Antibiotic use in mandarin production (Citrus reticulata Blanco) in major mandarin-producing areas in Thailand: A survey assessment.

BACKGROUND: Antimicrobial resistance (AMR), one of the major global threats to human security, has serious negative consequences for both health and economies. Excessive and inappropriate uses of antibiotics are the main drivers of the emergence of resistant bacterial strains. In Thailand, antibiotics have been used in citrus production since 2012 to treat citrus greening disease or Huanglongbing disease, despite no antibiotics being registered for use in mandarin. This raises concerns about irrational use of antibiotics, which can cause AMR. OBJECTIVE: To assess the status of greening disease and the use of antibiotics in mandarin production. METHOD: A face-to-face interview survey in 2017 with 221 mandarin growers in two major mandarin-producing areas. FINDINGS: Greening disease is one of the most serious diseases in mandarins and farmers in the two major mandarin-producing areas in Thailand used ampicillin, amoxicillin, tetracycline and penicillin to treat it. As no antibiotics are registered for use in plants, farmers used antibiotics (registered with the Thai Food and Drug Administration) for human use, either active pharmaceutical ingredients or finished products. They commonly purchased them from retail pharmacies or agrochemical suppliers. Farmers were influenced to use antibiotics by their orchard neighbours and advice from a few academics. The farmers injected antibiotics into the tree trunks approximately three to four times a year and stopped for more than two months before harvesting for in-season fruits. CONCLUSION: Antibiotics registered for human use are being applied to control greening diseases. We recommend scaling up sustainable disease control measures and curtail the use of antibiotics through close and effective dialogue among 'One Health' partners.

Strategic purchasing and health system efficiency: A comparison of two financing schemes in Thailand.

Strategic purchasing is an essential health financing function. This paper compares the strategic purchasing practices of Thailand's two tax-financed health insurance schemes, the Universal Coverage Scheme (UCS) and the Civil Servant Medical Benefit Scheme (CSMBS), and identifies factors contributing to successful universal health coverage outcomes by analysing the relationships between the purchaser and government, providers and members. The study uses a cross-sectional mixed-methods design, including document review and interviews with 56 key informants. The Comptroller General Department (CGD) of Ministry of Finance manages CSMBS as one among civil servant welfare programmes. Their purchasing is passive. Fee for service payment for outpatient care has resulted in rapid cost escalation and overspending of their annual budget. In contrast, National Health Security Office (NHSO) manages purchasing for UCS, which undertakes a range of strategic purchasing actions, including applying closed ended provider payment, promoting primary healthcare's gate keeping functions, exercising collective purchasing power and engaging views of members in decision making process. This difference in purchasing arrangements resulted in expenditure per CSMBS member being 4 times higher than UCS in 2014. The governance of the purchaser organization, the design of the purchasing arrangements including incentives and use of information, and the institutional capacities to implement purchasing functions are essential for effective strategic purchasing which can improve health system efficiency as a whole.

Auxiliary midwives in hard to reach rural areas of Myanmar: filling MCH gaps.

BACKGROUND: Auxiliary Midwives (AMWs) are community health volunteers supporting the work of midwives, especially maternal and child health services in hard to-reach areas in Myanmar. This paper assessed the contributions of AMW to maternal and child health services, factors influencing their productivity and their willingness to serve the community. METHOD: The study applied quantitative cross-sectional survey using census method. Total of 1,185 AMWs belonging to three batches: trained prior to 2000, between 2000 and 2011, and in 2012, from 21 townships of 17 states and regions in Myanmar participated in the study. Multiple logit regression was used to examine the impact of age, marital status, education, domicile, recruitment pattern and 'batch of training', on AMW's confidence level in providing care, and their intention to serve the community more than 5 years. RESULTS: All AMWs were able to provide essential maternal and child health services including antenatal care, normal delivery and post-natal care. They could identify and refer high-risk pregnancies to larger health facilities for proper management. On average, 9 deliveries, 11 antenatal and 9 postnatal cases were performed by an AMW during the six months prior to this study. AMWs had a comparative advantage for longer service in hard-to-reach villages where they lived, spoke the same dialect as the locals, understood the socio-cultural dimensions, and were well accepted by the community. Despite these contributions, 90 % of the respondents expressed receiving no adequate supervision, refresher training, replenishment of the AMW kits and transportation cost. AMWs in the elder age group are significantly more confident in taking care of the patients than those in the younger groups. Over 90 % of the respondents intended to stay more than five years in the community. The confidence in catering services appeared to have significant association with a longer period of stay in AMW jobs as evidenced by the odds ratio of 3.5, compared to those reporting unconfident. CONCLUSIONS: Comprehensive support system and national policy are needed to sustain and strengthen the contributions of AMWs, in sharing the workload of midwives, particularly in hard-to-reach areas of Myanmar.

Health workforce contributions to health system development: a platform for universal health coverage.

PROBLEM: In the 1970s, Thailand was a low-income country with poor health indicators and low health service coverage. The local health infrastructure was especially weak. APPROACH: In the 1980s, measures were initiated to reduce geographical barriers to health service access, improve the health infrastructure at the district level, make essential medicines more widely available and develop a competent, committed health workforce willing to service rural areas. To ensure service accessibility, financial risk protection schemes were expanded. LOCAL SETTING: In Thailand, district hospitals were practically non-existent in the 1960s. Expansion of primary health care (PHC), especially in poor rural areas, was considered essential for attaining universal health coverage (UHC). Nationwide reforms led to important changes in a few decades. RELEVANT CHANGES: Over the past 30 years, the availability and distribution of health workers, as well as their skills and competencies, have greatly improved, along with national health indicators. Between 1980 and 2000 coverage with maternal and child health services increased substantially. By 2002, Thailand had attained UHC. Overall health system development, particularly an expanded health workforce, resulted in a functioning PHC system. LESSONS LEARNT: A competent, committed health workforce helped strengthen the PHC system at the district level. Keeping the policy focus on the development of human resources for health (HRH) for an extended period was essential, together with a holistic approach to the development of HRH, characterized by the integration of different kinds of HRH interventions and the linking of these interventions with broader efforts to strengthen other health system domains.

Equity of access to and utilization of reproductive health services in Thailand: national Reproductive Health Survey data, 2006 and 2009.

This study assessed trends in equity of access to reproductive health services and service utilization in terms of coverage of family planning, antenatal care and skilled birth attendance in Thailand. Two health indicators were measured: the prevalence of low birthweight and exclusive breastfeeding. Equity was measured against the combined urban-rural areas and geographic regions, women's education level and quintiles of household assets index. The study used data from two nationally representative household surveys, the 2006 and 2009 Reproductive Health Surveys. Very high coverage of family planning (79.6%), universal antenatal care (98.9%) and skilled birth attendance (99.7%), with very small socioeconomic and geographic disparities, were observed. The public sector played a dominant role in maternity care (90.9% of all deliveries in 2009). The private sector also had a role among the higher educated, wealthier women living in urban areas. Public sector facilities, followed by drug stores, were a major supplier of contraception, which had a high use rate. High coverage and low inequity were the result of extensive investment in the health system by successive governments, in particular primary health care at district and sub-district levels, reaching universality by 2002. While maintaining these achievements, methodological improvements in measuring low birthweight and exclusive breastfeeding for future reproductive health surveys are recommended.

Economic evaluation of palliative management versus peritoneal dialysis and hemodialysis for end-stage renal disease: evidence for coverage decisions in Thailand.

OBJECTIVE: To examine the value for money of including peritoneal dialysis (PD) or hemodialysis (HD) into the universal health insurance scheme of Thailand. METHODS: A probabilistic Markov model applied to end-stage renal disease (ESRD) patients aged 20 to 70 years was developed to examine the incremental cost-effectiveness ratio (ICER) of palliative care versus 1) providing PD as an initial treatment followed by HD if complications/switching occur; and 2) providing HD followed by PD if complications/switching occur. Input parameters were extracted from a national cohort, the Thailand Renal Replacement Therapy Registry, and systematic reviews, where possible. The study explored the effects of uncertainty around input parameters, presented as cost-effectiveness acceptability frontier, as well as the value of obtaining further information on chosen parameters, i.e., partial expected value of perfect information. RESULTS: Using a societal perspective, the average ICER of initial treatment with PD and the average ICER of initial treatment with HD were 672,000 and 806,000 Baht per quality-adjusted life-year (QALY) gained (52,000 and 63,000 purchasing power parity [PPP] US$/QALY) compared with palliative care. Providing treatments for younger ESRD patients resulted in a significant improvement of survival and gain of QALYs compared with the older aged group. The cost-effectiveness and cost-utility ratios of both options for the older age group were relatively similar. CONCLUSIONS: The results suggest that offering PD as initial treatment was a better choice than offering HD, but it would only be considered a cost-effective strategy if the social willingness-to-pay threshold was at or higher than 700,000 Baht per QALY (54,000 PPP US$/QALY) for the age 20 group and 750,000 Baht per QALY (58,000 PPP US$/QALY) for age 70 years.