The impact of a complex school nutrition intervention on double burden of malnutrition among Thai primary school children: a 2-year quasi-experiment.

OBJECTIVE: This study assessed the impacts of the Dekthai Kamsai programme on overweight/obesity, underweight and stunting among male and female primary school students. STUDY DESIGN: A quasi-experiment was conducted in 16 intervention and 19 control schools across Thailand in 2018 and 2019. In total, 896 treated and 1779 control students from grades 1 to 3 were recruited. In intervention schools, a set of multifaceted intervention components were added into school routine practices. Anthropometric outcomes were measured at baseline and at the beginning and end of every school term. METHODS: Propensity score matching with linear and Poisson difference-in-difference analyses were used to adjust for the non-randomisation and to analyse the intervention's effects over time. RESULTS: Compared with controls, the increases in mean BMI-for-age Z-score (BAZ) and the incidence rate of overweight/obesity were lower in the intervention schools at the 3rd, 4th and 8th measurements and the 3rd measurement, respectively. The decrease in mean height-for-age Z-score (HAZ) was lower at the 4th measurement. The decrease in the incidence rate of wasting was lower at the 5th, 7th and 8th measurements. The favourable impacts on BAZ and HAZ were found in both sexes, while the favourable impact on overweight/obesity and unfavourable impact on wasting were found in girls. CONCLUSIONS: This intervention might be effective in reducing BAZ, overweight/obesity, poor height gain, but not wasting. These findings highlight the benefits of a multifaceted school nutrition intervention and a need to incorporate tailor-made interventions for wasting to comprehensively address the double burden of malnutrition.

Implementing national strategies on antimicrobial resistance in Thailand: potential challenges and solutions.

BACKGROUND: Thailand has developed a national strategic plan on antimicrobial resistance (NSP-AMR) and endorsed by the Cabinet in August 2016. This study reviewed the main contents of the NSP-AMR and the mandates of relevant implementing agencies and identified challenges and recommends actions to mitigate implementation gaps. METHODS: This study analysed the contents of NSP-AMR, reviewed institutional mandates and assessed the implementation gaps among agencies responsible for NSP-AMR. RESULTS: Two of six strategies are related to monitoring and surveillance of AMR and antimicrobial consumption in human and animal. Two other strategies aim to improve antibiotic stewardship and control the spread of AMR in both clinical and farm settings. The remaining two strategies aim to increase knowledge and public awareness on AMR and establish national governance for inter-sectoral actions. Strategies to overcome implementation challenges are sustaining cross-sectoral policy commitments, effective cross-sectoral coordination using One Health approach, generating evidence which guides policy implementation, and improving enforcement capacities in regulatory authorities. CONCLUSIONS: To address AMR, Thailand requires significant improvements in implementation capacities in two dimensions. First, technical capacities among implementing agencies are needed to translate policies into practice. Second, governance and organizational capacities enable effective multi-sectoral actions across human, animal, and environmental sectors.

Targeting antiretroviral therapy: lessons from a longitudinal study of morbidity and treatment in relation to CD4 count in Thailand.

The aim of the study was to quantify the incidence of illness and treatment behaviour in relation to CD4 count, age, and gender among a cohort of persons living with HIV/AIDS in Thailand. 464 participants with a CD4 count between 50 and 550 cells/mm3 were followed up for 12 months. Multiple Poisson regression was used to model the adjusted incidence rate ratio of illness and care seeking at different levels. The incidence of morbidity and treatment pattern were significantly different among participants with different CD4 count, age and gender. For example, morbidity incidence was significantly higher among participants with CD4 count of less than 200 cells/mm3, among female participants, and participants aged 35 years or over. Females made significantly higher use of hospital ambulatory care and private clinics than males and males made significantly more use of private pharmacies. The potential opportunity cost of not providing ART to these different groups can be estimated and used to inform further economic evaluation and policy decisions on whether to provide ART at all and which patient groups to prioritise.

Cost effectiveness and delivery study for future HIV vaccines.

Research teams from five countries, Brazil, China, Kenya, Peru and Thailand, have initiated a policy-maker survey on vaccine delivery, cost studies for future HIV vaccination programmes, and associated simulation modeling exercises analysing the relative cost-effectiveness of potential HIV vaccination strategies. The survey assesses challenges and opportunities for future country-level HIV vaccination strategies, providing data on the vaccine characteristics (e.g. vaccine efficacies for susceptibility, infectiousness and disease progression) and vaccination programme strategies to be considered in the cost-effectiveness modeling analyses. The study will provide decision-makers with modeling data on vaccination policy considerations that will assist in developing country-level capacities for future HIV vaccine policy adoption and effective delivery systems, and will help delineate the long-term financial requirements for sustainable HIV vaccination programmes. The WHO-UNAIDS HIV Vaccine Initiative and the collaborating researchers welcome comments or questions from policy makers, health professionals and other stakeholders in the public and private sectors about this effort to help advance policy and capacity related to future potential HIV vaccines.

The potential demand for an AIDS vaccine in Thailand.

The recent ongoing phase III clinical trial of a preventive vaccine in Thailand has prompted studies on potential demand for the vaccine among public, employers and households. This study aims to demonstrate the impact of HIV/AIDS, estimate the AIDS vaccine budget required and design the vaccination strategies for different population groups. The analysis is based on available secondary data and several assumptions on levels of secondary infections among various risk groups. Among 15 groups, we identified eight groups as potential vaccinees: Direct CSW, IDU in treatment, IDU out of treatment, male STD, transport workers, CSW indirect, conscripts and prisoners. The vaccine budget, excluding other operating expenditure, was estimated based on a single dose regimen ranging from 100 Baht (3 US dollars) to 1000 Baht (29 US dollars) per dose. A total of 1.8-17.7 million US dollars is required for non-infected catch-up population and 0.2-1.9 million US dollars for the maintenance population in the subsequent year. We foresee a relative inefficient and inequitable consumption of AIDS vaccine, which requires proper policy analysis and government interventions. Before vaccine adoption, strong preventive measures must be in place. AIDS vaccine could play an additional, not a substituting, role. A thorough understanding, a wide consultation with stakeholders and public debates are crucial steps for sound policy formulation.

Health impacts of rapid economic changes in Thailand.

The economic crisis in Thailand in July 1997 had major social implications for unemployment, under employment, household income contraction, changing expenditure patterns, and child abandonment. The crisis increased poverty incidence by 1 million, of whom 54% were the ultra-poor. This paper explores and explains the short-term health impact of the crisis, using existing data and some special surveys and interviews for 2 years during 1998-99. The health impacts of the crisis are mixed, some being negative and some being positive. Household health expenditure reduced by 24% in real terms; among the poorer households, institutional care was replaced by self-medication. The pre-crisis rising trend in expenditure on alcohol and tobacco consumption was reversed. Immunization spending and coverage were sustained at a very high level after the crisis, but reports of increases in diphtheria and pertussis indicate declining programme quality. An increase in malaria, despite budget increases, had many causes but was mainly due to reduced programme effectiveness. STD incidence continued the pre-crisis downward trend. Rates of HIV risky sexual behaviour were higher among conscripts than other male workers, but in both groups there was lower condom use with casual partners. HIV serosurveillance showed a continuation of the pre-crisis downward trend among commercial sex workers (CSW, both brothel and non-brothel based), pregnant women and donated blood; this trend was slightly reversed among male STD patients and more among intravenous drug users. Condom coverage among brothel based CSW continued to increase to 97.5%, despite a 72% budget cut in free condom distribution. Poverty and lack of insurance coverage are two major determinants of absence of or inadequate antenatal care, and low birthweight. The Low Income Scheme could not adequately cover the poor but the voluntary Health Card Scheme played a health safety net role for maternal and child health. Low birthweight and underweight among school children were observed during the crisis. The impact of the crisis on health was minimal in some sectors but not in the others if the pre-crisis condition is efficient and healthy and vice versa. We demonstrated some key health status parameters during the 2-year period after the 1997 crisis but do not have firm conclusions on the impact of the economic crisis on health status, as our observation is too short and there is uncertainty on how long the crisis will last.

The response of providers to capitation payment: a case-study from Thailand.

Those designing payment systems for health care in low and middle income countries are increasingly looking to capitation payment, in order to avoid the cost inflation experienced with fee-for-service payment. However, there is virtually no documentation of the experience of introducing capitation payment, or of its effects. This paper draws on several research studies to explore responses by health care providers at both the market and facility level to the introduction of capitation payment, in the context of a new compulsory insurance scheme for workers in Thailand. The paper ends by identifying lessons for both Thailand itself and for other countries.

Patient satisfaction in Bangkok: the impact of hospital ownership and patient payment status.

INTRODUCTION: Patient satisfaction with care received is an important dimension of evaluation that is examined only rarely in developing countries. Evidence about how satisfaction differs according to type of provider or patient payment status is extremely limited. OBJECTIVE: To (i) compare patient perceptions of quality of inpatient and outpatient care in hospitals of different ownership and (ii) explore how patient payment status affected patient perception of quality. METHODS: Inpatient and outpatient satisfaction surveys were implemented in nine purposively selected hospitals: three public, three private for-profit and three private non-profit. RESULTS: Clear and significant differences emerged in patient satisfaction between groups of hospitals with different ownership. Non-profit hospitals were most highly rated for both inpatient and outpatient care. For inpatient care public hospitals had higher levels of satisfaction amongst clientele than private for-profit hospitals. For example 76% of inpatients at public hospitals said they would recommend the facility to others compared with 59% of inpatients at private for-profit hospitals. This pattern was reversed for outpatient care, where public hospitals received lower ratings than private for-profit ones. Patients under the Social Security Scheme, who are paid for on a capitation basis, consistently gave lower ratings to certain aspects of outpatient care than other patients. For inpatient care, patterns by payment status were inconsistent and insignificant. CONCLUSIONS: The survey confirms, to some extent, the stereotypes about quality of care in hospitals of different ownership. The results on payment status are intriguing but warrant further research.

Profit, payment and pharmaceutical practices: perspectives from hospitals in Bangkok.

Means by which to improve the quality of care offered in the private sector have received increasing interest. This paper considers the influences upon hospital physician prescribing practices. It presents data on drug management practices and prescribing patterns in a sample of private for-profit, private non-profit and public hospitals in Bangkok. Clear differences emerge in prescription patterns between the different groups of hospitals: public hospitals exhibit greater use of essential drugs and generic prescribing than either group of private hospital, and prescriptions at private for-profit hospitals tended to have more essential drugs and drugs prescribed by generic name than non-profit hospitals. Prescribing patterns in public hospitals are probably largely explained by national government policy on pharmaceutical procurement. In contrast, prescribing patterns in private for-profit hospitals appear heavily influenced by pressure upon management to contain costs, in circumstances where high drug costs cannot be passed on to purchasers. Hence hospital management have developed policies encouraging the use of generic drugs and essential drugs. These same financial pressures also explain some less desirable forms of behaviour in private for-profit hospitals such as prescribing courses of antibiotic treatment of extremely short duration. Possible measures which government may take to encourage appropriate prescribing within private hospitals are discussed.

The social security scheme in Thailand: what lessons can be drawn?

The Social Security Scheme was launched in 1990, covering formal sector private employees for non-work related sickness, maternity and invalidity including cash benefits and funeral grants. The scheme is financed by tripartite contributions from government, employers and employees, each of 1.5% of payroll (total of 4.5%). The scheme decided to pay health care providers, whether public or private, on a flat rate capitation basis to cover both ambulatory and inpatient care. Registration of the insured with a contractor hospital was a necessary consequence of the chosen capitation payment system. The aim of this paper is to review the operation of the scheme, and to explore the implications of capitation payment and registration for utilisation levels and provider behaviour. A key weakness of the scheme's design is suggested to be the initial decision to give employers not employees the responsibility for choosing the registered hospitals. This was done for administrative reasons, but it contributed to low levels of use of the contractor hospitals. In addition, low levels of use were also probably the result of the potential for cream skimming, cost shifting from inpatient to ambulatory care and under-provision of patient care, though since monitoring mechanisms by the Social Security Office were weak, these effects are difficult to detect conclusively. Mechanisms to improve utilisation levels were gradually introduced, such as employee choice of registered hospitals and the formation of sub-contractor networks to improve access to care. A beneficial effect of the capitation payment system was that the Social Security Fund generated substantial reserves and expenditures on sickness benefits were well stabilised. The paper ends by recommending that future policy amendments should be guided by research and empirical findings and that tougher monitoring and enforcement of quality of care standards are required.

National Health Accounts development: lessons from Thailand.

National Health Accounts (NHA) are an important tool to demonstrate how a country's health resources are spent, on what services, and who pays for them. NHA are used by policy-makers for monitoring health expenditure patterns; policy instruments to re-orientate the pattern can then be further introduced. The National Economic and Social Development Board (NESDB) of Thailand produces aggregate health expenditure data but its estimation methods have several limitations. This has led to the research and development of an NHA prototype in 1994, through an agreed definition of health expenditure and methodology, in consultation with peer and other stakeholders. This is an initiative by local researchers without external support, with an emphasis on putting the system into place. It involves two steps: firstly, the flow of funds from ultimate sources of finance to financing agencies; and secondly, the use of funds by financing agencies. Five ultimate sources and 12 financing agencies (seven public and five private) were identified. Use of consumption expenditures was listed under four main categories and 32 sub-categories. Using 1994 figures, we estimated a total health expenditure of 128,305.11 million Baht; 84.07% consumption and 15.93% capital formation. Of total consumption expenditure, 36.14% was spent on purchasing care from public providers, with 32.35% on private providers, 5.93% on administration and 9.65% on all other public health programmes. Public sources of finance were responsible for 48.79% and private 51.21% of the total 1994 health expenditure. Total health expenditure accounted for 3.56% of GDP (consumption expenditure at 3.00% of GDP and capital formation at 0.57% of GDP). The NESDB consumption expenditure estimate in 1994 was 180,516 million Baht or 5.01% of GDP, of which private sources were dominant (82.17%) and public sources played a minor role (17.83%). The discrepancy of consumption expenditure between the two estimates is 2.01% of GDP. There is also a large difference in the public and private proportion of consumption expenses, at 46:54 in NHA and 18:82 in NESDB. Future NHA sustainable development is proposed. Firstly, we need more accurate aggregate and disaggregated data, especially from households, who take the lion's share of total expenditure, based on amended questionnaires in the National Statistical Office Household Socio-Economic Survey. Secondly, partnership building with NESDB and other financing agencies is needed in the further development of the financial information system to suit the biennial NHA report. Thirdly, expenditures need breaking down into ambulatory and inpatient care for monitoring and the proper introduction of policy instruments. We also suggest that in a pluralistic health care system, the breakdown of spending on public and private providers is important. Finally, a sustainable NHA development and utilization of NHA for planning and policy development is the prime objective. International comparisons through collaborative efforts in standardizing definition and methodology will be a useful by-product when developing countries are able to sustain their NHA reports.

Cost-effectiveness analysis of three short-course anti-tuberculosis programmes compared with a standard regimen in Thailand.

The present study was undertaken to compare the efficacy, effectiveness and cost-effectiveness of three short-course regimens with a standard programme for treatment of new tuberculosis (TB) cases. The study was conducted by reviewing the results of TB treatment in 1642 newly diagnosed, sputum positive pulmonary TB patients with four drug regimens carried out in five zonal TB centres throughout Thailand in 1987-1989. Analysis showed that the three-short-course regimens were more cost-effective than the standard regimen from the perspective of both providers and patients. Among the three short-course programmes, isoniazid, rifampicin and pyrazinamide for 2 months, followed by isoniazid and rifampicin twice a week for 4 months was the most cost-effective (US$70.24/effectiveness from providers' perspective and US$103.31/effective from patients' perspective). The result of this study throws some light on the development of new policy options, with scarce health resources, in the treatment of tuberculosis by the National Tuberculosis Programme in Thailand.

Anti-tuberculosis programs in Thailand: a cost analysis.

The standard regimen, a combination of isoniazid and thiacetazone, which has been used for treatment of tuberculosis (TB) in Thailand for the past 20 years is inexpensive, but possesses a high degree of toxicity and requires 18-24 months of continuous treatment, resulting in poor compliance and a low success rate of treatment. The more efficacious short-course chemotherapy introduced into the National Tuberculosis Program in 1985 is limited by the high costs of drugs. However, the cost of providing care is not limited only to drug costs but also includes other services costs. The present study was undertaken to compare the total provider costs of 3 short-course regimens with that of the standard program in the treatment of newly diagnosed pulmonary TB. Data were collected at 4 zonal TB centers through out Thailand in 1987-1988. Analysis showed that the 3 short-course regimens had lower costs than the standard regimen from the provider perspective. Among these 3 regimens that of isoniazid, rifampicin and pyrazinamide for 2 months, followed by isoniazid and rifampicin twice a week for 4 months had the lowest costs (Baht 1,499). Despite the lowest drug cost (B 431) of the standard regimen, the total provider costs were the highest (B 2,541) due to the highest routine service cost of B 2,066. Thus to determine the cost of a disease requires consideration of both drug costs and also other cost components.