Disparity in the Burden of Caring for Older Persons between Families Living in Housing Estates and Traditional Communities in Thailand.

Thailand's rapid population aging and reliance on family-based long-term care requires research into disparities in family caregiver burden. Since the type of residence matters to the caregiving outcome, this research aimed to examine the difference in caregiver burden between residents of private housing estates and traditional village communities. This cross-sectional study was conducted with 1276 family caregivers of community-dwelling Thai older adults, in Chiang Mai province, Thailand. The caregiver burden was examined using the Caregiver Burden Inventory (CBI), and the care recipients' dependency status was examined using Barthel's Activity of Daily Living (ADL). Descriptive analysis, multivariate analysis of variance test, and multiple logistic regression analysis were performed. Family caregivers living in a traditional village community were 1.607 times more likely to experience emotional burden (adj. OR 1.607, 95% CI: 1.049, 2.462) and 2.743 times more likely to experience overall caregiver burden (adj. OR: 1.163, 95% CI: 1.163, 6.471) compared to those in the private housing estate group. Our findings showed significant differences in caregiver burden based on residential area, contributing with insights to evidence-based policies, interventions, and programs to minimize disparities and promote family caregivers' health and well-being.

Cost-Utility and Budget Impact Analyses of Oral Chemotherapy for Stage III Colorectal Cancer: Real-World Evidence after Policy Implementation in Thailand.

This study conducted a cost-utility analysis and a budget impact analysis (BIA) of outpatient oral chemotherapy versus inpatient intravenous chemotherapy for stage III colorectal cancer (CRC) in Thailand. A Markov model was constructed to estimate the lifetime cost and health outcomes based on a societal perspective. Eight chemotherapy strategies were compared. Clinical and cost data on adjuvant chemotherapy were collected from the medical records of 1747 patients at Siriraj Hospital, Thailand. The cost-effectiveness results were interpreted against a Thai willingness-to-pay threshold of USD 5003/quality-adjusted life year (QALY) gained. A 5-year BIA was performed. Of the eight strategies, CAPOX then FOLFIRI yielded the highest life-year and QALY gains. Its total lifetime cost was also the highest. An incremental cost-effectiveness ratio of CAPOX then FOLFIRI compared to 5FU/LV then FOLFOX, a commonly used regimen USD was 4258 per QALY gained.The BIA showed that when generic drug prices were applied, 5-FU/LV then FOLFOX had the smallest budgetary impact (USD 9.1 million). CAPOX then FOLFIRI required an approximately three times higher budgetary level (USD 25.1 million). CAPOX then FOLFIRI is the best option. It is cost-effective compared with 5-FU/LV then FOLFOX. However, policymakers should consider the relatively high budgetary burden of the CAPOX then FOLFIRI regimen.

Towards Cultural Adequacy of Experience-Based Design: A Qualitative Evaluation of Community-Integrated Intermediary Care to Enhance the Family-Based Long-Term Care for Thai Older Adults.

In this qualitative study, we provided an in-depth understanding of how Community-Integrated Intermediary Care (CIIC), a new service model for family-based long-term care (LTC), was perceived by its users. The CIIC, established in Chiang Mai, Northern Thailand, consisted of three main interventions: (1) A temporary respite care center; (2) A family-centered care capacity building; (3) Functional training delivered as community group exercise and home exercise to improve healthy ageing for independent older adults. Ten pairs of dependent Thai older adults, their primary family caregivers, and ten village health volunteers were recruited using the purposive sampling method. Data were collected via semistructured in-depth interviews. A thematic descriptive qualitative analysis was used for data analysis. The findings revealed that CIIC helped reduce the burden of family caregivers by providing respite, relief, and care coordination. The experiences of the CIIC users indicated possibilities for service redesign, development, and delivery strategies to better meet the LTC needs of older adults and family caregivers. Following the local stakeholders' commitment and local community health volunteers' network, a well-integrated formal and informal care CIIC model can be implied as an effective and sustainable ageing care service model in Thailand and other Asian countries in the future.

Effectiveness of a community-integrated intermediary care (CIIC) service model to enhance family-based long-term care for Thai older adults in Chiang Mai, Thailand: a cluster-randomized controlled trial TCTR20190412004.

BACKGROUND: Populations around the world are ageing faster, with the majority living in low- and middle-income countries where health and social care are yet to be universal and inclusive for the ageing population. This community-integrated intermediary care (CIIC) model is a novel prevention-based, long-term care model enhancing the family-based care system traditionally practised in Thailand and neighbouring Asian countries, and many low-and middle-income countries globally. This study assessed the effectiveness of the CIIC model in Chiang Mai, Thailand. METHODS: The two-arm parallel intervention study was designed as a cluster-randomized controlled trial. The study population at randomization and analysis was 2788 participants: 1509 in six intervention clusters and 1279 in six control clusters. The research protocol was approved by the WHO Research Ethics Review Committee (WHO/ERC ID; ERC.0003064). The CIIC service intervention model is a combination of formal care and informal care in a subdistrict setting consisting of three components: (1) care prevention delivered as community group exercise and home exercise; (2) care capacity-building of the family caregiver; and (3) community respite service. The primary outcome was family caregivers' burden at 6-month follow-up, and secondary outcome was activities of daily living. Analysis applied the intention-to-treat approach using cluster-level analysis via STATA 16 SE. RESULTS: Baseline characteristics did not differ between the two arms. Loss of follow up was 3.7%. Mean age of the participants was 69.53 years. Women constituted 60%. The COVID-19 pandemic caused delayed implementation. The proportion of families with reduced caregiver burden at 6-month follow-up was higher among the intervention clusters (mean 39.4%) than control clusters (mean 28.62%). The intervention clusters experienced less functional decline and fewer people with depression. CONCLUSIONS: When communities are integrated for preventing care, and families are empowered for giving care, it is possible to secure universal access to health and social care for the older persons, with basic resources mobilized from communities. This study had shown the CIIC model as an effective and potential step to the realization of universal health and long-term care coverage being inclusive of ageing populations in Thailand and globally. TRIAL REGISTRATION: This trial was registered at the Thailand Clinical Trial Registry-Trial registration number TCTR20190412004, https://www.thaiclinicaltrials.org/.

Determinants of Health-Related Quality of Life Among Community-Dwelling Thai Older Adults in Chiang Mai, Northern Thailand.

Background: Population aging has been growing worldwide and Thailand has become an aged society with 20% of its population aged 60 and over. Age-related decline in physical and mental health impacts the health-related quality of life (HRQOL) of older adults. Purpose: We aimed to describe the HRQOL of Thai older adults, residing in the community. Methods: This cross-sectional survey was part of a Community-Integrated Intermediary Care project (CIIC), TCTR20190412004. A total of 1509 participants from an intervention arm of a cluster randomized controlled trial were included. A Thai version of the Euro-Qol questionnaire (EQ-5D-5L) was used to determine the HRQOL and associated sociodemographic background, health behaviors and underlying diseases of a representative sample from Maehia, Chiang Mai, Thailand. SPSS version 24 was used to analyze data via descriptive analysis and binary logistic regression. Results: The mean age of the participants was 69.31±7.10 years, and nearly a quarter (23.8%) was older than 75 years. The mean EQ index score was 0.81±0.23 and older age, lower educational attainment, unemployment, lack of exercise habits, current smokers, having history of a fall in the last 6 months, diabetes, hyperlipidemia, dependency assessed using Barthel's Activity of Daily Living (ADL) Index, and depression using the Geriatric Depression Scale (GDS) were more likely to represent HRQOL-related problems. Conclusion: Our findings have highlighted the factors affecting the HRQOL of community-dwelling older adults which could be of importance in preparing for active and healthy aging communities. The routine dependency assessment using the ADL index will be useful in estimating the HRQOL of the aging population. Fall prevention programs are also recommended to reduce dependency. Moreover, the association of having diabetes and hyperlipidemia with problems in HRQOL dimensions highlight the need for public health intervention not only to prevent the increasing burden of non-communicable diseases but also to improve the HRQOL of older adults.

Depression and Associated Factors among Community-Dwelling Thai Older Adults in Northern Thailand: The Relationship between History of Fall and Geriatric Depression.

BACKGROUND: Globally, population aging is happening more quickly than in the past, and Thailand ranks the world's number three among the rapidly aging countries. Age-related decline in physical and mental health would impact depression among older adults. We aimed to determine the depression among the community-dwelling Thai older adults in Chiang Mai, Thailand. METHODS: The baseline data, collected by door-to-door household visits of an intervention arm from a cluster randomized controlled trial (Community-Integrated Intermediary Care (CIIC): TCTR20190412004), were included in this cross-sectional study. Descriptive analysis and binary logistic regression were applied. RESULTS: The mean age was 69.31 ± 7.10 years and 23.8% of study participants were older than 75 years. The Thai geriatric depression scale showed 6.5% had depression. Adjusted risk factors for depression were older age, being single, drinking alcohol daily, having diabetes, having experience of a fall last year, self-rated health as neutral, poor/very poor, and moderate/severe dependency by ADL scoring. CONCLUSION: Our findings highlighted the potentially modifiable risk factors in addition to the common predictors affecting depression among community-dwelling older adults. Fall prevention programs and public health interventions to prevent diabetes are recommended. Furthermore, self-rated health and Barthel's ADL scoring would be simple tools to predict risk factors for geriatric depression.

Estimating Service Demand for Intermediary Care at a Community Integrated Intermediary Care Center among Family Caregivers of Older Adults Residing in Chiang Mai, Northern Thailand.

BACKGROUND: Thailand's population is currently the third most rapidly aging in the world, with an estimated 20 million ageing population by 2050. Sustainability of the family based long-term care model is challenged by the chronic burden on family caregivers and by smaller family sizes. We aimed to introduce a new service model, Community Integrated Intermediary Care (CIIC), TCTR20190412004, including free of charge intermediary care services at CIIC centers in the local community, to help older adults whose caregivers are temporarily unable to sustain care at home. Since Thai society upholds values of gratefulness, it is better to estimate willingness to use such an intermediary care service first, before introducing the service. METHODS: A total of 867 pairs of senior citizens and their family caregivers were interviewed with structured-questionnaires in 2019. Descriptive analysis and binary logistic regression were applied to determine the predictors of family caregivers' willingness to use the CIIC service, guided by Anderson's model of health services use. RESULTS: About 26.8% of elderly participants and 24.0% of family caregivers were willing to use an intermediary care service. The family caregiver determinants of predisposing factors (kinship: spouse caregivers, other relatives, maid or friends; job types: own business and private company staff), enabling factors (original community residents and monthly income ≤9000 baht), and need factors (caregiver burden total scores ≥24, taking leave for caregiving, and having diabetes), were found to be significantly associated with willingness to use the CIIC service. CONCLUSIONS: The baseline survey data noted that caregivers' sociodemographic factors and burden determined their willingness to use the intermediary care service, although the dependency of care recipients was low in this study. This, nonetheless, indicated that there is need for a backup respite care to strengthen current family based long-term aging care in Thailand.

Caregiver Burden and Associated Factors for the Respite Care Needs among the Family Caregivers of Community Dwelling Senior Citizens in Chiang Mai, Northern Thailand.

BACKGROUND: Families are the backbone of caregiving for older adults living in communities. This is a tradition common to Thailand and many low- and middle-income countries where formal long-term care services are not so available or accessible. Therefore, population aging demands more and more young people engaging as family caregivers. Informal caregiving can become an unexpected duty for anyone anytime. However, studies measuring the burden of informal caregivers are limited. We aimed to determine the caregiver burden, both from the perspective of the caregivers as well as that of their care recipients. METHOD: We used the baseline survey data from a cluster randomized controlled trial providing a community integrated intermediary care (CIIC) service for seniors in Chiang Mai, Thailand, TCTR20190412004. Study participants were 867 pairs of older adults and their primary family caregivers. Descriptive analysis explored the characteristics of the caregivers and binary logistic regression identified factors influencing the caregivers' burden. RESULTS: The mean age of family caregivers was 55.27 ± 13.7 years and 5.5% indicated the need for respite care with Caregiver Burden Inventory (CBI) scores ≥24. The highest burden was noted in the time-dependence burden domain (25.7%). The significant associated factors affecting CBI ≥24 were as follows: caregivers older than 60 years, being female, current smokers, having diabetes, and caring for seniors with probable depression and moderate to severe dependency. CONCLUSIONS: A quarter of caregivers can have their careers disturbed because of the time consumed with caregiving. Policies to assist families and interventions, such as respite service, care capacity building, official leave for caregiving, etc., may reduce the burden of families struggling with informal care chores. Furthermore, caregiver burden measurements can be applied as a screening tool to assess long-term care needs, complementing the dependency assessment. Finally, implementation research is required to determine the effectiveness of respite care services for older people in Thailand.

Thai Older People's Willingness (Intention) to Participate in a Care Prevention, Community Group Exercise Program: An Assessment before Implementing an Intervention Trial in Chiang Mai, Northern Thailand.

BACKGROUND: Sustainability of a current family-based long-term care model in Thailand has been challenged by demographic aging, and the rising burden of non-communicable diseases and age-related morbidities. In order to overcome these challenges, a community-integrated intermediary care (CIIC) service model, including functional training as one of the interventions, was introduced. To increase program uptake and adherence, it is vital to understand the facilitators and barriers for joining this group exercise. Therefore, we aimed to explore the determinants of older adults' willingness to participate in it. METHODS: A total of 1509 participants from an intervention arm of a cluster randomized trial were interviewed with a structured questionnaire. A descriptive analysis and binary logistic regression were applied. RESULTS: More than half of participants (51.4%) were willing to join community-based care prevention, functional training exercise program. Significant associated motivators were being of younger age, female, married, working seniors, original community residents, having (regular and irregular) exercise habits, history of a fall in the last six months, needs for walking aids and secondary caregivers. CONCLUSION: Our findings highlighted both personal and social factors motivated old people to access health promotion activities. It might help design or implement effective programs to promote healthy aging among community-dwelling seniors in Thailand. This research is analysis of baseline results from a Community Integrated Intermediary Care project. TCTR20190412004.

Community-Integrated Intermediary Care (CIIC) Service Model to Enhance Family-Based, Long-Term Care for Older People: Protocol for a Cluster Randomized Controlled Trial in Thailand.

BACKGROUND: Thailand is one of the most rapidly aging countries in Asia. Traditional family-based care, which has been the basis of most care for older people, is becoming unsustainable as families become smaller. In addition, women tend to be adversely affected as they still form the bulk of caregivers for older people, and many are likely to exit the labor market in order to provide care. Many family caregivers also have no or minimal training, and they may be called upon to provide quite complex care, increasing the proportion of older people receiving suboptimal care if they rely only on informal care that is provided by families and friends. Facing the increasing burden of noncommunicable diseases and age-related morbidity, Thai communities are increasingly in need of community-integrated care models for older persons that can link existing health systems and reduce the burden upon caring families. This need is common to many countries in the Association of Southeast Asian Nations (ASEAN). OBJECTIVE: In this study, we aimed to assess the effectiveness of a community-integrated intermediary care (CIIC) model to enhance family-based care for older people. METHODS: This paper describes a cluster randomized controlled trial comprised of 6 intervention clusters and 6 control clusters that aim to recruit 2000 participants in each arm. This research protocol has been approved by the World Health Organization Ethics Review Committee. The intervention clusters will receive an integrated model of care structured around (1) a community respite service, (2) the strengthening of family care capacity, and (3) an exercise program that aims to prevent entry into long-term care for older people. Control group clusters receive usual care (ie, the current system of long-term care common to all provinces in Thailand), consisting principally of a volunteer-assisted home care service. The trial will be conducted over a period of 2 years. The primary outcome is family caregiver burden measured at a 6-month follow-up, as measured by the Caregiver Burden Inventory. Secondary outcomes consist of biopsychosocial indicators including functional ability, as measured using an activity of daily living scale; depression, as measured by the Geriatric Depression Scale; and quality of life of older people, as measured by the EuroQol 5-dimensions 5-levels scale. Intention-to-treat analysis will be followed. RESULTS: The CIIC facility has been established. Community care prevention programs have been launched at the intervention clusters. Family caregivers are receiving training and assistance. However, the COVID-19 pandemic delayed the intervention. CONCLUSIONS: Since ASEAN and many Asian countries share similar traditional family-based, long-term care systems, the proposed CIIC model and the protocol for its implementation and evaluation may benefit other countries wishing to adopt similar community-integrated care models for older people at risk of needing long-term care. TRIAL REGISTRATION: Thai Clinical Trials Registry TCTR20190412004; http://www.thaiclinicaltrials.org/. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/20196.

Estimating the preferences and willingness-to-pay for colorectal cancer screening: an opportunity to incorporate the perspective of population at risk into policy development in Thailand.

AIMS: Colorectal cancer (CRC) is one of the public health burdens that can be lowered by early detection. This study aims to examine the preferences and willingness-to-pay of a population at risk for CRC screening in Thailand. Understanding the preferences for these individuals at risk would help Thailand, as an example of LMICs, to design effective population-based CRC screening programs. MATERIALS AND METHODS: A discrete choice experiment (DCE) was conducted among screening-naïve adults aged 50-75 years, who were at risk of CRC, in the out-patient department of a tertiary care hospital in Thailand. A DCE questionnaire was developed from six CRC screening attributes. Each questionnaire was composed of six choice sets and each contained two alternatives described by the different levels of attributes and an opt-out alternative. Participants were asked to choose one alternative from each choice set. A multinomial logit model was developed to determine the relative preference of each attribute. The willingness-to-pays for all attributes and screening modalities and the estimated preferred choices of the annual fecal immunochemical test (FIT), 10-yearly colonoscopy, 5-yearly double-contrast barium enema (DCBE), 5-yearly computed tomographic colonography (CTC), 5-yearly flexible sigmoidoscopy (FS), and no screening was calculated and compared. RESULTS: Four hundred participants were included. All attributes, except pain and less bowel preparation, were statistically associated with the participants' preference (p < .05). They preferred screenings with a high-risk reduction of CRC-related mortality, no complication, 5-year interval, and lower cost. The estimated preferred choices of FIT, colonoscopy, DCBE, CTC, and FS were 38.2%, 11.4%, 14.6%, 9.2%, and 11.4%, respectively. The willingness-to-pays for each screening modality was US$251, US$189, US$183, US$154, and US$142 (8,107, 6,105, 5,911, 4,974, and 4,587 THB) per episode, respectively. CONCLUSIONS: The risk reduction of CRC-related mortality, complication, screening interval, and cost influenced the CRC screening preferences of Thai adults. FIT was the most preferred. Policymakers can develop a successful CRC screening campaign using these findings, incorporating the perspective of the population at risk in policy formulation to accomplish their goals.

Cost-effectiveness and budget impact analyses of colorectal cancer screenings in a low- and middle-income country: example from Thailand.

Objectives: Colorectal cancer (CRC) screening programs have been reported to be cost-effective in many high-income countries. However, there was no such study in low- and middle-income countries. This study aimed to evaluate cost-effectiveness and budget impact of CRC screening modalities for average-risk persons in Thailand.Methods: A decision tree coupled with a Markov model was used to estimate lifetime costs and health benefits of fecal immunochemical test (FIT) and colonoscopy using a societal perspective. The input parameters were obtained from a CRC screening project at a Thai tertiary care hospital, Thai health care costs and databases, and systematic literature review. Results were reported as incremental cost-effectiveness ratios (ICERs) in 2017 US Dollars (USD) per quality-adjusted life year (QALY) gained. Sensitivity analyses were performed to assess the influence of parameter uncertainty. Finally, budget impact analysis was conducted.Results: At the Thai ceiling threshold of societal willingness-to-pay of 4,706 USD, the screening colonoscopy every 10 years and annual FIT, starting at age 50, was cost-effective, as compared to no screening resulting in 15.09 and 15.00 QALYs with the ICERs of 600.20 and 509.84 USD/QALY gained, respectively. Colonoscopy every 10 years and annual FIT could prevent 17.9% and 5.7% of early stage cancer and 27.8% and 9.2% of late stage cancer per 100,000 screening over lifetime when compared to no screening, respectively. The colonoscopy screening was cost-effective with the ICER of 646.53 USD/QALY gained when compared to FIT. The probabilities of being cost-effective for the colonoscopy and FIT were 75% and 25%, respectively. Budget impact analysis showed the colonoscopy screening required an 8-times higher budget than FIT.Conclusions: Colonoscopy offers the best value for money of CRC screenings in Thailand. Annual FIT is potentially feasible since it requires less resources. Our findings can be used as part of evidence for informing policy decision making.Key points for decision makersThere was a lack of cost-effective study of colorectal cancer screening programs in low- and middle-income countries.This study evaluated lifetime health outcomes and costs, and the cost-effectiveness of colorectal screening options for average-risk persons in Thailand.Colonoscopy screening every 10 years is cost-effective with high probability of being cost-effective as compared with annual fecal immunochemical test.Screening by annual fecal immunochemical test is more feasible in terms of human resource and budgetary burden.Colorectal screening programs provides an opportunity for early diagnosis and treatments to prevent advance colorectal stages and avoid higher consequent costs.This study contributes a new evidence-based knowledge for Thailand and can be used to support policy decision making process.

The Impact of Tobacco Consumption on Rural Household Expenditure and Self-rated Health Among Rural Household Members in China.

OBJECTIVES: To estimate how tobacco consumption affects household expenditure on other goods and services in rural China and to assess the tobacco consumption affects self-rated health among rural household members in China. METHODS: A Seemingly Unrelated Regression was used to assess the impact of tobacco consumption on rural household expenditure. To detect tobacco consumption causing heterogeneity in self-rated health among adults in rural China, this study employed a random effects generalized ordered probit model. 2010-2014 China Family Panel Studies was used for the analysis. The data set included 3,611 households and 10,610 adults in each wave. RESULTS: Tobacco consumption households assign significantly lower budget shares to food, health care, dress, and education in rural China. Moreover, self-rated health factor has a significantly positive coefficient with respect to non-smokers and ex-smokers, that is, when the individuals is a non-smoker or ex-smoker, he/ she will be more likely to report his/her health status as positive. CONCLUSIONS: The first analysis showed that tobacco consumption crowds out expenditures on food, dress, health care, and education for rural households in China, and the second analysis indicated that non-smokers and ex-smokers are more likely to report their health status as better compared with last year. The results of the present study revealed that Chinese policymakers might consider controlling tobacco consumption since tobacco control can improve not only rural household welfare but also rural household members' health status. Therefore, the tobacco tax policy and brief clinical interventions by the doctor should be implemented in rural China.

Cost-effectiveness analysis of ultrasonography screening for nonalcoholic fatty liver disease in metabolic syndrome patients.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) can be diagnosed early by noninvasive ultrasonography; however, the cost-effectiveness of ultrasonography screening with intensive weight reduction program in metabolic syndrome patients is not clear. This study aims to estimate economic and clinical outcomes of ultrasonography in Thailand. METHODS: Cost-effectiveness analysis used decision tree and Markov models to estimate lifetime costs and health benefits from societal perspective, based on a cohort of 509 metabolic syndrome patients in Thailand. Data were obtained from published literatures and Thai database. Results were reported as incremental cost-effectiveness ratios (ICERs) in 2014 US dollars (USD) per quality-adjusted life year (QALY) gained with discount rate of 3%. Sensitivity analyses were performed to assess the influence of parameter uncertainty on the results. RESULTS: The ICER of ultrasonography screening of 50-year-old metabolic syndrome patients with intensive weight reduction program was 958 USD/QALY gained when compared with no screening. The probability of being cost-effective was 67% using willingness-to-pay threshold in Thailand (4848 USD/QALY gained). Screening before 45 years was cost saving while screening at 45 to 64 years was cost-effective. CONCLUSIONS: For patients with metabolic syndromes, ultrasonography screening for NAFLD with intensive weight reduction program is a cost-effective program in Thailand. Study can be used as part of evidence-informed decision making. TRANSLATIONAL IMPACTS: Findings could contribute to changes of NAFLD diagnosis practice in settings where economic evidence is used as part of decision-making process. Furthermore, study design, model structure, and input parameters could also be used for future research addressing similar questions.

General Practitioners' Prescribing Patterns at Primary Healthcare Centers in National Health Insurance, Gezira, Sudan.

BACKGROUND: The appropriate use of medicines is essential for the provision of quality health services, patient safety, and the rational use of health resources. In Sudan, general practitioners (GPs) provide 80 % of insured patients' health services. Pharmaceutical service costs have been increasing since 2010. OBJECTIVES: We aimed to use the World Health Organization (WHO) and International Network for the Rational Use of Drugs prescribing indicators to assess prescription quality among GPs in different types of primary healthcare centers (PHCCs) within the National Health Insurance Fund (NHIF) in Gezira State, Sudan. METHOD: We followed established WHO guidelines to conduct a cross-sectional retrospective study. The study was carried out over 6 months and involved 197 GPs with valid prescriptions, representing 90 % of the total study population of 220 GPs. We collected a systematic random sample of 100 prescriptions for each GP and used Stata 12 to analyze the 19,700 prescriptions. RESULTS: The mean ± standard deviation number of medications was 2.55 ± 1.32 per patient; 46.32 % of drugs prescribed were generics; 54.71 % of prescriptions were for antibiotics and 12.84 % were for injectable formulations; and 81.19 % of prescribed medicines were from the NHIF medicines list. The overall Index of Rational Drug Prescribing (IRDP) indicator was 3.39, and the average cost per prescription was 40.57 Sudanese pounds (SDG). Disregarding prescriptions for antibiotics, the prescribing quality of GPs in NHIF facilities was farther from optimal prescribing practice than those in State Ministry of Health-owned facilities and facilities owned by private groups, universities, and non-governmental organizations. CONCLUSION: The present study provides strong evidence of irrational prescribing practice among GPs, with significant disparities, particularly in terms of antibiotic overuse, generic drug underuse, and adherence to the NHIF medicines list.

A New Approach of Measuring Hospital Performance for Low- and Middle-income Countries.

Efficiency of the hospitals affects the price of health services. Health care payments have equity implications. Evidence on hospital performance can support to design the policy; however, the recent literature on hospital efficiency produced conflicting results. Consequently, policy decisions are uncertain. Even the most of evidence were produced by using data from high income countries. Conflicting results were produced particularly due to differences in methods of measuring performance. Recently a management approach has been developed to measure the hospital performance. This approach to measure the hospital performance is very useful from policy perspective to improve health system from cost-effective way in low and middle income countries. Measuring hospital performance through management approach has some basic characteristics such as scoring management practices through double blind survey, measuring hospital outputs using various indicators, estimating the relationship between management practices and outputs of the hospitals. This approach has been successfully applied to developed countries; however, some revisions are required without violating the fundamental principle of this approach to replicate in low- and middle-income countries. The process has been clearly defined and applied to Nepal. As the results of this, the approach produced expected results. The paper contributes to improve the approach to measure hospital performance.

Contracting private hospitals: experiences from Southeast and East Asia.

In resource-scarce settings governments have increasingly looked at ways of engaging the private sector in achieving national health system goals. This study is a comparative analysis of institutional contracting for hospital services in three southeast and east Asian countries, namely Thailand, the Philippines and South Korea. In addition, the case of Singapore, where public hospitals are corporatized, is reviewed. Primary data were collected through in-depth-interviews and analysed under a triangulation approach. Institutional contracting is only used in three out of four countries. In these three countries, institutional contracting inter alia aims at increasing access to hospital services, although the scale of private hospital participation depends on contextual factors. Neither strategic provider selection mechanisms nor a preferred provider system is part of the institutional contracting models reviewed. In Thailand and the Philippines, performance-based rewards or sanctions have played a limited role so far and there is relatively little dialogue between contract parties, indicating that the contracting tool has not been used to the fullest extent possible and suggesting that capacity development especially regarding contract and relationship management is needed. Although there is virtually no information available about the cost of contracting, the findings of this study suggest that the potential of institutional contracting arrangements should be explored further to improve health system outcomes and thereby support countries in their quest for universal health coverage.

Cost utility analysis of endoscopic biliary stent in unresectable hilar cholangiocarcinoma: decision analytic modeling approach.

BACKGROUND/AIMS: Endoscopic biliary drainage using metal and plastic stent in unresectable hilar cholangiocarcinoma (HCA) is widely used but little is known about their cost-effectiveness. This study evaluated the cost-utility of endoscopic metal and plastic stent drainage in unresectable complex, Bismuth type II-IV, HCA patients. METHODOLOGY: Decision analytic model, Markov model, was used to evaluate cost and quality-adjusted life year (QALY) of endoscopic biliary drainage in unresectable HCA. Costs of treatment and utilities of each Markov state were retrieved from hospital charges and unresectable HCA patients from tertiary care hospital in Thailand, respectively. Transition probabilities were derived from international literature. Base case analyses and sensitivity analyses were performed. RESULTS: Under the base-case analysis, metal stent is more effective but more expensive than plastic stent. An incremental cost per additional QALY gained is 192,650 baht (US$ 6,318). From probabilistic sensitivity analysis, at the willingness to pay threshold of one and three times GDP per capita or 158,000 baht (US$ 5,182) and 474,000 baht (US$ 15,546), the probability of metal stent being cost-effective is 26.4% and 99.8%, respectively. CONCLUSIONS: Based on the WHO recommendation regarding the cost-effectiveness threshold criteria, endoscopic metal stent drainage is cost-effective compared to plastic stent in unresectable complex HCA.

Decision-making process of Kala Azar care: results from a qualitative study carried out in disease endemic areas of Nepal.

BACKGROUND: Analysis of consumer decision making in the health sector is a complex process of comparing feasible alternatives and evaluating the levels of satisfaction associated with the relevant options. This paper makes an attempt to understand how and why consumers make specific decisions, what motivates them to adopt a specific health intervention, and what features they find attractive in each of the options. METHOD: The study used a descriptive-explanatory design to analyze the factors determining the choices of healthcare providers. Information was collected through focus group discussions and in-depth interviews. RESULTS: The results suggest that the decision making related to seeking healthcare for Kala Azar (KA) treatment is a complex, interactive process. Patients and family members follow a well-defined road map for decision making. The process of decision making starts from the recognition of healthcare needs and is then modified by a number of other factors, such as indigenous knowledge, healthcare alternatives, and available resources. Household and individual characteristics also play important roles in facilitating the process of decision making. The results from the group discussions and in-depth interviews are consistent with the idea that KA patients and family members follow the rational approach of weighing the costs against the benefits of using specific types of medical care. CONCLUSION: The process of decision making related to seeking healthcare follows a complex set of steps and many of the potential factors affect the decision making in a non-linear fashion. Our analysis suggests that it is possible to derive a generalized road map of the decision-making process starting from the recognition of healthcare needs, and then modifying it to show the influences of indigenous knowledge, healthcare alternatives, and available resources.

Choice of providers for treating a neglected tropical disease: an empirical analysis of kala azar in Nepal.

OBJECTIVE: To examine the choice of healthcare providers for treating kala azar (KA) in Nepal. METHODS: Information was collected from clinically diagnosed KA patients seeking care from public hospitals located in KA endemic districts. The survey collected information from more than 25 percent of total KA cases in the country. For empirical estimation of probability of choosing a provider-type as a first contact healthcare provider, a multinomial logit model was defined with five alternative options with self care as the reference category. RESULTS: The empirical model found that price of medical care services, income of households, knowledge of patients on KA and KA treatment, borrowing money, age of patient, perceived quality of provider types, etc. determine the likelihood of seeking care from the alternative options considered in the analysis. All variables have expected signs and are consistent with earlier studies. The price and income elasticity were found to be very high indicating that poorer households are very sensitive to price and income changes, even for a severe disease like KA. Using the empirical models, we have analyzed two policy instruments: demand side financing and interventions to improve the knowledge index about KA. CONCLUSIONS: Due to high price elasticity of KA care and high spillover effects of KA on the society, policy makers may consider demand side financing as an instrument to encourage utilization of public hospitals.