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.

Measuring the economic burden for TB patients in the End TB Strategy and Universal Health Coverage frameworks.

Tuberculosis (TB) is a disease of poverty. Ensuring access to health care without the risk of financial hardship due to out-of-pocket health care expenditures (Universal Health Coverage [UHC]) is essential for providing accessible care to underprivileged populations, but this is not enough. The End TB Strategy promotes both patient-centred TB services and social protection measures, which aim to mitigate the economic hardship faced by TB patients and their households due to direct medical and non-medical expenditures, as well as to lost income. The strategy includes a target that no families should face catastrophic total costs due to TB. The indicator linked to this target aims to capture the total economic burden linked to TB care, and thus differs from the 'catastrophic expenditure on health' indicator, a key component of the UHC monitoring framework aligned with the Sustainable Development Goals. Countries, and particularly high TB burden countries, are expected to conduct nationally representative TB patient cost surveys to establish baseline measurements for the catastrophic costs indicator. Findings from these surveys should also help identify entry points for developing policies to ensure better financial and social protection for TB patients. In this paper, we define the key measurable concepts for TB patient cost surveys, notably the types of costs that are captured, and related affordability measures. We discuss methods for measuring these notions in the UHC framework and contrast them with how they are measured in TB patient cost surveys.

How to do (or not to do) Measuring health worker motivation in surveys in low- and middle-income countries.

A health system's ability to deliver quality health care depends on the availability of motivated health workers, which are insufficient in many low income settings. Increasing policy and researcher attention is directed towards understanding what drives health worker motivation and how different policy interventions affect motivation, as motivation is key to performance and quality of care outcomes. As a result, there is growing interest among researchers in measuring motivation within health worker surveys. However, there is currently limited guidance on how to conceptualize and approach measurement and how to validate or analyse motivation data collected from health worker surveys, resulting in inconsistent and sometimes poor quality measures. This paper begins by discussing how motivation can be conceptualized, then sets out the steps in developing questions to measure motivation within health worker surveys and in ensuring data quality through validity and reliability tests. The paper also discusses analysis of the resulting motivation measure/s. This paper aims to promote high quality research that will generate policy relevant and useful evidence.

Willingness to pay for voluntary health insurance in Tanzania.

OBJECTIVE(S): To assess how willing people would be to join a voluntary health insurance scheme and to see how they respond to changes in the benefit package. We also examined willingness to cross-subsidise the poor. DESIGN: Cross-sectional study. SUBJECTS: Two thousand two hundread and twenty four households comprising of 1,163 uninsured household heads asked about their willingness to pay for insurance in seven districts/councils (three urban and four rural) and 1,061 insured households were asked about their willingness to pay for insurance premiums for the poor in their community. Uninsured respondents were presented with two scenarios, the first reflected the current design of the Community Health Fund/Tiba Kwa Kadi (CHF/TIKA), the second offered expanded benefits, and included inpatient care in public facilities and transport. RESULTS: Only 30% of uninsured rural households were willing to pay more than Tsh 5,000 the current premium level, their average amount was Tsh 10,741, while in urban areas one percent of households were willing to pay more than Tsh 5,000. There was very limited willingness to pay more than 5,000 Tsh, even with an expanded package in rural areas. Household from rural areas were more willing to cross-subsidise the poor, but contribution levels were higher in urban areas. CONCLUSION: Communities need to be sensitised about the existence of the CHF/TIKA to encourage enrollment. Expanding the benefit package would further increase enrollment. However, few people would be willing to pay more than the current premium.

Comparison of costs of home and facility-based basic obstetric care in rural Bangladesh.

This study compared the costs of providing antenatal, delivery and postnatal care in the home and in a basic obstetric facility in rural Bangladesh. The average costs were estimated by interviewing midwives and from institutional records. The main determinants of cost in each setting were also assessed. The cost of basic obstetric care in the home and in a facility was very similar, although care in the home was cheaper. Deliveries in the home took more time but this was offset by the capital costs associated with facility-based care. As use-rates increase, deliveries in a facility will become cheaper. Antenatal and postnatal care was much cheaper to provide in the facility than in the home. Facility-based delivery care is likely to be a cheaper and more feasible method for the care provider as demand rises. In settings where skilled attendance rates are very low, home-based care will be cheaper.

Costs of near-miss obstetric complications for women and their families in Benin and Ghana.

This paper estimates the total cost to women and their families associated with a spontaneous vaginal delivery and five types of 'near-miss' obstetric complication in Benin and Ghana, and assesses affordability in relation to household cash expenditure. A retrospective evaluation of costs was carried out among 121 mothers in three hospitals in Ghana. A prospective evaluation of costs was undertaken among 420 pregnant women in two hospitals in Benin. Information was collected on the cost of travel to the facilities and of direct medical and non-medical costs incurred during their stay in hospital. In Benin, costs ranged from an average of 15 US dollars for a spontaneous delivery to 256 US dollars for a near-miss complication caused by dystocia. In Ghana, average costs ranged from 18 US dollars for a spontaneous vaginal delivery to 115 US dollars for a near-miss complication caused by haemorrhage. Medical costs accounted for the largest share of total costs, mainly drugs and medical supplies in Ghana and costs of the delivery and any surgical intervention in Benin. Payments associated with a spontaneous vaginal delivery amounted to at least 2% of annual household cash expenditure in both countries. In the case of severe obstetric complications, costs incurred reached a high of 34% of annual household cash expenditure in Benin. The economic burden of hospital-based delivery care in Ghana and Benin is likely to deter or delay women's use of health services. Should a woman develop severe obstetric complications while in labour, the relatively high costs of hospital care could have a potentially catastrophic impact on the household budget.

Is hygiene promotion cost-effective? A case study in Burkina Faso.

OBJECTIVES: To estimate the incremental cost-effectiveness of a large-scale urban hygiene promotion programme in terms of reducing the incidence of childhood diarrhoeal disease in Bobo-Dioulasso, Burkina Faso. METHODS: Total and incremental costs of the programme were estimated retrospectively from the perspectives of the provider, from the households who change their behaviour as a result of the programme and from society (the sum of the two). The programme effects were derived from an intervention study that estimated the impact on handwashing with soap after handling child stools through a time-series method of observing 37 319 mothers. Using data from the literature, the associated reductions in childhood morbidity and mortality were estimated. The direct medical savings and indirect savings of caregiver time and lost productivity associated with child death were estimated from interviews with households and health workers. The cost and outcome data were combined to provide an estimate of the cost per mother who starts handwashing with soap as a result of the programme and the cost per case of childhood diarrhoea averted. RESULTS: The total provider cost (including start-up and 3-year running costs) was $302 507. Core programme activities accounted for 31% of the cost, administration 40%. The total cost to the 7286 households associated with changing behaviour during the 3 years of programme implementation was $160 125 ($7.3 per year per household). An estimated 8638 cases of diarrhoea, 864 outpatient consultations, 324 hospital referrals and 105 deaths were averted by the programme during this time. Savings to the provider from reduced treatment costs were estimated at $10 716 and savings to the households from averted treatment cost were $9136, resulting in a total saving to society of $19 852, increasing to $393 967 if indirect savings are included. The incremental provider cost per case of diarrhoea averted was $33.8. The incremental cost to society was $51.3 falling to $7.9 if indirect savings are included. If the programme were to be replicated elsewhere, savings in the international research input and start-up costs could reduce provider costs to $26.9 per case of diarrhoea averted. The annual cost of the programme represents 0.001% of the national health budget for Burkina Faso. The direct annual cost of implementing the programme at the household level represents 1.3% of annual household income. CONCLUSION: Hygiene promotion reduces the occurrence of childhood diarrhoea in Burkina Faso at less than 1% of the Ministry of Health budget and less than 2% of the household budget, and could be widely replicated at lower cost.

Economic impact of using mirtazapine compared to amitriptyline and fluoxetine in the treatment of moderate and severe depression in the UK.

This study modelled the economic impact of mirtazapine, compared to amitriptyline and fluoxetine, in the management of moderate and severe depression in the UK, as well as the costs related to discontinuation of antidepressant treatment. Decision models of the management of moderate and severe depression were developed from clinical trial data, resource use obtained from interviews with general practitioners and psychiatrists, and published literature, and were used to estimate the expected direct National Health Service (NHS) costs of managing a patient with moderate or severe depression. The expected cost of healthcare resource use attributable to managing a patient suffering from moderate or severe depression who discontinues antidepressant treatment, irrespective of the initial treatment, was estimated to be pounds sterling 206 (range pounds sterling 50 to pounds sterling 504) over five months. Using mirtazapine instead of amitriptyline for seven months increases the proportion of successfully treated patients by 21% (from 19.2 to 23.2%) and reduces the expected direct NHS cost by pounds sterling 35 per patient (from pounds sterling 448 to pounds sterling 413). Using mirtazapine instead of fluoxetine for six months increases the proportion of successfully treated patients by 22% (from 15.6 to 19.1%), albeit for an additional cost to the NHS of pounds sterling 27 per patient (from pounds sterling 394 to pounds sterling 420). In conclusion, this study suggests that mirtazapine is a cost-effective antidepressant compared to amitriptyline and fluoxetine in the management of moderate and severe depression in the UK.