animal’s immunity and improve its health instead of spending time

and money on antibiotic drugs to cure them. The next plan of CP and the FAO is the

intention to bring AMR germs to study. This might include cooperation with the

World Health Organization Collaborating Center (WHOCC) at the Faculty of

Medicine Siriraj Hospital in the cultivation of the bacteria to produce a vaccine for

food-animals.

4.7 Drugs Residues in Thai Shrimp: Voice from Farmers

Shrimp exports are counted as one of the most important products that

generate a lot of income for Thailand. Thailand is one of the largest seafood exporters

of the globe. The Thai Frozen Foods Association (n.d.) revealed that the shrimp

exports generated approximately $3 billion per year from 2011 to 2013. Antibiotic

medicines have also been associated with shrimp to make them stronger and grow

faster. However, it also harms human health by leaving antibiotic resistance strains in

the human body and humans become infected with AMR without knowing where the

strain came from. At the end of 2012, the overall trends of global shrimp production

was going down, especially for the production in Asia, because of the outbreak of the

Early Mortality Syndrome (EMS) disease. It was first found in southern China. The

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EMS spread from place to place because of the shrimp larvae (baby shrimp) export

and import made EMS get transmitted from one country to another. The EMS then

spread to ponds of shrimp farmers and shrimp become infected. Although the

treatment of EMS is not related with the use of antibiotics in treatment, the shrimp

productivity in the country is decreased and antibiotics take part here as a growth

accelerator for the farmers who want to maintain productivity and have healthy

shrimp. Thailand was severely impacted by EMS in 2013 and mostly occurred with

the white shrimp (Penaeus vannamei), the most profitable shrimp of Thailand and the

world. According to Biotec, (2014) EMS impacted over 50% of shrimp production in

Thailand. In 2014 the Thai shrimp farming industry could produce only 270,000 tons

of shrimp for the market. This reduction made the global shrimp production decrease

by 11%. For this, some private shrimp industries tried to use antibiotics or other drugs

to maintain the productivity and make a profit when the global market was having

high demand of shrimp.

The credibility of shrimp exports in Thailand seemed to meet a big problem

when frozen shrimp was exported by one of the largest shrimp producers in Thailand

and then rejected by the U.S. Food and Drug Administration (FDA) because of drug

residues in the exported shrimp. The USFDA detected the antibiotic strains called

Nitrofusan, an antibiotic drug that can increase the risk of cancer in humans if the

humans consume it over a long period of time. (Lee & Phelps, 2014) Veterinary

medicines were also found in white frozen shrimp exported by Narong Seafood Co.,

Ltd. (Thailand). In addition, the company was involved in violating Thai law and

international human rights. The International Labor Rights Forum & Warehouse

Workers United (2013) revealed the “Walmart Effect” caused by the Narong Seafood

Company who violated domestic law by running a sweatshop like company, hiring

underage employees, excessive fees for work permits, and forcing workers to work

overnight without payment. Later on the company was listed on the high-alert list of

imports by the US in 2016. Traced back to 2002, the European Commission (2002)

also found Nitrofusan and other drug residues in shrimp imported from Myanmar,

Vietnam, and Thailand. From that time, the European Union proposed that all EU

members to test all shrimp products imported from those three countries and put them

on a high alert list. The trend in 2017 started with a large number of Thai shrimp

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being rejected for antibiotic contamination. The USFDA refused five shipments of

Narong Seafood, two shipments from Vietnam, and one shipment from China as all of

these eight shipments were contaminated with antibiotic residues. If the trend for the

private sector continues like this for the next 2 – 3 years the Thai shrimp industry

might lose big markets in the US and EU because of the drug residue in the frozen

shrimp.

However, there is a little hope for the aquaculture industry in Thailand. The

author conducted a semi-structured interview with a Thai shrimp farmer who has been

working for one of the biggest leading agro-industrial companies for twelve years.

Mr. Attaphol Nopphaklao, Head of the Shrimp Production Unit in the farm owned by

Charoen Pokphand Foods PCL. (CPF) in Chumphon, a southern province in Thailand,

explained how the leading private sector produces shrimp and distributes them to

markets. He explained that his job here is to make sure that his farm can maintain a

stable production of healthy shrimp for the market. Attaphol and his team operated the

shrimp production starting from larvae to mature shrimp. The shrimp have been raised

in the Evaporative Air Cooling System (EVAP) to make sure that all of the process is

operated under hygienic standards. He confirmed that AGP in shrimp feed stopped

five years ago because of the regulations on the aquaculture of the company. Instead,

the shrimp have been fed by using Probiotic aquaculture feed to increase the growth

of microorganisms, intestinal flora, and the enhancement of nonpathogenic bacteria to

be efficient for shrimp health. “Shrimp in the EVAP farm are very hygienic because

all activities, i.e. feeding, collecting, and eliminating are monitored by the auditor”, he

insisted (Nopphaklao, personal communication, May 19, 2017). The farm operates

under the ISO14001 which certified the safe environmental management system in

the farm. The shrimp have been raised by following the Bio Security standard, the

Code of Conduct (CoC) in sustainable shrimp farming and Good Aquaculture Practice

(GAP). Atthaphol reported that the Department of Fisheries pays a visit annually to

the farm for monitoring new emerging diseases in shrimp and to ensure the farm is

following the CoC and GAP. The shrimp farmers in Chumphon have been educated

by CPF to be aware of using AGP or any treatments. The infected and ill shrimp will

be taken for elimination according to the policy of the company. Some shrimp that

died by natural causes, as they could not adapt themselves to the new water or

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environment after farm cleaning or accidents, will be brought to be made as a

fertilizer for agriculture in a community or thumbon. In the end, the farmers are

confident that shrimp productivity can stay positive if they keep the farm hygienic and

follow the standards imposed by the company headquarters. Nopphaklao (personal

communication, May 19, 2017) explained, “What the farmers like us are worried

about right now is outbreaks of EMS, chemical hazard safeness in cleaning the farm,

and the cleanliness of water systems in the farm that might harm the health of

shrimp.” Therefore, the contract farm of CPF needs to maintain the cleanliness and

follow the guideline made by the headquarters to meet international standards before

sending them as the product for consumers to eat.

4.8 Legislative System on AMR in Thailand

One of the specific problems for Thailand is that the people or any farmers can

access antibiotics easily. The domestic law nowadays is not able to cover the

antibiotic prescriptions because of some conditions on the medical side, such as the

implications of the workload of the doctors. Banning antibiotic medicines in drug

stores would result in more patients coming to hospitals and asking for antibiotics

from doctors and more visiting hospitals. This might cause difficulties in most of the

public hospitals, where is very crowded every day. Siriraj Hospital already receives

over 5,000 out-patients per day and 3 million annually, not including in-patients. Even

if the domestic law can be amended, passing the legislative system, and making it so

all antibiotic medicines cannot be sold in drug stores without a doctor’s prescription,

it could not be enforced tomorrow. Therefore, some kinds of antibiotic medicines will

continue to be available over the counter at pharmacies in Thailand for a long time.

The antibiotic medicines or substances can be bought without a prescription from

doctors in Thailand and this is one of the causes of the prevalence of AMR in

Thailand. Prof. Visanu illustrated that the farmers in Chiang Mai bought the

antibiotics pills in the agricultural drugs store, crushed them into powder and

dissolved them with water and injected them into fruit trees to increase yield and for

curing some particular bacterial infections.

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To be sure, the law on the usage of antibiotic medicine in animals is already in

place, since using antibiotics as a growth promoter (AGP) is unlawful according to

the Animal Feed Quality Control Act B.E. 2558 (2015). However, using antibiotic

medicine for treating animals is still lawful according to the animal welfare act. So

farmers can justify using antibiotics for illness prevention (such as Prophylactic

Antibiotics), which reflects a gap in the domestic law. This can be illustrated through

the coverage of the law, particularly regarding lawful prescription. If one village has

two farms, (farm A) and (farm B), when there is an outbreak in farm B, farm A would

want to take precautions against the outbreak spreading to their farm. In such a

situation, in Thailand, it is lawful for farm A to use antibiotics to prevent their

livestock from contracting diseases from farm B, but only with a prescription from a

veterinarian. In Europe, farmers are punished under the European Union Law on

Veterinary Medicines for using antibiotics without a prescription (EU Press Release,

2016), but in Thailand, even though the domestic law on antibiotics for prevention is

in place, it is not enforced and this is a very important issue in Thailand that needs to

be solved. “The legislative system on the prophylactic antibiotics use in animals must

be very important in Thailand, farmers cannot make their own decisions for using

prophylactic antibiotics for their animals because it is like you are using it as a AGP,

which is a potential for abuse.”, commented Brown (personal communication, March

22, 2017). This problem requires a lot of inspection and a monitoring system from the

state to enforce the law for all stakeholders.

Another problem of the domestic law in countering antibiotic resistance is

“enforcement”. Law is nothing without enforcement, no matter if it is international or

national law. Road Safety in Thailand was ranked as having the 2nd highest morbidity

and mortality rates in the world and this is not because of the transportation legislative

system, which is quite good, but the problem is there is no authority to enforce the

law. The police do nothing, and even if they do, they might be taking bribes and let

the person who did wrong get away from real punishment imposed by the legislative

system. This is similar to the legislative system concerning the antibiotic issue.

Although it has been designed and it took a lot of time to come up with good domestic

laws related to antibiotics, the legislative system cannot function because there is no

one who enforces the law. In this context, the public authority might turn a blind eye

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to bribery. In the case of Thailand, enforcement cannot function because of the option

of the antibiotic users. The farmers do not have alternative choices to use another

medicine to cure their animals or plants. According to Kalpravidh (personal

communication, May 22, 2017), “the inadequate knowledge leaves the local farmers

with no choice but to choose antibiotic medicines for their animal and plants”.

Sometimes, the enforcement is also ineffective in case of a cost-benefit comparison.

For example, if a pharmaceutical company makes a lot of profit by selling antibiotic

medicines intended for human use only to local famers to feed to their food-animals in

the community and when they get caught by the authorities, the fine for violating the

law on animal feed is very small comparing to the profit they earn. The enforcement

of the law problem also reflects the imbalance of the cost and benefits by the private

sectors’ thoughts.

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CHAPTER 5

DISCUSSION

5.1 Challenges faced in Countering AMR in Thailand

From the interviews, all respondents claimed that Thailand faced many

challenges in countering AMR. However, these challenges are similar to other

countries in Asia, e.g. China and Vietnam who have faced two similar challenges with

Thailand, the availability of antibiotics and awareness in agriculture. Both countries

were get caught by the USFDA on the antibiotic resistant residues in shrimp at about

the same period as the company from Thailand, according to the European

Commission (2002). The fact is, we need to remember that we cannot eradicate the

antimicrobial resistance entirely because the development of AMR is a natural

phenomenon in the human body. Sir Alexander Fleming also warned everyone about

the use of antibiotics with the emergence of “penicillin” on September 3rd, 1928:

“The time may come when penicillin can be bought by anyone in the shops,…then there is the danger that the ignorant man may easily underdose himself and by exposing his microbes to nonlethal quantities of the drug make them resistant.” Sir Fleming (1945) warned.

He knew from the beginning that it is a process of nature. Inattentive use by

man-made activities in both public health and agriculture will accelerate the resistance

in humans, animals, and plants.

We can bring international relations theory into the study of AMR within the

context of cooperation and compliance through multilateralism to minimize the

problem. Neoliberal institutionalism allowed the author to understand the important

roles of the tripartite institutions: the WHO, FAO, and OIE, in assisting states in their

domestic implementation to reach international standards in an anarchical state system

with no global central government to manage the world’s problems. In transnational

health issues, like the AMR problem in Thailand, neoliberal institutionalism projected

several lessons for states: first, the AMR problem cannot be handled alone, that is

why the institution called for the collective collaboration and multisectoral

cooperation; second, cheating and non-compliance by states can have consequences

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as threats to cooperation and trade, e.g. banning products on drug residues from

Thailand by the USFDA.; and third, the effective implementation of strong rules and

norms and how this may constrain states and stakeholders from cheating.

Firstly, nature and scale of the AMR made it difficult to deal with by the

Royal Thai Government. AMR involved multisectoral players, and working

multisectorally needs a lot of coordination and good monitoring systems. However,

existing studies of the AMR value chain in Thailand are still not adequate. AMR as

both a natural and man-made phenomenon needs to be studied from the beginning to

the end of the AMR supply chain. The FAO (Kalpravidh, personal communication,

May 22, 2017) coined this AMR value chain as the “Antimicrobials Distribution in

Stakeholders Value Chain” which is the channel of distribution of antibiotics from

the starting point to the end and how AMR spread through each user: animal,

agriculture, and human. The FAO admitted that the study in this ADSVC is not yet

completed and they are still waiting for the results of information gathering with the

support from voluntary private sectors and INGOs. The Antibiotics Distribution in

Stakeholders Value Chain as from the interview with Dr. Wantanee Kalpravidh,

Regional Manager of FAO Thailand can be illustrated as below:

Figure 5.1: Antimicrobials Distribution in Stakeholders Value Chain (Kalpravidh, 2017)

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From the diagram, the starting point is at the antibiotic producers from

government or private pharmaceutical companies (domestic / international). The

producers send the antibiotic products to be certified by the Thai FDA. When

approved, it leads to the distribution process that involves many stakeholders like

retailers, co-sellers, drug stores, hospitals, private agro-industries, and local farms.

The antibiotics can be categorized in two types: human use only and animal use only.

Antibiotics for humans can also be used in animals if necessary to prevent infection,

while the antibiotics intended for animals can be used in agriculture like plants and

fruits. Sometimes, local farmers use the antibiotics for humans in their agriculture as

well. The use of antibiotic for all stakeholders is in the frame of the environment.

AMR can occur in nature and in residues from the misuse of antibiotics by

stakeholders in the environment. The enforcement of the law that covers the use of

antibiotics by all stakeholders needs a good monitoring system from the government

authority. In addition, this value chain cannot be permanently used, it can only be

used for the time being because transnational health issues nowadays, including

AMR, is evolving quickly due to the rapid process of globalization and socio-

economic factors, as explained by Kalpravidh, (personal communication, May 22,

2017) below:

“We term this challenge as “disease landscape” that changes and develops all the time in the 21st century. Therefore, we need to be well adapted by adhering to the same principles of the National Strategic Plan, which is coherent and in conformity with the Global Action Plan”, (Kalpravidh, personal communication, May 22, 2017). Therefore, a systematic monitoring system should be advocated in Thailand

with the assistance of the WHO, FAO, and OIE. States need to follow international

standards of the GAP by implementing it in a National Strategic Plan. All

stakeholders, like agricultural industries, pharmaceutical companies, and pharmacies

need to be approached by the government for monitoring the use of antibiotics in

humans, animals, and plants.

Secondly, the challenge turns to the scope of private sectors and stakeholders.

There is an incompatible relationship between the need to produce foods and the need

of reducing antibiotic usage in agricultural sectors. There are several debates

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concerning to what extent antibiotic medicines are necessary for food-animal

production in Thailand. The clash of views between medical doctors in the medical

field and the private sector is always heated. Medical doctors, microbiologists, and

researchers argued in many meetings, as follows:

“Producers should realize that they are the main cause of AMR in the supply chain, from farm to forks, and they should stop giving antibiotics to animals in farming. We came up with a lot of studies revealing there are resistant strains in both aquatic and terrestrial animal meats!”, Tribuddharat (personal communication, May 22, 2017).

In contrast, the private sectors argue:

“What we are doing is to keep the animals healthy and we can maintain productivity in our farms. Without using antibiotic medicines in our farm, animals will be sick and die and that means we cannot produce enough protein to serve the consumers”, Chaturavittawong (personal communication, May 20, 2017).

If this kind of debate happens all the time at AMR meetings, the way forward towards

a National Strategic Plan will not make progress because the negotiations fail.

Although the legislative system in Thailand is in place to comply, there are

few enforcement mechanisms used by authorities. The effort to enforce the law could

be undermined by bribery and ignorance. Sometimes, the interpretation of a law can

be a problem too.

“Some private sectors announced they have stopped the Antibiotic as Growth Promoters or another antibiotic medicine for human use only to feed animals which is wrong according to the domestic law, however, they can use like the prophylactic antibiotic purpose for the animal for preventing infection”, (Tribuddharat, personal communication, May 22, 2017).

The interpretation of the law by avoiding some technical words in Thai is very

vulnerable. Farmers or big private companies might not interpret the law in good faith

to avoid the real interpretation which will make them violate the law. This is the gap

of the law that most of private sectors know and try to avoid when they get arrested

by the authorities.

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Fourth, the joint-assessment of Thailand in countering AMR paid less

attention on the agricultural side of the problem and focused more on the human side.

Dr. Wantanee argued that the criticism for the prevalence of AMR in agricultural

sectors and animals is very heavy:

“Consumers and public health players always claim that most of the AMR is caused by the agricultural sectors. We admit that and we are working on it but when the budgeting planning and engagement by the public authorities, e.g. Ministry of Public Health and Thai institutions take place, we receive less attention than the human health sectors”, (Kalpravidh, personal communication, May 22, 2017).

Dr. Wantanee explained by drawing a so called “Joint Pre-Assessment of the Public

Health” as below:

From the Joint Pre-Assessment of the Public Health, we can see that the

problem in agriculture and animal health prevails, but receives less engagement from

authorities. There are many programs going on, but it does not turn into public

attention. The overall engagement in this matter should be adjusted and reconsidered

by the authority in the working group.

Public Health

Agricultural and Animal Health

Criticism on the cause of

AMR

Human Health

Agricultural and Animal

Health

Human Health

Overall Engagement & Funding

Support

Figure 5.2: Joint Pre-Assessment of the Public Health, (Kalpravidh, 2017)

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Last but not least, the availability of antibiotic medicines without a

veterinarian’s prescription in the agriculture sector still undermines Thailand’s public

health security. However, this needs to be linked with the lack of awareness of

farmers as well. The farmers in rural areas do not have enough knowledge on the

consequences of using antibiotic medicines for therapeutic use and this should be of

primary focus of the state in its implementation of the National Strategic Plan on

Antimicrobial Resistance (NSP-AMR). In attentive non-therapeutic use of antibiotic

medicines will lead to antibiotic resistance in farms. In addition, improper use, such as

using antibiotic medicine intended for humans in animals, will leave a resistant strain

in the animals’ bodies. Apart from this, there is also a misbelief adhered by local

farms who think that using antibiotic medicine in animals will speed up an animal’s

growth. This belief is partially true and partially false. It is true that antibiotic

medicines can maintain the health of animals and that can make them continue their

life span to grow. However, it is false in the sense that it is not a wonder pill that can

directly boost up an animal’s growth without consequences. The knowledge sharing

and awareness of proper use of antibiotic medicines in agriculture is essential in order

to educate local farmers about the optimization of the use of antibiotics to reduce

AMR in agricultural sectors. In this challenge, knowledge, awareness, and practice

among the farmers are essential and should be advocated and firmly guided by the

leading private sectors via best practices.

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5.2 Discussion of the Refined Analytical Framework

The findings collected by the author also reflected the weakness of the

analytical framework utilized by the author called “the Process of Global Health

Governance and International Standard of Domestic Implementation”. The

weakness of this framework is that it could not explain what and how individuals,

stakeholders, and the private sector involved in AMR could contribute to the public

sector down the line to achieve the international standard. What the author learned

from interviewing key persons like Dr. Brown and Dr. Kalpravidh on the cooperation

between the public and private sectors on international standards to combat AMR is

that there is not only one input which came from the GAP in a top down process, but

there is contributions from the AMR working group in each organization, i.e. Country

Cooperation Strategy framework of WHO, Country Program Framework of FAO, and

Focal Points Framework of OIE, who helped states tackle the AMR problem. For this,

the process of multisectoral collaboration from the old analytical framework has been

refined to be more deepening and widening as it presents the output, which came into

a bottom up process to contribute to the achievement of National Strategic Plan on

Antimicrobial Resistance’s Goal. If the state can gain the output like this and achieve

the NSP-AMR goals, the state’s accomplishment can rationally be beneficial for their

Figure 5.3: Impact of Antibiotic Use in Food-Producing Animals, (WHO, 2016)

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people and the international community. The state’s ultimate goal is the reduction of

Antimicrobial Resistance in Thailand and the improvement of Thai people’s well-

being in both medical and agricultural fields. The author, therefore, developed the

refined analytical framework as supported by the findings obtained from the study of

the cooperation between public and private sectors in relation towards international

standards set by international organizations. The revised analytical framework can be

called “The Multisectoral Framework of Global Health Governance in

Antimicrobial Resistance: the case of Thailand” as illustrated in the diagram

below:

With this framework the author can have a broad view of how a multi-sector

works together in order to help a state (Thailand) achieve its National Strategic Plan

on Antimicrobial Resistance. The top down process allowed the author and readers to

understand how the Global Action Plan has been implemented into the domestic

implementation. On the other hand, the GAP has been implemented into the National

Strategic Plan by adhering to the concepts of “One Health” and “Triangle that Moves

Figure 7: The Multisectoral Framework of Global Health Governance in AMR

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the Mountains”. The NSP-AMR launched by having the WHO (CCS), FAO (CPF),

and OIE (FPF), who specialized in the different areas: public health, agriculture, food

and feed, environment, and animal health and welfare to support the state in every

dimension. This becomes an output the down line for players like individuals,

farmers, and stakeholders in countering AMR.

In addition, Neoliberal institutionalism in IR theory assisted the author to

understand how states cooperate with others through coordination, compliance to the

certain rules and norms, working in multilateralism, understand the cheating as a

threat to cooperation and replace it with incentives. The output completed by the

down line players can be contributed and evaluated as “effectiveness” on countering

the AMR problem in Thailand according to the NSP-AMR. Traced back to what the

author learnt by using neoliberal institutionalism in analyzing this phenomenon,

neoliberal institutionalism is somewhat useful, but it can partially be applied through

the case study of Thailand on the domestic implementation to achieve the

international standard. To say so, it did project the cooperation between Thailand and

non-state actors like international organizations (WHO, FAO, and OIE) and the

private sector (CPF, Betragro, and others) within the anarchical state system

environment to pursue the national interest, which is the reduction of AMR infection

and the well-being of Thai people. In order to pursue national interest, Thailand, as a

state, followed certain rules and norms, in this case, the Global Action Plan on

Antimicrobial Resistance guided and supported by international organizations for

Thailand to have their own National Strategic Plan on Antimicrobial Resistance and

to implement it domestically in Thailand. This was done through private sectors,

stakeholders, and farmers, which influenced state national interest. Cheating and non-

compliance occurred in this process as a threat to cooperation as argued by neoliberal

institutionalism.

Although neoliberal institutionalism caught some of the key elements of the

phenomenon, it could not allow the author to crystalize the complete process of how

multisectoral collaboration worked or how to assist Thailand pursue its national

interest. Neoliberal institutionalism also could not explain the function of how the

state generated the working mechanism with international organizations and lead to

the output for achieving the national goals. Moreover, apart from non-state players

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like international organizations and the private sector, neoliberal institutionalism

dismissed the domestic organs of the state’s government, i.e. Ministries and Thai

institutions that responded with the NSP-AMR, which assisted the state in pursuing

goals by coordinating with international organizations and the down line players. For

this, the refined framework helped the author to understand the overall picture of what

happened in the AMR phenomenon in Thailand.

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CHAPTER 6

CONCLUSIONS AND RECOMMENDATIONS

6.1 Conclusions

The Global Action Plan launched by the tripartite collaboration of the WHO,

FAO, and OIE seemed to be ineffective in the past, not because of a lack of

cooperation between public and private sectors, but because of inadequate knowledge

and recognition on the consequences of inattentive, inappropriate, and irrational usage

of antimicrobial and antibiotic medicines by stakeholders in the private sector and by

local farmers. The legislative system in Thailand is not weak because of a lack of the

cooperation between public and private sectors, but because it can only be enforced

on some particular players in the AMR scheme, such as local farmers. It totally fails

to enforce the law against big private companies, such as the agricultural industries,

food producing companies, as well as the pharmaceutical companies selling

antibiotics to farmers. Even local farmers might not be complying with the law

because they do not have other medicines to use for their animals, plants or fruits.

Moreover, the domestic law cannot be enforced on key players like the private sector,

who are playing influential roles in the AMR scheme, because the punishment of the

law is too soft comparing to the benefit that the private sector earns.

Passing or making an amendment of the domestic law on the availability of

antibiotic medicine in drug stores in Thailand is quite difficult and cannot be done

overnight, with some particular reasons, such as the absence of antibiotic medicines

will increase the workload of professionals like doctors and veterinarians as there will

be more visitations to hospitals by patients requesting antibiotics. That might disturb

the public hospitals that are already crowded. In agricultural and livestock production,

there is a gap in the legislative body that allows the private sector to avoid a good

faith interpretation of laws relating to the usage of antibiotic medicines in their

products. Instead of using the phrase Antibiotic as a Growth Promoter (AGP) they are

using antibiotics as “prevention”. What the Thai government needs to do is to fix this

problem by convincing the down line players, i.e. private sectors, stakeholders, and

farmers, to follow the domestic implementation (NSP-AMR) by incentivizing them,

and close the gap of the legislative system in agriculture and enforce the laws

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equitably. A prescription by veterinarians should be required for stakeholders,

especially farmers, in use at their farms for prophylactic reasons, and generate correct

understanding on the consequences of AMR in agriculture and in humans for those

who remain undereducated. Nonetheless, it is too early to judge the Global Action

Plan as being ineffective in Thailand in the agricultural sectors. The analytical

framework of the author, which was used to analyze cooperation between

International Organizations and the public and private sectors in combating the

Antimicrobial Resistance in Thailand, can explain the overall picture in general but

cannot deepen the mechanism inside that will contribute to the Global Action Plan.

The findings indicate that apart from the top down process according to the author’s

analytical framework, there is a bottom up process contributing back to the Global

Action Plan because of multisectoral collaboration between International

Organizations, states, public authorities, and private sectors. This study has led to the

creation of an advanced scientific knowledge application relating to AMR in

Thailand. The author coined this revised, widened, and deepened analytical

framework as “The Multisectoral Framework of Global Health Governance in

Antimicrobial Resistance” as illustrated in the diagram below:

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As transnational health issues, especially in the scheme of AMR, is changing

and evolving all the time by many factors, the study of the National Strategic Plan on

Antimicrobial Resistance using the Multisectoral Framework of Global Health

Governance in Antimicrobial Resistance must be further studied after the NSP-AMR

has been in existence for four or five years in the future.

6.2 Recommendations

Everyone exposed to antimicrobial and antibiotic medicines commercially

should be held responsible for the AMR problem in Thailand. As AMR is both an

emerging natural process and a man-made phenomenon, we cannot one hundred

percent eradicate AMR from the world, but at least we can control and reduce

infection rates. In the Global Health Governance system, the Global Action Plan by

the tripartite collaboration of the WHO, FAO, OIE is right there for the Thai public

authority to adhere to and implement as a National Strategic Plan. The answer of the

research question of this paper, according to the findings, is the Global Action Plan by

the tripartite collaboration went dysfunctional in the past because of inadequate

knowledge, irrational, and inattentive actions on antimicrobial and antibiotic medicine

usage among stakeholders, i.e. the private sector and local farmers. The hypothesis of

this dissertation proved that the legislative system in Thailand is weak because it

insufficiently enforces the law impartially on influential players, like the private

sector, and can only be enforced on local farmers. It is not because of a lack of the

cooperation between the public and private sectors. Moreover, neoliberal

institutionalism, in this case, pinpointed that the legislative system in Thailand is also

weak because influential players are cheating and avoiding the common set of rules.

The enforcement of domestic laws is lacking and intentional misinterpretation of the

laws as well as briberies is rampant. Non-compliance and cheating by the down line

players, i.e. private sectors, stakeholders, and farmers will only contribute to

shortcomings to the state and make the domestic implementation guided by

international organizations combating AMR more ineffective, as argued by neoliberal

institutionalism.

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6.2.1 Pay more Attention to the AMR from the Agriculture Side

Thai public authorities may wish to pay more attention to AMR in

agricultural sectors, especially in relation to influential players’ compliance with the

domestic legislative system. The findings of the joint-assessment of Thailand in

countering AMR indicated that less attention has been paid to AMR in the agricultural

sector than to the human side. The ultimate goal of countering AMR in Thailand aims

to reduce AMR infection in public health. According to the joint-assessment figures

the Ministry of Public Health may need to be more engaged with the Ministry of

Agriculture and Cooperatives, Department of Livestock and Department of Fisheries,

on information sharing, research and development of animal medicine between

researchers and veterinarians. This also includes the consideration of budget

allocation in the agricultural field. As AMR is a threat to public health that is also

caused from agricultural sectors, MOPH should lead a health agenda, support

agricultural sectors, and propose more funds from the Royal Thai Government by

addressing this problem in cabinet meetings.

6.2.2 Encourage Best Practices through Public and Private

Partnerships (PPPs)

According to the findings, there are several leading agro-industrial companies

who voluntary support the plan of the government in dealing with AMR to achieve

Global Food Security. For example, Betagro started their pilot campaign on antibiotic

free animal meat, like pork and chicken, according to domestic demand from Thai

authorities (Betagro, 2013). However, what about the rest who still do not support the

National Strategic Plan? We can convince private stakeholders to join the plan.

Neoliberal institutionalism claims that states can provide cooperative engagement

with incentives (public goods) or learn how to cooperate with each other (reciprocity)

with private sectors to be part of the state’s plan. What Betagro is doing can be called

“Corporate Social Responsibility”, the Ministry of Agriculture and Cooperatives can

invite and convince the private sector by bringing this CSR campaign to them,

incentivizing them with tax cuts if they join the CSR program on Antibiotic Free in

Meat. The state should participate in private sector CSR programs by monitoring,

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verifying, and ensuring that they really do it for the society. Therefore, the state

authorities can play a monitoring and inspecting role as well as giving incentives to

the private sector for making good efforts and assisting them in contributing to the

society. Moreover, the role of the state here is to convince stakeholders that a

reduction in using antibiotics can reduce their cost. This campaign could contribute

and pave the way for more intense and comprehensive collaboration between public

and private sectors and create a new entity called “Public and Private Partnerships” to

combat AMR in Thailand.

6.2.3 Strengthen the Domestic Law to Cover all AMR Players

In the legislative body, although passing a domestic law prohibiting

selling antimicrobial and antibiotic medicines in Thailand seems to be impossible, we

can still encourage an amendment of the law that should impose harsher punishments,

i.e. revoking licenses of health professions like pharmacists or veterinarians who

dispense antibiotics for human use to farmers to use in their farms. Consumer powers,

civil society, and NGOs together can push forward this to policy to policy makers in

AMR high level meetings and propose that the Thai government considers and

endorses it in the future.

6.2.4 Improve AMR Awareness in Farmers

At the individual level, awareness in AMR is also essential in agricultural

sectors. The findings proved that most of the farmers do not know how the resistance

threatens human lives and that is because the problems derive from agricultural

sectors. With the assistance of the FAO, the Department of Livestock should push

forward the campaign to raise the awareness and generate further education for local

farmers about “Antibiotic Smart Usage”. In the long run, this campaign will be

diluted. Therefore, the Ministry of Agricultural and Cooperatives should enhance the

inspection system of local farmers in parallel with this campaign. Moreover, best

practices and success story telling in the leading private sectors like CP and Betagro

could help to educate and optimize the correct use of antibiotic medicines. The AMR

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value chains should also be studied more by the private sector with the assistance of

the FAO to find the root cause of AMR at every single channel of distribution.

Thailand is trying harder than other countries in Southeast Asia to combat

AMR (Thamlikitkul, 2015) and many academics and AMR experts believe that their

work is making positive progress (Tribuddharat, 2017). The assistance and framework

of International Organizations like the WHO, FAO, and OIE have been put in place

for Thailand to implement their own National Strategic Plan. The public authority

needs to push forward with this for all stakeholders, private sectors, and individuals

by giving them access to knowledge about AMR. One thing to bear in mind is AMR

will always need multisectoral coordination and cooperation from all involved players

in order to ensure effective containment of AMR sustainably and efficiently.

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APPENDICES

APPENDIX A

Semi-structured Interview Guideline

Topic: Global health governance and domestic implementation of international

standards

Participant: Program Officer of Antimicrobial Resistance, WHO Country

Office, Thailand

Objective: To study and understand why the global action plan to counter Antibiotic

Resistance launched by International Organizations is not effective in the case of

Thailand in terms of the agricultural side.

Instructions for interviewers

Introduce your name and organisation.

Explain the interview purpose: To study the relationship between Thai public

authority with Private sectors on countering Antibiotics Resistance problem in

Thailand.

Confirm that the interviewee is the key member.

Arrange a quiet place to speak to the participant.

Record interview date, time and address.

Read Informed Consent:

o If consent is REFUSED, record the reason for refusal on the Informed

Consent form.

o If consent is GIVEN, proceed with the interview guide.

Ask permission to record and take notes.

Ask permission to use name in the appendix of the report and assure the

participant that NO name is attributed to any quotes in the report.

I. Background Information

• Name (Mr/Mrs/Ms/Miss) and contact number:

• Position and Community:

• How long have you worked in this position?

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II. Knowledge and Practices Regarding on Countering Antibiotic Resistance in

Thailand (The Interview questions will be listed in this point)

III. Wrapping-up

Do you have any suggestions as to how Thailand could meet international standards

as prescribed by the Global Action Plan ?

Thank the interviewee and ask permission to come back for clarification or further

information if required.

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APPENDIX B

Informed Consent for Participation in the Interview I agree to participate in a study conducted by Thammasat University to find the

possible and sustainable way to make Private sectors cooperate with the Thai public

authority in order to decrease Antibiotics Resistance problem in Thailand under the

Global Action Plan launched by the WHO. I understand that this end of project

evaluation is designed to gather information about strength and weaknesses of WHO

activities and factors leading to or inhibiting success, in order to inform future

projects.

• My participation in this evaluation is voluntary. I understand that I will not be

paid for my participation. I may withdraw and discontinue participation at any

time. If I decline to participate or withdraw from the evaluation, no one will be

told. If I feel uncomfortable in any way during the interview session, I have the

right to decline to answer any question or to end the interview.

• Participation involves being interviewed by the student named Mr. Puttinant

Rungsunlohakul, a student from Faculty of Political Sciences in International

Relations. The interview will last approximately 30-45 minutes. Notes will be

written during the interview. An audiotape of the interview may be made. If I do

not want to be taped, I have the right to refuse the taping.

Permission: Yes:_____; No:_____.

• I understand that the interviewer will not identify me by name in any quotes in

the report using information obtained from this interview. My name will only be

mentioned in the list of participants in the appendix if I give my permission.

Permission: Yes:_____; No:_____.

• I have read and understand the explanation provided to me. I have been given a

copy of this consent form.

Interviewee’s Signature: _________________________ Date: _________________

Interviewer’s Signature: _________________________ Date: __________________

For further information please contact: Charlie Thame, Dissertation’s Advisor,

Thammasat University, 081-181-6132, [email protected]

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BIOGRAPHY

Name Mr. PUTTINANT RUNGSUNLOHAKUL

Date of Birth May 12, 1989

Educational Attainment 2016: Master of Political Sciences

Work Position International Relations Specialist

Faculty of Medicine Siriraj Hospital

Mahidol University

Scholarship 2015-2017: Siriraj Development Scholarship

APA Reference Style

Work Experiences International Relations Specialist

Faculty of Medicine Siriraj Hospital

Mahidol University

2013 – Present

Academic Officer

Silpakorn University International College

2011 – 2013

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