A Qualitative Study on the Practice Patterns of Pharmacies Engaged in the Common Illness Project in Thailand

A Qualitative Study on the Practice Patterns of Pharmacies Engaged in the Common Illness Project in Thailand | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Qualitative Study on the Practice Patterns of Pharmacies Engaged in the Common Illness Project in Thailand Kridsadadanudej Wongwejwiwat, Siwaporn Peecharoensap, Phoobet Kotseekieo This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7949655/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Thailand’s Common Illness (CI) Project—launched in 2023 by the National Health Security Office (NHSO) and the Pharmacy Council—integrates accredited community pharmacies into primary care to manage 32 minor ailments, aiming to improve access and relieve hospital crowding amid universal health coverage (UHC). 1 , 2 Empirical evidence on real-world implementation and system barriers remains limited. Methods We undertook a qualitative descriptive study across 13 health regions (March–June 2025). Fourteen licensed pharmacists from CI-accredited pharmacies were purposively sampled to ensure diversity in geography, ownership model, and experience. Semi-structured online interviews (45–60 minutes) explored workflow, supply management, barriers, and perceived impacts. Audio was transcribed verbatim in Thai and analysed using inductive content analysis guided by COREQ. 3 Three analysts coded independently, compared matrices, and resolved discrepancies by consensus. English translations of verbatim quotes underwent back-translation. Results Pharmacies consistently performed core steps—eligibility verification, ID authentication, history-taking against 32 conditions, A-MED documentation, counselling/dispensing, day-3 follow-up, and claim submission—yet varied in supplementary practices (proactive patient explanation, supplementary record forms, photo/signature confirmation, risk-factor recording, systematic follow-up documentation). Barriers clustered at system (A-MED glitches, ambiguous rules, claim delays), patient (misconceptions, antibiotic expectations), pharmacy (equipment, staffing, workload), and financing (appeals, tax uncertainty). Perceived impacts included improved access (especially for low-income groups), enhanced professional identity, and reduced hospital burden, with administrative workload as a trade-off. We propose a standardised workflow to harmonise delivery. Conclusions The CI Project demonstrates the feasibility of pharmacy-based primary care under UHC, but quality and equity would benefit from national SOPs, digital supports, and monitoring incentives that institutionalise follow-up and documentation. Community pharmacy Minor ailments Implementation Universal health coverage Thailand Qualitative research Figures Figure 1 Introduction High-performing health systems rely on timely, accessible first-contact care, where community-based providers help absorb demand, coordinate care, and support rational medicine use. 4 , 5 Community pharmacies are among the most geographically accessible providers; international programmes (e.g., UK Minor Ailment Services [MAS] and Canada’s Pharmacist First ) show that structured pharmacist-led care can reduce unnecessary urgent/primary-care utilisation and improve patient experience. 6 , 7 In Spain, pragmatic trials of MAS reported improved referral appropriateness and patient-reported outcomes when pharmacists followed standardised consultation protocols and safety-netting follow-up. 8 Thailand’s UHC has progressively expanded the role of pharmacies in primary care; the CI Project (2023) formalised pharmacy management for 32 common ailments to reduce overcrowding, shorten travel/wait time, and strengthen community-level access under NHSO contracting. 1 , 2 Policy briefs and local evaluations suggest high patient satisfaction and favourable cost implications, yet routine implementation data remain sparse, and the degree of workflow standardisation across pharmacies is unclear. 1 , 2 Thai social-pharmacy literature has advanced competency frameworks for evolving community pharmacy services. 9 Community pharmacists also demonstrated adaptive and expanded professional practice during the COVID-19 pandemic. 10 Still, qualitative evidence on how workflows actually unfold, where barriers concentrate, and how impacts are perceived within the health-system context is limited. We therefore explored (1) practice patterns and workflow of CI services in community pharmacies, (2) barriers to implementation across patient/system/pharmacy/financing domains, and (3) perceived impacts on patients, providers, and the wider health system. By mapping step-by-step processes and variation, we aim to inform a standard operating procedure (SOP) and policy levers for scale-up under UHC. Methods Study design and rationale This study adopted a qualitative descriptive design within a constructivist paradigm to capture participants’ lived experiences of implementing the Common Illness (CI) Project in real practice contexts. Such a design was considered appropriate for service delivery research where practical insights are prioritised over theoretical abstraction. 11 The approach allows for rich, contextualised descriptions that inform policy adjustments and health-system implementation strategies. The study was conducted between March and June 2025, approximately one year after the CI Project’s nationwide rollout. This period was strategically chosen to provide pharmacies with sufficient operational experience while minimising recall bias. The research questions were guided by three principles central to health-service research: feasibility, acceptability, and sustainability of new service models. 12 Setting and programme context The CI Project enables accredited community pharmacies to manage 32 specified minor conditions for beneficiaries under the Universal Coverage Scheme (UCS), reimbursed through the NHSO. Pharmacies access the A-MED online platform for registration, documentation, and claim submission. Participating pharmacies must meet Quality pharmacy standards accredited by the Thai Pharmacy Council, maintain a dedicated consultation space, and employ at least one full-time pharmacist. However, infrastructure and IT readiness vary substantially between independent and chain pharmacies. Sampling strategy and participant recruitment A purposive maximum-variation sampling approach was used to capture heterogeneity across regions, ownership (independent vs. chain), and years of practice. Provincial pharmaceutical associations were contacted to identify potential participants. Fourteen pharmacists were recruited—one from each of 13 health regions, with one additional from Region 7 to balance gender and ownership profiles. Participants were invited via official email with study information sheets and consent forms. Inclusion criteria were: Licensed community pharmacist accredited under the CI Project. Minimum of six months’ experience providing CI services. Ability to participate in a one-hour online interview. Exclusion criteria were pharmacists who were not directly involved in service delivery or had less than 6 months’ experience. Recruitment continued until thematic saturation was reached—defined as the point at which new interviews yielded no novel codes or insights regarding workflow, barriers, or impacts. 13 Data collection procedures A semi-structured interview guide and a data recording form were explicitly developed for this study, informed by relevant literature and expert consultation in pharmacy practice and health service research. The instruments were piloted with two non-participant pharmacists to refine question clarity and sequencing before complete data collection. The interview guide explored six domains: (1) CI service delivery workflow, (2) pharmaceutical supply management, (3) collaboration with other healthcare providers, (4) use of digital tools and reporting systems (A-MED), (5) barriers and challenges, and (6) perceived impacts on practice, patients, and the health system. The corresponding data recording form was used to document contextual observations and participant demographics during interviews. The complete English-language versions of the interview guide and data recording form are provided as a Supplementary record form for transparency and reproducibility. Data processing, translation, and management Recordings were transcribed verbatim in Thai. Transcripts were verified for accuracy by two bilingual researchers. English translations were subsequently back-translated into Thai by an independent translator to ensure semantic fidelity. The final bilingual dataset was stored on an encrypted institutional drive accessible only to the research team. Data analysis and coding framework Data were analysed using inductive qualitative content analysis following Elo and Kyngäs (2008). 14 Preparation: immersion in data through repeated reading to grasp the overall meaning. Open coding: assigning short descriptive labels to meaning units. Organisation: clustering similar codes into categories. Abstraction: developing higher-order themes. Coding was conducted manually by three researchers (KW, SP, PK). To enhance dependability, an initial codebook was jointly developed after coding three pilot transcripts. Inter-coder reliability was discussed biweekly; discrepancies were resolved through negotiated consensus. Rigour and reflexivity Four quality criteria were addressed per Lincoln and Guba’s framework: Credibility: data triangulation (multi-coder analysis, participant validation). Dependability: transparent audit trail of coding decisions. Confirmability: reflexive journaling to minimise researcher bias. Transferability: thick description of context enabling readers to assess applicability. The primary analyst (KW) is a lecturer in pharmacy practice with prior collaboration with NHSO but no administrative role, which mitigated conflict of interest while allowing insider understanding. Results Participant characteristics Baseline characteristics of participating pharmacists and pharmacies are presented in Table 1 . The 14 pharmacists represented diverse practice environments: 11 independent pharmacies (six urban, five rural) and three chain pharmacies. Participants’ years of professional experience ranged from 5 to 25 years (median = 12). All had used the A-MED platform and submitted at least five claims per month under the CI Project. Table 1 Baseline characteristics of participating pharmacists and pharmacies (n = 14) Characteristic n (%) or range Details/description Gender Female = 8 (57.1%) ; Male = 6 (42.9%) Age group (years) 30–59 (range 34–58) Median = 44 years Years of professional experience 5–25 (range 8–23) Median = 12 years Professional role Pharmacy owner / licensee = 11 (78.6%); Staff pharmacist = 3 (21.4%) Type of pharmacy Independent = 11 (78.6%); Chain = 3 (21.4%) Chain pharmacies belonged to national retail groups Setting Urban = 6 (42.9%); Semi-urban = 3 (21.4%); Rural = 5 (35.7%) Region represented 13 health regions nationwide North = 2; Northeast = 5; Central = 4; South = 3 Duration of CI Project participation 6–12 months All ≥ 6 months continuous participation Average monthly CI encounters per pharmacy 20–80 cases Median = 45 cases per month Computer / A-MED system access Desktop only = 8 (57.1%); Desktop + Tablet = 4 (28.6%); Multiple devices = 2 (14.3%) All pharmacies had internet access. Follow-up modality Telephone = 12 (85.7%); LINE messaging = 6 (42.9%); Mixed methods = 4 (28.6%) Several pharmacies used ≥ 1 method Reported major barriers A-MED technical issue = 10 (71.4%); Claim delay = 9 (64.3%); Patient misunderstanding = 8 (57.1%); Equipment shortage = 6 (42.9%) Multiple responses possible Following analysis of participant characteristics, the interview data were examined to identify recurring patterns and relationships across cases. Thematic content analysis generated a set of interrelated categories that reflected how pharmacists perceived and enacted the CI Project in routine practice. These categories were subsequently synthesised into five overarching themes capturing the workflow of CI service delivery, pharmaceutical management, barriers to implementation, and perceived impacts on pharmacies, pharmacists, and the wider health system. Themes, subthemes, and representative quotes are summarised in Table 2 . Table 2 Themes, Sub-themes and Representative Quotes Main theme Sub-theme Representative quotes (illustrative excerpts) 1. Practice patterns of CI service a) Core workflow consistency “Every CI encounter begins the same way – verify UC card, take history, enter A-MED, dispense, follow-up.” (P6, Region 5) b) Patient communication approaches “We explain the CI scheme first; if people know it’s free, they’re more cooperative.” (P4, Region 6) c) Supplementary practices documentation “A-MED misses some details, so we use our own paper form for comorbidities and allergies.” (P12, Region 13) d) Follow-up strategies “Many patients ignore unknown numbers – we use LINE messages for day-3 check-ups.” (P11, Region 7) 2. Pharmaceutical supply management a) Use of existing inventory “We use our normal stock; no separate shelf for CI drugs.” (P2, Region 3) b) Programme-specific procurement “We ordered vetiver mouthwash especially for this project.” (P12, Region 13) c) Perceived future risks “If patient numbers drop, I worry we’ll be left with slow-moving items.” (P9, Region 2) 3. Barriers and challenges a) System barriers (A-MED instability, unclear scope) “Sometimes A-MED freezes; it takes a long time to log in again.” (P5, Region 10) / “With 32 conditions now, boundaries are unclear.” (P12, Region 13) b) Patient barriers (misconception, antibiotic demand) “Some asked for antibiotics for colds – we had to explain it was viral.” (P3, Region 4) c) Pharmacy barriers (workload, equipment) “The card reader often fails; we only have one computer.” (P14, Region 12) d) Financial barriers (claim delay, cash-flow) “Claims take months; small pharmacies struggle with cash.” (P11, Region 7) 4. Perceived impacts a) On pharmacies (reputation and trust) “People trust us more now that we’re part of the NHSO system.” (P2, Region 6) b) On pharmacists (professional role) “It feels like we’re real primary-care providers now.” (P14, Region 12) c) On patients (access and equity) “Elderly patients save travel costs and get care faster.” (P7, Region 11) d) On the health system (hospital decongestion) “Hospitals see fewer minor cases now – patients prefer coming to us.” (P13, Region 8) Theme 1: Practice patterns of CI service Across all sites, core processes were implemented consistently. The eligibility verification step used a UC card or mobile authentication; most pharmacists manually checked identity numbers due to system delays. History-taking covered symptoms, comorbidities, allergy history, and contraindications. Some used WHO symptom checklists integrated into A-MED, while others relied on experience. “The checklist is there, but I often expand questions to match the case. If a patient has asthma, I double-check before giving cold medicine.” (P3, Region 4) “The pharmacy created a small patient record form for history-taking, including name, phone number, comorbidities, and presenting symptoms.” (Region 13, P12) Counselling and dispensing were typically carried out by the pharmacist, with emphasis on dosage, red-flag signs, and lifestyle advice. Follow-up occurred mainly via telephone at day 3; however, up to 40% of patients could not be reached. Several pharmacies introduced creative alternatives such as LINE OA messaging, appointment cards, or reminder stickers on medication packages. “We attach a QR code linking to our LINE OA—patients can report their condition without answering calls.” (P7, Region 11) Documentation remained the weakest point: some pharmacists only entered essential data in A-MED, while others created supplementary record forms. Theme 2: Pharmaceutical supply management Most participants used their existing inventory without separate procurement lines. However, pharmacists perceived that NHSO’s formulary coverage indirectly influenced stocking decisions. Chain pharmacies negotiated central purchasing to reduce costs. Independent pharmacies expressed concern that reimbursement prices occasionally fell below acquisition cost, particularly for branded generics. “We purchased specific products for the project, such as vetiver mouthwash, which we normally would not stock.” (Region 13, P12) Issues regarding expired medicines were not reported, mainly because the project had been implemented only recently. A few pharmacies bought specific products, such as herbal preparations, to meet local demand or align with project expectations. No participant reported drug experiences, but several anticipated future challenges with stock rotation once utilisation stabilises. Theme 3: Barriers and challenges System-level barriers. Nearly all pharmacists reported A-MED technical instability, including slow server response times, login failures, and mismatched patient profiles. Additionally, claim verification sometimes took longer than expected, affecting cash flow. “When the service covered 12 conditions, the scope was clearer. With 32 conditions now, we are often uncertain about the exact boundaries.” (Region 13, P12) Policy-level barriers. Expansion from 12 to 32 conditions blurred the inclusion criteria: “At first, it was clear which diseases qualified. Now we need to check online each time; the definitions are similar.” (P9, Region 2) Pharmacy-level barriers. Hardware shortages, inadequate staff, and space constraints were common. In some single-pharmacist shops, workload forced delegation of preliminary tasks to assistants, potentially affecting counselling quality. “Most of the problems were related to equipment, especially the card reader and computer system.” (Region 14, P14) Patient-level barriers. Public awareness of the CI Project remained limited. Many believed it required payment or confused it with promotional campaigns. Misconceptions around antibiotics persisted. Included misconceptions about the project, such as demands for unnecessary or excessive medicines. “Some patients requested to stockpile paracetamol, asking for a whole bottle just to keep at home—this happened in about 40% of cases.” (Region 7, P11) Financial barriers. Reimbursement lag ranged from 1 to 3 months. Some claims were rejected without reason, requiring resubmission. Small independents described cash-flow stress. “Reimbursements were sometimes delayed… there were also cases where claims were rejected, and we had to file an appeal.” (Region 7, P11) Theme 4: Perceived impacts On pharmacies. Participation enhanced community trust and visibility: “Once people realised the service was free, they started recommending us to neighbours.” (P2, Region 6) “The number of customers increased, though perhaps not as much as we expected.” (Region 7, P11) On pharmacists. Professional satisfaction increased through expanded clinical responsibility and recognition from local health networks. “I could apply a broader range of knowledge… it felt like I had developed as a professional.” (Region 14, P14) Among patients, reduced travel and waiting time were observed, particularly among daily-wage earners and elderly individuals. The service improved accessibility to medicines and reduced financial burden, especially for low-income groups. “It became more convenient and helped people with limited financial resources to access medicines more easily.” (Region 13, P12) On the health system. Pharmacists noted fewer minor-ailment visits at nearby hospitals and clinics, echoing early NHSO monitoring data (informal feedback shared during interviews). “The project reduced the burden on hospitals to some extent, as patients did not want to spend long hours waiting there.” (Region 13, P12) Theme 5: Cross-case workflow variation Table 1 (supplementary) presents a cross-matrix of 14 pharmacies versus 10 key workflow steps. Core steps (eligibility check → counselling → follow-up → claim) achieved > 90% adherence; optional steps averaged 55–70%. The proposed best-practice SOP (Fig. 1 ) integrates both mandatory and recommended steps to support monitoring and scale-up. Workflow of CI service delivery Across all 14 pharmacies, a typical workflow for delivering CI services was observed, though some steps were inconsistently applied. Table 3 summarises the identified steps, highlighting those performed universally, variably implemented, or omitted. Table 3 Workflow steps identified across 14 participating pharmacies Workflow step Universally performed Variably performed Rarely/Not performed Explaining the CI project and patient eligibility Most pharmacies Some skipped if patients already knew – Verifying eligibility (UC card / New Authen) ✔ – – ID card insertion and authentication ✔ – – History-taking and screening (32 conditions) ✔ – – Use of additional self-made patient record forms – ✔ (3–4 pharmacies) ✔ (majority) Documentation in A-MED ✔ – – Use of POS/Seamless for parallel entry – ✔ (several pharmacies) ✔ (others) Patient confirmation (signature/photo) – ✔ (many pharmacies) ✔ (some omitted) Counselling and dispensing medicines ✔ – – Recording risk factors (smoking, alcohol, etc.) – ✔ (few pharmacies) ✔ (most did not) Closing the case and saving the PDF ✔ – – Patient follow-up at 3 days (telephone) ✔ ✔ (some not consistent for all patients) – Documenting follow-up outcomes – ✔ (few pharmacies) ✔ (several omitted) Referral to hospital/other provider ✔ (as needed) – – Claiming and verifying reimbursement in Seamless ✔ – – All pharmacies followed the core sequence of eligibility verification, history-taking, A-MED entry, dispensing, follow-up, and claim submission. However, significant variation was observed in how specific tasks were implemented. Patient communication: Some pharmacies consistently explained the CI project to patients, while others skipped this step if patients appeared familiar with their rights. Documentation: While A-MED use was universal, some pharmacies developed additional paper-based or electronic patient record forms. A minority routinely recorded risk factors such as smoking or alcohol use. Patient confirmation: Procedures such as taking photos or obtaining signatures varied; some pharmacists considered them optional or burdensome. Follow-up: Although almost all pharmacists attempted to follow up by phone within three days, adherence was inconsistent, particularly when patients did not answer calls. System use: POS and Seamless systems were integrated in some pharmacies for parallel data management, while others relied solely on A-MED. This variation underscores the lack of standardised operating procedures across pharmacies, despite common workflow elements. Proposed standardised workflow Based on an analysis of 14 pharmacies, a consolidated best-practice workflow is proposed (Fig. 1 ). This represents an optimal, step-by-step process for community pharmacies to adopt to ensure consistent CI service delivery. This workflow shows that although most pharmacies followed similar core processes, inconsistencies emerged in patient confirmation, follow-up documentation, and supplementary record-keeping. Establishing a straightforward standard operating procedure (SOP) could help harmonise practices, reduce claim rejections, and improve continuity of care. The proposed flow chart provides a practical guide for pharmacies newly joining the CI project, ensuring quality and uniformity in service delivery. The flow chart summarises the consolidated steps derived from 14 participating pharmacies. Core processes included eligibility verification, ID authentication, history-taking, A-MED documentation, counselling, dispensing, patient confirmation, follow-up, and claim submission. Optional but recommended steps, such as recording risk factors, were identified in some pharmacies. When patients improved, pharmacists proceeded with claim submission; unresolved or worsening conditions led to referral to hospitals or other providers. This standardised workflow provides a practical guide to ensuring consistent, high-quality CI service delivery. Discussion This study reveals both operational strengths and implementation gaps in Thailand’s CI Project, providing system-level insights for scaling community-pharmacy participation in UHC. Interpreting implementation through health-system lenses Our findings resonate with frameworks such as Normalisation Process Theory (NPT) and RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance). 16 , 17 Coherence : Pharmacists understood the rationale of CI services, but varied in interpreting boundaries after condition expansion. Cognitive participation : Engagement was high; most viewed CI as professionally rewarding. Collective action : Resource gaps (equipment, staffing) constrained complete execution. Reflexive monitoring : Absent structured feedback, limited continuous improvement. Thus, sustainability depends on clarifying roles, stabilising digital infrastructure, and institutionalising monitoring loops. Comparison with international experiences The CI Project’s early success in accessibility mirrors outcomes from the UK MAS, Spain, and Canada, which also improved convenience and equity. 6 – 8 However, the Thai experience emphasises unique implementation inequities between chain and independent pharmacies—inequities that are less discussed in high-income settings. BMC HSR papers on “task-sharing in primary care” and “integration of private providers in UHC” highlight similar tensions between central policy ambition and local capacity. 18 , 19 Digital and operational challenges A-MED instability and opaque claim processes align with barriers observed across global digital health scale-ups. 14 Evidence from the NHS England digital minor-ailment pilot shows that real-time analytics and responsive technical support were crucial to sustain engagement. 20 For Thailand, embedding technical help desks, automated patching, and data dashboards within A-MED could enhance trust and efficiency. Professional identity and stewardship Consistent with studies from LMICs 10 , 15 , pharmacists in this study perceived expanded professional legitimacy through CI participation. Yet, antibiotic stewardship challenges persisted, reflecting the cultural inertia of patient expectations. 21 Introducing structured communication scripts and visual aids within CI consultations could mitigate pressure to dispense inappropriate medications. Policy implications for UHC strengthening From a policy perspective, CI pharmacies constitute a strategic decentralisation mechanism for primary care. Ensuring their long-term contribution requires: Codified SOPs and digital templates defining required vs optional steps. Capacity-building and peer-learning clusters for continuous quality improvement. Equitable financing models considering small-pharmacy liquidity constraints. Data-driven monitoring integrated with NHSO dashboards to track coverage, follow-up rates, and rejection ratios. These recommendations align with WHO guidance on engaging the private sector in UHC through structured contracting, data transparency, and accountability mechanisms. 22 Strengths and limitations revisited Methodologically, this study’s multi-region qualitative design allowed insight into national heterogeneity. The bilingual data approach strengthens transferability. However, potential recall and desirability biases may arise, as participants may portray compliance in a favourable light. Furthermore, the small sample restricts inference to representativeness, though qualitative depth compensates by elucidating processes invisible in routine data. Future research Future mixed-methods studies should quantify SOP adherence and examine associations between fidelity and outcomes (symptom resolution, re-consultation rates, hospital load reduction). Economic evaluations could assess cost per successfully managed case, while implementation research could explore digital-innovation adoption pathways using frameworks such as Diffusion of Innovation. 23 Conclusions The Common Illness Project demonstrates Thailand’s capacity to mobilise community pharmacies as first-contact primary-care providers within UHC. While core processes are firmly embedded, inconsistency in documentation and follow-up underscores the need for robust SOPs, supportive digital infrastructure, and equitable financing. Strengthening these dimensions will transform pharmacy participation from a pilot intervention into a sustainable pillar of national primary healthcare. Declarations Ethics approval and consent to participate The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Ethical approval was granted by the Human Research Ethics Committee, Faculty of Pharmacy, Siam University (Approval No. 003/2025). All participants provided written informed consent before participation. Consent for publication Not applicable. No identifiable personal data is included. Competing interests The authors declare no competing interests. Funding This research received no external funding. Author Contribution KW conceptualised the study, oversaw methods, and led manuscript drafting. SP and PK conducted interviews, contributed to coding/analysis, and reviewed drafts. All authors approved the final manuscript. Acknowledgements We thank participating pharmacists for their time and insights, and colleagues who provided methodological feedback on qualitative analysis and health-system framing. Data Availability The datasets generated and analysed in this study are available in the supplementary materials and from the corresponding author upon reasonable request. References Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457–502. 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Empowering Thai community pharmacists to improve antibiotic supply practices: a mixed-methods study. Antibiot (Basel). 2024;13(8):945. May C, Finch T. Implementing, embedding, and integrating practices: an outline of Normalisation Process Theory. Sociology. 2009;43(3):535–54. Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89(9):1322–7. Lehmann U, Gilson L. Action learning for health-system strengthening: qualitative insights from South Africa. BMC Health Serv Res. 2013;13:144. Balabanova D, et al. Engaging private providers in UHC: lessons from low- and middle-income countries. BMC Health Serv Res. 2022;22(1):1173. Barker I, et al. Digital minor ailment services in English community pharmacies: mixed-methods evaluation. BMC Health Serv Res. 2020;20:935. Kotwani A, Wattal C. Community use of antibiotics in developing countries and resistance implications. Clin Microbiol Infect. 2017;23(7):452–8. World Health Organization. Engaging the private health service delivery sector through governance in mixed health systems: strategy report. Geneva: WHO; 2020. Rogers EM. Diffusion of innovations. 5th ed. New York: Free; 2003. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7949655","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":539320574,"identity":"71af0a1c-764f-4a3a-a521-83e8c36e7f7c","order_by":0,"name":"Kridsadadanudej Wongwejwiwat","email":"data:image/png;base64,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","orcid":"","institution":"Siam University","correspondingAuthor":true,"prefix":"","firstName":"Kridsadadanudej","middleName":"","lastName":"Wongwejwiwat","suffix":""},{"id":539320575,"identity":"434029ec-714b-465b-8979-a4983ffb6942","order_by":1,"name":"Siwaporn Peecharoensap","email":"","orcid":"","institution":"Siwaporn Pharmacy","correspondingAuthor":false,"prefix":"","firstName":"Siwaporn","middleName":"","lastName":"Peecharoensap","suffix":""},{"id":539320576,"identity":"91977fcb-fa69-43b0-bd9c-98c92586293d","order_by":2,"name":"Phoobet Kotseekieo","email":"","orcid":"","institution":"Plai Pharmacy","correspondingAuthor":false,"prefix":"","firstName":"Phoobet","middleName":"","lastName":"Kotseekieo","suffix":""}],"badges":[],"createdAt":"2025-10-27 11:06:50","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7949655/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7949655/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":95103787,"identity":"a1bc799d-87b2-4194-860a-8c2889823f78","added_by":"auto","created_at":"2025-11-04 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10:24:48","extension":"xml","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":80088,"visible":true,"origin":"","legend":"","description":"","filename":"528322b545f24be2a281e01a1acbd5681structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7949655/v1/2d5bafa8fcab6e3fb0e1dc8e.xml"},{"id":95103807,"identity":"d32b974d-ce91-4d95-a103-a6d5a6cb2f4e","added_by":"auto","created_at":"2025-11-04 10:24:57","extension":"html","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":89158,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7949655/v1/651487aa441dc592b5c74b1d.html"},{"id":95103780,"identity":"921f7223-a2d2-4f80-80cf-fae5e877f65d","added_by":"auto","created_at":"2025-11-04 10:24:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":46402,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStandardised workflow for CI service delivery in community pharmacies.\u003cbr\u003e\n\u003c/strong\u003eThe flow chart summarises the consolidated steps derived from 14 participating pharmacies. Core processes included eligibility verification, ID authentication, history-taking, A-MED documentation, counselling, dispensing, patient confirmation, follow-up, and claim submission. Optional but recommended steps, such as recording risk factors, were identified in some pharmacies. When patients improved, pharmacists proceeded with claim submission; unresolved or worsening conditions led to referral to hospitals or other providers. This standardised workflow provides a practical guide to ensuring consistent, high-quality CI service delivery.\u003c/p\u003e","description":"","filename":"CIserviceworkflow.png","url":"https://assets-eu.researchsquare.com/files/rs-7949655/v1/ba96836c5e1e476efa4ace4c.png"},{"id":95653949,"identity":"6248e2f3-be0b-4b91-9b94-a34c1c71f40b","added_by":"auto","created_at":"2025-11-11 16:06:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1243579,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7949655/v1/7145dba5-36d9-49f3-ad16-33c0d7bcc6b7.pdf"},{"id":95103678,"identity":"94ccc892-1ba4-4981-a3ea-814a3dc52379","added_by":"auto","created_at":"2025-11-04 10:24:39","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":17974,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTableS1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7949655/v1/2ed9cc680e18c8a769c587e6.docx"},{"id":95103741,"identity":"5fd4f174-b27c-462a-b388-1cc8e3ce94ac","added_by":"auto","created_at":"2025-11-04 10:24:49","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20342,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryInterviewGuideandDataRecordingForm.docx","url":"https://assets-eu.researchsquare.com/files/rs-7949655/v1/bb185cf4a3327bb777fd8c20.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Qualitative Study on the Practice Patterns of Pharmacies Engaged in the Common Illness Project in Thailand","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHigh-performing health systems rely on timely, accessible first-contact care, where community-based providers help absorb demand, coordinate care, and support rational medicine use.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Community pharmacies are among the most geographically accessible providers; international programmes (e.g., UK Minor Ailment Services [MAS] and Canada\u0026rsquo;s \u003cem\u003ePharmacist First\u003c/em\u003e) show that structured pharmacist-led care can reduce unnecessary urgent/primary-care utilisation and improve patient experience.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e In Spain, pragmatic trials of MAS reported improved referral appropriateness and patient-reported outcomes when pharmacists followed standardised consultation protocols and safety-netting follow-up.\u003csup\u003e8\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThailand\u0026rsquo;s UHC has progressively expanded the role of pharmacies in primary care; the CI Project (2023) formalised pharmacy management for 32 common ailments to reduce overcrowding, shorten travel/wait time, and strengthen community-level access under NHSO contracting.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Policy briefs and local evaluations suggest high patient satisfaction and favourable cost implications, yet routine implementation data remain sparse, and the degree of workflow standardisation across pharmacies is unclear.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Thai social-pharmacy literature has advanced competency frameworks for evolving community pharmacy services.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Community pharmacists also demonstrated adaptive and expanded professional practice during the COVID-19 pandemic.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Still, qualitative evidence on how workflows actually unfold, where barriers concentrate, and how impacts are perceived within the health-system context is limited.\u003c/p\u003e\u003cp\u003eWe therefore explored (1) practice patterns and workflow of CI services in community pharmacies, (2) barriers to implementation across patient/system/pharmacy/financing domains, and (3) perceived impacts on patients, providers, and the wider health system. By mapping step-by-step processes and variation, we aim to inform a standard operating procedure (SOP) and policy levers for scale-up under UHC.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design and rationale\u003c/h2\u003e\u003cp\u003eThis study adopted a qualitative descriptive design within a constructivist paradigm to capture participants\u0026rsquo; lived experiences of implementing the Common Illness (CI) Project in real practice contexts. Such a design was considered appropriate for service delivery research where practical insights are prioritised over theoretical abstraction.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e The approach allows for rich, contextualised descriptions that inform policy adjustments and health-system implementation strategies.\u003c/p\u003e\u003cp\u003eThe study was conducted between March and June 2025, approximately one year after the CI Project\u0026rsquo;s nationwide rollout. This period was strategically chosen to provide pharmacies with sufficient operational experience while minimising recall bias.\u003c/p\u003e\u003cp\u003eThe research questions were guided by three principles central to health-service research: feasibility, acceptability, and sustainability of new service models.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSetting and programme context\u003c/h3\u003e\n\u003cp\u003eThe CI Project enables accredited community pharmacies to manage 32 specified minor conditions for beneficiaries under the Universal Coverage Scheme (UCS), reimbursed through the NHSO. Pharmacies access the A-MED online platform for registration, documentation, and claim submission.\u003c/p\u003e\u003cp\u003eParticipating pharmacies must meet Quality pharmacy standards accredited by the Thai Pharmacy Council, maintain a dedicated consultation space, and employ at least one full-time pharmacist. However, infrastructure and IT readiness vary substantially between independent and chain pharmacies.\u003c/p\u003e\n\u003ch3\u003eSampling strategy and participant recruitment\u003c/h3\u003e\n\u003cp\u003eA purposive maximum-variation sampling approach was used to capture heterogeneity across regions, ownership (independent vs. chain), and years of practice. Provincial pharmaceutical associations were contacted to identify potential participants. Fourteen pharmacists were recruited\u0026mdash;one from each of 13 health regions, with one additional from Region 7 to balance gender and ownership profiles.\u003c/p\u003e\u003cp\u003e Participants were invited via official email with study information sheets and consent forms. Inclusion criteria were:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eLicensed community pharmacist accredited under the CI Project.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eMinimum of six months\u0026rsquo; experience providing CI services.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAbility to participate in a one-hour online interview.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eExclusion criteria were pharmacists who were not directly involved in service delivery or had less than 6 months\u0026rsquo; experience.\u003c/p\u003e\u003cp\u003eRecruitment continued until thematic saturation was reached\u0026mdash;defined as the point at which new interviews yielded no novel codes or insights regarding workflow, barriers, or impacts.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003ch3\u003eData collection procedures\u003c/h3\u003e\n\u003cp\u003eA semi-structured interview guide and a data recording form were explicitly developed for this study, informed by relevant literature and expert consultation in pharmacy practice and health service research. The instruments were piloted with two non-participant pharmacists to refine question clarity and sequencing before complete data collection.\u003c/p\u003e\u003cp\u003eThe interview guide explored six domains: (1) CI service delivery workflow, (2) pharmaceutical supply management, (3) collaboration with other healthcare providers, (4) use of digital tools and reporting systems (A-MED), (5) barriers and challenges, and (6) perceived impacts on practice, patients, and the health system.\u003c/p\u003e\u003cp\u003eThe corresponding data recording form was used to document contextual observations and participant demographics during interviews.\u003c/p\u003e\u003cp\u003eThe complete English-language versions of the interview guide and data recording form are provided as a Supplementary record form for transparency and reproducibility.\u003c/p\u003e\n\u003ch3\u003eData processing, translation, and management\u003c/h3\u003e\n\u003cp\u003eRecordings were transcribed verbatim in Thai. Transcripts were verified for accuracy by two bilingual researchers. English translations were subsequently back-translated into Thai by an independent translator to ensure semantic fidelity. The final bilingual dataset was stored on an encrypted institutional drive accessible only to the research team.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData analysis and coding framework\u003c/h2\u003e\u003cp\u003eData were analysed using inductive qualitative content analysis following Elo and Kyng\u0026auml;s (2008).\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003ePreparation: immersion in data through repeated reading to grasp the overall meaning.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eOpen coding: assigning short descriptive labels to meaning units.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eOrganisation: clustering similar codes into categories.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAbstraction: developing higher-order themes.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eCoding was conducted manually by three researchers (KW, SP, PK). To enhance dependability, an initial codebook was jointly developed after coding three pilot transcripts. Inter-coder reliability was discussed biweekly; discrepancies were resolved through negotiated consensus.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eRigour and reflexivity\u003c/h3\u003e\n\u003cp\u003eFour quality criteria were addressed per Lincoln and Guba\u0026rsquo;s framework:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eCredibility: data triangulation (multi-coder analysis, participant validation).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eDependability: transparent audit trail of coding decisions.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eConfirmability: reflexive journaling to minimise researcher bias.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eTransferability: thick description of context enabling readers to assess applicability.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThe primary analyst (KW) is a lecturer in pharmacy practice with prior collaboration with NHSO but no administrative role, which mitigated conflict of interest while allowing insider understanding.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eParticipant characteristics\u003c/h2\u003e\u003cp\u003eBaseline characteristics of participating pharmacists and pharmacies are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The 14 pharmacists represented diverse practice environments: 11 independent pharmacies (six urban, five rural) and three chain pharmacies. Participants\u0026rsquo; years of professional experience ranged from 5 to 25 years (median\u0026thinsp;=\u0026thinsp;12). All had used the A-MED platform and submitted at least five claims per month under the CI Project.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline characteristics of participating pharmacists and pharmacies (n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en (%) or range\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDetails/description\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u0026thinsp;=\u0026thinsp;8 (57.1%) ; Male\u0026thinsp;=\u0026thinsp;6 (42.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge group (years)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30\u0026ndash;59 (range 34\u0026ndash;58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMedian\u0026thinsp;=\u0026thinsp;44 years\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eYears of professional experience\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u0026ndash;25 (range 8\u0026ndash;23)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMedian\u0026thinsp;=\u0026thinsp;12 years\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eProfessional role\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePharmacy owner / licensee\u0026thinsp;=\u0026thinsp;11 (78.6%); Staff pharmacist\u0026thinsp;=\u0026thinsp;3 (21.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eType of pharmacy\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndependent\u0026thinsp;=\u0026thinsp;11 (78.6%); Chain\u0026thinsp;=\u0026thinsp;3 (21.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eChain pharmacies belonged to national retail groups\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSetting\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUrban\u0026thinsp;=\u0026thinsp;6 (42.9%); Semi-urban\u0026thinsp;=\u0026thinsp;3 (21.4%); Rural\u0026thinsp;=\u0026thinsp;5 (35.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRegion represented\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 health regions nationwide\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNorth\u0026thinsp;=\u0026thinsp;2; Northeast\u0026thinsp;=\u0026thinsp;5; Central\u0026thinsp;=\u0026thinsp;4; South\u0026thinsp;=\u0026thinsp;3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDuration of CI Project participation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6\u0026ndash;12 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAll \u0026ge;\u0026thinsp;6 months continuous participation\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAverage monthly CI encounters per pharmacy\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20\u0026ndash;80 cases\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMedian\u0026thinsp;=\u0026thinsp;45 cases per month\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eComputer / A-MED system access\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDesktop only\u0026thinsp;=\u0026thinsp;8 (57.1%); Desktop\u0026thinsp;+\u0026thinsp;Tablet\u0026thinsp;=\u0026thinsp;4 (28.6%); Multiple devices\u0026thinsp;=\u0026thinsp;2 (14.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAll pharmacies had internet access.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFollow-up modality\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTelephone\u0026thinsp;=\u0026thinsp;12 (85.7%); LINE messaging\u0026thinsp;=\u0026thinsp;6 (42.9%); Mixed methods\u0026thinsp;=\u0026thinsp;4 (28.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSeveral pharmacies used\u0026thinsp;\u0026ge;\u0026thinsp;1 method\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eReported major barriers\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eA-MED technical issue\u0026thinsp;=\u0026thinsp;10 (71.4%); Claim delay\u0026thinsp;=\u0026thinsp;9 (64.3%); Patient misunderstanding\u0026thinsp;=\u0026thinsp;8 (57.1%); Equipment shortage\u0026thinsp;=\u0026thinsp;6 (42.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMultiple responses possible\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFollowing analysis of participant characteristics, the interview data were examined to identify recurring patterns and relationships across cases. Thematic content analysis generated a set of interrelated categories that reflected how pharmacists perceived and enacted the CI Project in routine practice. These categories were subsequently synthesised into five overarching themes capturing the workflow of CI service delivery, pharmaceutical management, barriers to implementation, and perceived impacts on pharmacies, pharmacists, and the wider health system. Themes, subthemes, and representative quotes are summarised in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThemes, Sub-themes and Representative Quotes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMain theme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSub-theme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRepresentative quotes (illustrative excerpts)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e1. Practice patterns of CI service\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ea) Core workflow consistency\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;Every CI encounter begins the same way \u0026ndash; verify UC card, take history, enter A-MED, dispense, follow-up.\u0026rdquo; (P6, Region 5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eb) Patient communication approaches\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;We explain the CI scheme first; if people know it\u0026rsquo;s free, they\u0026rsquo;re more cooperative.\u0026rdquo; (P4, Region 6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ec) Supplementary practices documentation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;A-MED misses some details, so we use our own paper form for comorbidities and allergies.\u0026rdquo; (P12, Region 13)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ed) Follow-up strategies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;Many patients ignore unknown numbers \u0026ndash; we use LINE messages for day-3 check-ups.\u0026rdquo; (P11, Region 7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e2. Pharmaceutical supply management\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ea) Use of existing inventory\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;We use our normal stock; no separate shelf for CI drugs.\u0026rdquo; (P2, Region 3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eb) Programme-specific procurement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;We ordered vetiver mouthwash especially for this project.\u0026rdquo; (P12, Region 13)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ec) Perceived future risks\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;If patient numbers drop, I worry we\u0026rsquo;ll be left with slow-moving items.\u0026rdquo; (P9, Region 2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e3. Barriers and challenges\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ea) System barriers (A-MED instability, unclear scope)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;Sometimes A-MED freezes; it takes a long time to log in again.\u0026rdquo; (P5, Region 10) / \u0026ldquo;With 32 conditions now, boundaries are unclear.\u0026rdquo; (P12, Region 13)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eb) Patient barriers (misconception, antibiotic demand)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;Some asked for antibiotics for colds \u0026ndash; we had to explain it was viral.\u0026rdquo; (P3, Region 4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ec) Pharmacy barriers (workload, equipment)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;The card reader often fails; we only have one computer.\u0026rdquo; (P14, Region 12)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ed) Financial barriers (claim delay, cash-flow)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;Claims take months; small pharmacies struggle with cash.\u0026rdquo; (P11, Region 7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e4. Perceived impacts\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ea) On pharmacies (reputation and trust)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;People trust us more now that we\u0026rsquo;re part of the NHSO system.\u0026rdquo; (P2, Region 6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eb) On pharmacists (professional role)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;It feels like we\u0026rsquo;re real primary-care providers now.\u0026rdquo; (P14, Region 12)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ec) On patients (access and equity)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;Elderly patients save travel costs and get care faster.\u0026rdquo; (P7, Region 11)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ed) On the health system (hospital decongestion)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;Hospitals see fewer minor cases now \u0026ndash; patients prefer coming to us.\u0026rdquo; (P13, Region 8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eTheme 1: Practice patterns of CI service\u003c/h2\u003e\u003cp\u003eAcross all sites, core processes were implemented consistently. The eligibility verification step used a UC card or mobile authentication; most pharmacists manually checked identity numbers due to system delays. History-taking covered symptoms, comorbidities, allergy history, and contraindications. Some used WHO symptom checklists integrated into A-MED, while others relied on experience.\u003c/p\u003e\u003cp\u003e\u0026ldquo;The checklist is there, but I often expand questions to match the case. If a patient has asthma, I double-check before giving cold medicine.\u0026rdquo; (P3, Region 4)\u003c/p\u003e\u003cp\u003e\u0026ldquo;The pharmacy created a small patient record form for history-taking, including name, phone number, comorbidities, and presenting symptoms.\u0026rdquo; (Region 13, P12)\u003c/p\u003e\u003cp\u003eCounselling and dispensing were typically carried out by the pharmacist, with emphasis on dosage, red-flag signs, and lifestyle advice. Follow-up occurred mainly via telephone at day 3; however, up to 40% of patients could not be reached. Several pharmacies introduced creative alternatives such as LINE OA messaging, appointment cards, or reminder stickers on medication packages.\u003c/p\u003e\u003cp\u003e\u0026ldquo;We attach a QR code linking to our LINE OA\u0026mdash;patients can report their condition without answering calls.\u0026rdquo; (P7, Region 11)\u003c/p\u003e\u003cp\u003eDocumentation remained the weakest point: some pharmacists only entered essential data in A-MED, while others created supplementary record forms.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eTheme 2: Pharmaceutical supply management\u003c/h2\u003e\u003cp\u003eMost participants used their existing inventory without separate procurement lines. However, pharmacists perceived that NHSO\u0026rsquo;s formulary coverage indirectly influenced stocking decisions. Chain pharmacies negotiated central purchasing to reduce costs. Independent pharmacies expressed concern that reimbursement prices occasionally fell below acquisition cost, particularly for branded generics.\u003c/p\u003e\u003cp\u003e\u0026ldquo;We purchased specific products for the project, such as vetiver mouthwash, which we normally would not stock.\u0026rdquo; (Region 13, P12)\u003c/p\u003e\u003cp\u003eIssues regarding expired medicines were not reported, mainly because the project had been implemented only recently. A few pharmacies bought specific products, such as herbal preparations, to meet local demand or align with project expectations. No participant reported drug experiences, but several anticipated future challenges with stock rotation once utilisation stabilises.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eTheme 3: Barriers and challenges\u003c/h2\u003e\u003cp\u003eSystem-level barriers. Nearly all pharmacists reported A-MED technical instability, including slow server response times, login failures, and mismatched patient profiles. Additionally, claim verification sometimes took longer than expected, affecting cash flow.\u003c/p\u003e\u003cp\u003e\u0026ldquo;When the service covered 12 conditions, the scope was clearer. With 32 conditions now, we are often uncertain about the exact boundaries.\u0026rdquo; (Region 13, P12)\u003c/p\u003e\u003cp\u003ePolicy-level barriers. Expansion from 12 to 32 conditions blurred the inclusion criteria:\u003c/p\u003e\u003cp\u003e\u0026ldquo;At first, it was clear which diseases qualified. Now we need to check online each time; the definitions are similar.\u0026rdquo; (P9, Region 2)\u003c/p\u003e\u003cp\u003ePharmacy-level barriers. Hardware shortages, inadequate staff, and space constraints were common. In some single-pharmacist shops, workload forced delegation of preliminary tasks to assistants, potentially affecting counselling quality.\u003c/p\u003e\u003cp\u003e\u0026ldquo;Most of the problems were related to equipment, especially the card reader and computer system.\u0026rdquo; (Region 14, P14)\u003c/p\u003e\u003cp\u003ePatient-level barriers. Public awareness of the CI Project remained limited. Many believed it required payment or confused it with promotional campaigns. Misconceptions around antibiotics persisted. Included misconceptions about the project, such as demands for unnecessary or excessive medicines.\u003c/p\u003e\u003cp\u003e\u0026ldquo;Some patients requested to stockpile paracetamol, asking for a whole bottle just to keep at home\u0026mdash;this happened in about 40% of cases.\u0026rdquo; (Region 7, P11)\u003c/p\u003e\u003cp\u003eFinancial barriers. Reimbursement lag ranged from 1 to 3 months. Some claims were rejected without reason, requiring resubmission. Small independents described cash-flow stress.\u003c/p\u003e\u003cp\u003e\u0026ldquo;Reimbursements were sometimes delayed\u0026hellip; there were also cases where claims were rejected, and we had to file an appeal.\u0026rdquo; (Region 7, P11)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eTheme 4: Perceived impacts\u003c/h2\u003e\u003cp\u003eOn pharmacies. Participation enhanced community trust and visibility:\u003c/p\u003e\u003cp\u003e\u0026ldquo;Once people realised the service was free, they started recommending us to neighbours.\u0026rdquo; (P2, Region 6)\u003c/p\u003e\u003cp\u003e\u0026ldquo;The number of customers increased, though perhaps not as much as we expected.\u0026rdquo; (Region 7, P11)\u003c/p\u003e\u003cp\u003eOn pharmacists. Professional satisfaction increased through expanded clinical responsibility and recognition from local health networks.\u003c/p\u003e\u003cp\u003e\u0026ldquo;I could apply a broader range of knowledge\u0026hellip; it felt like I had developed as a professional.\u0026rdquo; (Region 14, P14)\u003c/p\u003e\u003cp\u003eAmong patients, reduced travel and waiting time were observed, particularly among daily-wage earners and elderly individuals. The service improved accessibility to medicines and reduced financial burden, especially for low-income groups.\u003c/p\u003e\u003cp\u003e\u0026ldquo;It became more convenient and helped people with limited financial resources to access medicines more easily.\u0026rdquo; (Region 13, P12)\u003c/p\u003e\u003cp\u003eOn the health system. Pharmacists noted fewer minor-ailment visits at nearby hospitals and clinics, echoing early NHSO monitoring data (informal feedback shared during interviews).\u003c/p\u003e\u003cp\u003e\u0026ldquo;The project reduced the burden on hospitals to some extent, as patients did not want to spend long hours waiting there.\u0026rdquo; (Region 13, P12)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eTheme 5: Cross-case workflow variation\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e (supplementary) presents a cross-matrix of 14 pharmacies versus 10 key workflow steps. Core steps (eligibility check \u0026rarr; counselling \u0026rarr; follow-up \u0026rarr; claim) achieved\u0026thinsp;\u0026gt;\u0026thinsp;90% adherence; optional steps averaged 55\u0026ndash;70%.\u003c/p\u003e\u003cp\u003eThe proposed best-practice SOP (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) integrates both mandatory and recommended steps to support monitoring and scale-up.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eWorkflow of CI service delivery\u003c/h2\u003e\u003cp\u003eAcross all 14 pharmacies, a typical workflow for delivering CI services was observed, though some steps were inconsistently applied. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e summarises the identified steps, highlighting those performed universally, variably implemented, or omitted.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eWorkflow steps identified across 14 participating pharmacies\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWorkflow step\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUniversally performed\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eVariably performed\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRarely/Not performed\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExplaining the CI project and patient eligibility\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMost pharmacies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSome skipped if patients already knew\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVerifying eligibility (UC card / New Authen)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e✔\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eID card insertion and authentication\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e✔\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHistory-taking and screening (32 conditions)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e✔\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUse of additional self-made patient record forms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e✔ (3\u0026ndash;4 pharmacies)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e✔ (majority)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDocumentation in A-MED\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e✔\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUse of POS/Seamless for parallel entry\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e✔ (several pharmacies)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e✔ (others)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient confirmation (signature/photo)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e✔ (many pharmacies)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e✔ (some omitted)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCounselling and dispensing medicines\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e✔\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRecording risk factors (smoking, alcohol, etc.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e✔ (few pharmacies)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e✔ (most did not)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClosing the case and saving the PDF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e✔\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient follow-up at 3 days (telephone)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e✔\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e✔ (some not consistent for all patients)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDocumenting follow-up outcomes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e✔ (few pharmacies)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e✔ (several omitted)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReferral to hospital/other provider\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e✔ (as needed)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClaiming and verifying reimbursement in Seamless\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e✔\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAll pharmacies followed the core sequence of eligibility verification, history-taking, A-MED entry, dispensing, follow-up, and claim submission. However, significant variation was observed in how specific tasks were implemented.\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003ePatient communication: Some pharmacies consistently explained the CI project to patients, while others skipped this step if patients appeared familiar with their rights.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eDocumentation: While A-MED use was universal, some pharmacies developed additional paper-based or electronic patient record forms. A minority routinely recorded risk factors such as smoking or alcohol use.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePatient confirmation: Procedures such as taking photos or obtaining signatures varied; some pharmacists considered them optional or burdensome.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eFollow-up: Although almost all pharmacists attempted to follow up by phone within three days, adherence was inconsistent, particularly when patients did not answer calls.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSystem use: POS and Seamless systems were integrated in some pharmacies for parallel data management, while others relied solely on A-MED.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThis variation underscores the lack of standardised operating procedures across pharmacies, despite common workflow elements.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eProposed standardised workflow\u003c/h2\u003e\u003cp\u003eBased on an analysis of 14 pharmacies, a consolidated best-practice workflow is proposed (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). This represents an optimal, step-by-step process for community pharmacies to adopt to ensure consistent CI service delivery.\u003c/p\u003e\u003cp\u003eThis workflow shows that although most pharmacies followed similar core processes, inconsistencies emerged in patient confirmation, follow-up documentation, and supplementary record-keeping. Establishing a straightforward standard operating procedure (SOP) could help harmonise practices, reduce claim rejections, and improve continuity of care. The proposed flow chart provides a practical guide for pharmacies newly joining the CI project, ensuring quality and uniformity in service delivery.\u003c/p\u003e\u003cp\u003eThe flow chart summarises the consolidated steps derived from 14 participating pharmacies. Core processes included eligibility verification, ID authentication, history-taking, A-MED documentation, counselling, dispensing, patient confirmation, follow-up, and claim submission. Optional but recommended steps, such as recording risk factors, were identified in some pharmacies. When patients improved, pharmacists proceeded with claim submission; unresolved or worsening conditions led to referral to hospitals or other providers. This standardised workflow provides a practical guide to ensuring consistent, high-quality CI service delivery.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study reveals both operational strengths and implementation gaps in Thailand\u0026rsquo;s CI Project, providing system-level insights for scaling community-pharmacy participation in UHC.\u003c/p\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eInterpreting implementation through health-system lenses\u003c/h2\u003e\u003cp\u003eOur findings resonate with frameworks such as Normalisation Process Theory (NPT) and RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance).\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eCoherence\u003c/em\u003e: Pharmacists understood the rationale of CI services, but varied in interpreting boundaries after condition expansion.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eCognitive participation\u003c/em\u003e: Engagement was high; most viewed CI as professionally rewarding.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eCollective action\u003c/em\u003e: Resource gaps (equipment, staffing) constrained complete execution.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eReflexive monitoring\u003c/em\u003e: Absent structured feedback, limited continuous improvement.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThus, sustainability depends on clarifying roles, stabilising digital infrastructure, and institutionalising monitoring loops.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eComparison with international experiences\u003c/h2\u003e\u003cp\u003eThe CI Project\u0026rsquo;s early success in accessibility mirrors outcomes from the UK MAS, Spain, and Canada, which also improved convenience and equity.\u003csup\u003e\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e However, the Thai experience emphasises unique \u003cb\u003eimplementation inequities\u003c/b\u003e between chain and independent pharmacies\u0026mdash;inequities that are less discussed in high-income settings. BMC HSR papers on \u0026ldquo;task-sharing in primary care\u0026rdquo; and \u0026ldquo;integration of private providers in UHC\u0026rdquo; highlight similar tensions between central policy ambition and local capacity.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eDigital and operational challenges\u003c/h2\u003e\u003cp\u003eA-MED instability and opaque claim processes align with barriers observed across global digital health scale-ups.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Evidence from the NHS England digital minor-ailment pilot shows that real-time analytics and responsive technical support were crucial to sustain engagement.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e For Thailand, embedding technical help desks, automated patching, and data dashboards within A-MED could enhance trust and efficiency.\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eProfessional identity and stewardship\u003c/h2\u003e\u003cp\u003eConsistent with studies from LMICs\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e, pharmacists in this study perceived expanded professional legitimacy through CI participation. Yet, antibiotic stewardship challenges persisted, reflecting the cultural inertia of patient expectations.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e Introducing structured communication scripts and visual aids within CI consultations could mitigate pressure to dispense inappropriate medications.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003ePolicy implications for UHC strengthening\u003c/h2\u003e\u003cp\u003eFrom a policy perspective, CI pharmacies constitute a strategic decentralisation mechanism for primary care. Ensuring their long-term contribution requires:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eCodified SOPs and digital templates defining required vs optional steps.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eCapacity-building and peer-learning clusters for continuous quality improvement.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eEquitable financing models considering small-pharmacy liquidity constraints.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eData-driven monitoring integrated with NHSO dashboards to track coverage, follow-up rates, and rejection ratios.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eThese recommendations align with WHO guidance on engaging the private sector in UHC through structured contracting, data transparency, and accountability mechanisms.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003eStrengths and limitations revisited\u003c/h2\u003e\u003cp\u003eMethodologically, this study\u0026rsquo;s multi-region qualitative design allowed insight into national heterogeneity. The bilingual data approach strengthens transferability. However, potential recall and desirability biases may arise, as participants may portray compliance in a favourable light. Furthermore, the small sample restricts inference to representativeness, though qualitative depth compensates by elucidating processes invisible in routine data.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\u003ch2\u003eFuture research\u003c/h2\u003e\u003cp\u003eFuture mixed-methods studies should quantify SOP adherence and examine associations between fidelity and outcomes (symptom resolution, re-consultation rates, hospital load reduction). Economic evaluations could assess cost per successfully managed case, while implementation research could explore digital-innovation adoption pathways using frameworks such as Diffusion of Innovation.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe Common Illness Project demonstrates Thailand\u0026rsquo;s capacity to mobilise community pharmacies as first-contact primary-care providers within UHC. While core processes are firmly embedded, inconsistency in documentation and follow-up underscores the need for robust SOPs, supportive digital infrastructure, and equitable financing. Strengthening these dimensions will transform pharmacy participation from a pilot intervention into a sustainable pillar of national primary healthcare.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003e The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Ethical approval was granted by the Human Research Ethics Committee, Faculty of Pharmacy, Siam University (Approval No. 003/2025). All participants provided written informed consent before participation.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable. No identifiable personal data is included.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis research received no external funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eKW conceptualised the study, oversaw methods, and led manuscript drafting. SP and PK conducted interviews, contributed to coding/analysis, and reviewed drafts. All authors approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003e We thank participating pharmacists for their time and insights, and colleagues who provided methodological feedback on qualitative analysis and health-system framing.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and analysed in this study are available in the supplementary materials and from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eStarfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457\u0026ndash;502.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAnderson C, Blenkinsopp A, Armstrong M. The contribution of community pharmacy to improving the public\u0026rsquo;s health: evidence base. J Public Health (Oxf). 2003;25(1):29\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKringos DS, Boerma W, Hutchinson A, Saltman RB, editors. Building primary care in a changing Europe. Copenhagen: WHO Europe; 2015.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMossialos E, Naci H, Courtin E. Expanding the role of community pharmacists in public health. J R Soc Med. 2013;106(10):323\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWatson MC, Holland R, Ferguson J, Porteous T. Community pharmacy minor ailment schemes: effective, rapid and convenient. Pharm J. 2015;294:7859.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTsuyuki RT, et al. Pharmacist prescribing and patient outcomes: the Pharmacist First model in Canada. Can Pharm J (Ott). 2021;154(6):376\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAmador-Fern\u0026aacute;ndez N, et al. Effectiveness of a minor ailment service in Spanish community pharmacies: a pragmatic RCT. PLoS ONE. 2022;17(10):e0275252.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSuwannaprom P, et al. Development of pharmacy competency framework for changing services in Thailand. Pharm Pract (Granada). 2020;18(1):2141.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJarernsiripornkul N, Wongtaweepkij K, Pason D, Namwan T. Practices of community pharmacists during COVID-19 in Thailand. Pharm Pract (Granada). 2024;22(2):1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSandelowski M. Whatever happened to qualitative description? Res Nurs Health. 2000;23(4):334\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eElo S, Kyng\u0026auml;s H. The qualitative content analysis process. J Adv Nurs. 2008;62(1):107\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFauzi AA, et al. Perceptions of pharmacists/technicians on minor-ailment services in Indonesia: a qualitative study. Pharm (Basel). 2023;11(5):132.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGreenhalgh T, et al. Beyond adoption: a new framework for theorising and evaluating nonadoption, abandonment, scale-up, spread, and sustainability of health technologies. J Med Internet Res. 2017;19(11):e367.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSudjai A, et al. Empowering Thai community pharmacists to improve antibiotic supply practices: a mixed-methods study. Antibiot (Basel). 2024;13(8):945.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMay C, Finch T. Implementing, embedding, and integrating practices: an outline of Normalisation Process Theory. Sociology. 2009;43(3):535\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGlasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89(9):1322\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLehmann U, Gilson L. Action learning for health-system strengthening: qualitative insights from South Africa. BMC Health Serv Res. 2013;13:144.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBalabanova D, et al. Engaging private providers in UHC: lessons from low- and middle-income countries. BMC Health Serv Res. 2022;22(1):1173.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBarker I, et al. Digital minor ailment services in English community pharmacies: mixed-methods evaluation. BMC Health Serv Res. 2020;20:935.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKotwani A, Wattal C. Community use of antibiotics in developing countries and resistance implications. Clin Microbiol Infect. 2017;23(7):452\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Engaging the private health service delivery sector through governance in mixed health systems: strategy report. Geneva: WHO; 2020.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRogers EM. Diffusion of innovations. 5th ed. New York: Free; 2003.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Community pharmacy, Minor ailments, Implementation, Universal health coverage, Thailand, Qualitative research","lastPublishedDoi":"10.21203/rs.3.rs-7949655/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7949655/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThailand\u0026rsquo;s Common Illness (CI) Project\u0026mdash;launched in 2023 by the National Health Security Office (NHSO) and the Pharmacy Council\u0026mdash;integrates accredited community pharmacies into primary care to manage 32 minor ailments, aiming to improve access and relieve hospital crowding amid universal health coverage (UHC).\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Empirical evidence on real-world implementation and system barriers remains limited.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe undertook a qualitative descriptive study across 13 health regions (March\u0026ndash;June 2025). Fourteen licensed pharmacists from CI-accredited pharmacies were purposively sampled to ensure diversity in geography, ownership model, and experience. Semi-structured online interviews (45\u0026ndash;60 minutes) explored workflow, supply management, barriers, and perceived impacts. Audio was transcribed verbatim in Thai and analysed using inductive content analysis guided by COREQ.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Three analysts coded independently, compared matrices, and resolved discrepancies by consensus. English translations of verbatim quotes underwent back-translation.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003ePharmacies consistently performed core steps\u0026mdash;eligibility verification, ID authentication, history-taking against 32 conditions, A-MED documentation, counselling/dispensing, day-3 follow-up, and claim submission\u0026mdash;yet varied in supplementary practices (proactive patient explanation, supplementary record forms, photo/signature confirmation, risk-factor recording, systematic follow-up documentation). Barriers clustered at system (A-MED glitches, ambiguous rules, claim delays), patient (misconceptions, antibiotic expectations), pharmacy (equipment, staffing, workload), and financing (appeals, tax uncertainty). Perceived impacts included improved access (especially for low-income groups), enhanced professional identity, and reduced hospital burden, with administrative workload as a trade-off. We propose a standardised workflow to harmonise delivery.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe CI Project demonstrates the feasibility of pharmacy-based primary care under UHC, but quality and equity would benefit from national SOPs, digital supports, and monitoring incentives that institutionalise follow-up and documentation.\u003c/p\u003e","manuscriptTitle":"A Qualitative Study on the Practice Patterns of Pharmacies Engaged in the Common Illness Project in Thailand","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-04 10:24:09","doi":"10.21203/rs.3.rs-7949655/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"262048216427305436403393034417751941833","date":"2026-05-19T09:59:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"155617021690046479933499985699201835278","date":"2026-05-18T19:22:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-13T19:49:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"95878883330172914361617021666857540402","date":"2025-12-10T04:48:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"321281000934084936397581719641654049406","date":"2025-12-08T04:44:15+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-27T19:37:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-10T07:58:10+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-31T09:16:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-29T15:06:53+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-10-29T15:04:04+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"673bc9fd-5e8d-439a-a88a-c2f1341e36c1","owner":[],"postedDate":"November 4th, 2025","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"262048216427305436403393034417751941833","date":"2026-05-19T09:59:24+00:00","index":116,"fulltext":""},{"type":"reviewerAgreed","content":"155617021690046479933499985699201835278","date":"2026-05-18T19:22:16+00:00","index":115,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-27T19:53:06+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-04 10:24:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7949655","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7949655","identity":"rs-7949655","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}