Defining and conceptualising the commercial determinants of health.

Although commercial entities can contribute positively to health and society there is growing evidence that the products and practices of some commercial actors-notably the largest transnational corporations-are responsible for escalating rates of avoidable ill health, planetary damage, and social and health inequity; these problems are increasingly referred to as the commercial determinants of health. The climate emergency, the non-communicable disease epidemic, and that just four industry sectors (ie, tobacco, ultra-processed food, fossil fuel, and alcohol) already account for at least a third of global deaths illustrate the scale and huge economic cost of the problem. This paper, the first in a Series on the commercial determinants of health, explains how the shift towards market fundamentalism and increasingly powerful transnational corporations has created a pathological system in which commercial actors are increasingly enabled to cause harm and externalise the costs of doing so. Consequently, as harms to human and planetary health increase, commercial sector wealth and power increase, whereas the countervailing forces having to meet these costs (notably individuals, governments, and civil society organisations) become correspondingly impoverished and disempowered or captured by commercial interests. This power imbalance leads to policy inertia; although many policy solutions are available, they are not being implemented. Health harms are escalating, leaving health-care systems increasingly unable to cope. Governments can and must act to improve, rather than continue to threaten, the wellbeing of future generations, development, and economic growth.

Incidence of catastrophic health spending in Indonesia: insights from a Household Panel Study 2018-2019.

BACKGROUND: Indonesia implemented one of the world's largest single-payer national health insurance schemes (the Jaminan Kesehatan Nasional or JKN) in 2014. This study aims to assess the incidence of catastrophic health spending (CHS) and its determinants and trends between 2018 and 2019 by which time JKN enrolment coverage exceeded 80%. METHODS: This study analysed data collected from a two-round cross-sectional household survey conducted in ten provinces of Indonesia in February-April 2018 and August-October 2019. The incidence of CHS was defined as the proportion of households with out-of-pocket (OOP) health spending exceeding 10% of household consumption expenditure. Chi-squared tests were used to compare the incidences of CHS across subgroups for each household characteristic. Logistic regression models were used to investigate factors associated with incurring CHS and the trend over time. Sensitivity analyses assessing the incidence of CHS based on a higher threshold of 25% of total household expenditure were conducted. RESULTS: The overall incidence of CHS at the 10% threshold fell from 7.9% to 2018 to 4.4% in 2019. The logistic regression models showed that households with JKN membership experienced significantly lower incidence of CHS compared to households without insurance coverage in both years. The poorest households were more likely to incur CHS compared to households in other wealth quintiles. Other predictors of incurring CHS included living in rural areas and visiting private health facilities. CONCLUSIONS: This study demonstrated that the overall incidence of CHS decreased in Indonesia between 2018 and 2019. OOP payments for health care and the risk of CHS still loom high among JKN members and among the lowest income households. More needs to be done to further contain OOP payments and further research is needed to investigate whether CHS pushes households below the poverty line.

Coronavirus Disease 2019 (COVID-19) Vaccine Prioritization in Low- and Middle-Income Countries May Justifiably Depart From High-Income Countries' Age Priorities.

In high-income countries that were first to roll out coronavirus disease 2019 (COVID-19) vaccines, older adults have thus far usually been prioritized for these vaccines over younger adults. Age-based priority primarily resulted from interpreting evidence available at the time, which indicated that vaccinating the elderly first would minimize COVID-19 deaths and hospitalizations. The World Health Organization counsels a similar approach for all countries. This paper argues that some low- and middle-income countries that are short of COVID-19 vaccine doses might be justified in revising this approach and instead prioritizing certain younger persons when allocating current vaccines or future variant-specific vaccines.

Rehabilitation services and related health databases, Japan.

The demographic transition towards an ageing population and the epidemiological transition from communicable to noncommunicable diseases have increased the demand for rehabilitation services globally. The aims of this paper were to describe the integration of rehabilitation into the Japanese health system and to illustrate how health information systems containing real-world data can be used to improve rehabilitation services, especially for the ageing population of Japan. In addition, there is an overview of how evidence-informed rehabilitation policy is guided by the analysis of large Japanese health databases, such as: (i) the National Database of Health Insurance Claims and Specific Health Checkups; (ii) the long-term care insurance comprehensive database; and (iii) the Long-Term Care Information System for Evidence database. Especially since the 1990s, the integration of rehabilitation into the Japanese health system has been driven by the country's ageing population and rehabilitation is today provided widely to an increasing number of older adults. General medical insurance in Japan covers acute and post-acute (or recovery) intensive rehabilitation. Long-term care insurance covers rehabilitation at long-term care institutions and community facilities for older adults with the goal of helping to maintain independence in an ageing population. The analysis of large health databases can be used to improve the management of rehabilitation care services and increase scientific knowledge as well as guide rehabilitation policy and practice. In particular, such analyses could help solve the current challenges of overtreatment and undertreatment by identifying strict criteria for determining who should receive long-term rehabilitation services.

Tant la transition démographique vers un vieillissement de la population que la transition épidémiologique des maladies transmissibles vers les maladies non transmissibles ont entraîné une augmentation de la demande en services de réadaptation dans le monde. Le présent document poursuit plusieurs objectifs: décrire l'intégration de la réadaptation dans le système de santé au Japon, et illustrer comment les systèmes de santé contenant des données réelles peuvent être utilisés en vue d'améliorer de tels services, en particulier pour une population nipponne vieillissante. En outre, il offre un aperçu de la manière dont la politique de réadaptation étayée par des faits s'inspire de l'analyse de vastes bases de données sanitaires japonaises, parmi lesquelles: (i) la base de données nationale des demandes de remboursement au titre de l'assurance-maladie et des bilans de santé spécifiques; (ii) la base de données complète de l'assurance pour les soins longue durée; et enfin, (iii) la base de données du système d'information relatif aux attestations de soins longue durée. Le vieillissement de la population a poussé le Japon à inclure la réadaptation dans son système de santé, surtout depuis les années 1990; aujourd'hui, un nombre croissant de personnes âgées ont aisément accès à des services de réadaptation. Au Japon, l'assurance-maladie globale prend en charge la réadaptation intensive aiguë et post-aiguë (ou de rétablissement). De son côté, l'assurance pour les soins longue durée couvre la réadaptation dans les établissements dédiés et les infrastructures collectives accueillant des personnes âgées, avec pour but de contribuer à préserver l'autonomie au sein d'une population vieillissante. L'analyse de vastes bases de données sanitaires peut favoriser une meilleure gestion des services de réadaptation et accroître les connaissances scientifiques, mais aussi orienter les politiques et pratiques en la matière. Ce type d'analyse peut surtout aider à s'attaquer aux enjeux actuels que représentent les traitements excessifs ou insuffisants, en identifiant des critères stricts permettant de déterminer qui doit faire l'objet d'une réadaptation sur le long terme.

La transición demográfica hacia el envejecimiento de la población y la transición epidemiológica de las enfermedades transmisibles a las no transmisibles han aumentado la demanda de servicios de rehabilitación en todo el mundo. Los objetivos de este artículo son describir la integración de la rehabilitación en el sistema sanitario japonés e ilustrar cómo los sistemas de información sanitaria que contienen datos del mundo real se pueden utilizar para mejorar los servicios de rehabilitación, en especial para la población que envejece en Japón. Además, se ofrece una visión general de cómo la política de rehabilitación fundamentada en la evidencia se guía por el análisis de las grandes bases de datos sanitarias japonesas, como: (i) la Base de Datos Nacional de Reclamaciones al Seguro de Enfermedad y Chequeos Médicos Específicos; (ii) la base de datos integral del seguro de cuidados de larga duración; y (iii) la base de datos del Sistema de Información de Cuidados de Larga Duración para la Evidencia. En particular, desde la década de 1990, la integración de la rehabilitación en el sistema sanitario japonés se ha visto impulsada por el envejecimiento de la población del país y, en la actualidad, la rehabilitación se ofrece de forma generalizada a una cantidad cada vez mayor de adultos mayores. El seguro médico general de Japón cubre la rehabilitación intensiva aguda y posaguda (o de recuperación). El seguro de cuidados de larga duración cubre la rehabilitación en instituciones de larga estancia y centros comunitarios para adultos mayores con el objetivo de ayudar a mantener la independencia en una población que envejece. El análisis de las grandes bases de datos sanitarias puede servir para mejorar la gestión de los servicios de atención a la rehabilitación y aumentar los conocimientos científicos, así como para orientar la política y la práctica de la rehabilitación. En concreto, estos análisis podrían ayudar a resolver los problemas actuales de sobretratamiento y subtratamiento, al identificar criterios estrictos para determinar quién debe recibir servicios de rehabilitación de larga duración.

Multi-dimensional impacts of Coronavirus disease 2019 pandemic on Sustainable Development Goal achievement.

BACKGROUND: Health, social and economic crises triggered by the Coronavirus disease pandemic (COVID-19) can derail progress and achievement of the Sustainable Development Goals. This commentary analyses the complex nexus of multi-dimensional impacts of the pandemic on people, prosperity, planet, partnership and peace. From our analysis, we generate a causal loop diagram explaining these complex pathways and proposed policy recommendations. MAIN TEXT: Health systems, health and wellbeing of people are directly affected by the pandemic, while impacts on prosperity, education, food security and environment are indirect consequences from pandemic containment, notably social measures, business and school closures and international travel restrictions. The magnitude of impacts is determined by the level of prior vulnerability and inequity in the society, and the effectiveness and timeliness of comprehensive pandemic responses. CONCLUSIONS: To exit the acute phase of the pandemic, equitable access to COVID-19 vaccines by all countries and continued high coverage of face masks and hand hygiene are critical entry points. During recovery, governments should strengthen preparedness based on the One Health approach, rebuild resilient health systems and an equitable society, ensure universal health coverage and social protection mechanisms for all. Governments should review progress and challenges from the pandemic and sustain a commitment to implementing the Sustainable Development Goals.

Using measures of quality of care to assess equity in health care funding for primary care: analysis of Indonesian household data.

BACKGROUND: Many countries implementing pro-poor reforms to expand subsidized health care, especially for the poor, recognize that high-quality healthcare, and not just access alone, is necessary to meet the Sustainable Development Goals. As the poor are more likely to use low quality health services, measures to improve access to health care need to emphasise quality as the cornerstone to achieving equity goals. Current methods to evaluate health systems financing equity fail to take into account measures of quality. This paper aims to provide a worked example of how to adapt a popular quantitative approach, Benefit Incidence Analysis (BIA), to incorporate a quality weighting into the computation of public subsidies for health care. METHODS: We used a dataset consisting of a sample of households surveyed in 10 provinces of Indonesia in early-2018. In parallel, a survey of public health facilities was conducted in the same geographical areas, and information about health facility infrastructure and basic equipment was collected. In each facility, an index of service readiness was computed as a measure of quality. Individuals who reported visiting a primary health care facility in the month before the interview were matched to their chosen facility. Standard BIA and an extended BIA that adjusts for service quality were conducted. RESULTS: Quality scores were relatively high across all facilities, with an average of 82%. Scores for basic equipment were highest, with an average score of 99% compared to essential medicines with an average score of 60%. Our findings from the quality-weighted BIA show that the distribution of subsidies for public primary health care facilities became less 'pro-poor' while private clinics became more 'pro-rich' after accounting for quality of care. Overall the distribution of subsidies became significantly pro-rich (CI = 0.037). CONCLUSIONS: Routine collection of quality indicators that can be linked to individuals is needed to enable a comprehensive understanding of individuals' pathways of care. From a policy perspective, accounting for quality of care in health financing assessment is crucial in a context where quality of care is a nationwide issue. In such a context, any health financing performance assessment is likely to be biased if quality is not accounted for.

Public health policies and health-care workers' response to the COVID-19 pandemic, Thailand.

Since January 2020, the coronavirus disease 2019 (COVID-19) pandemic has had a far-reaching impact on global morbidity and mortality. The effects of varying degrees of implementation of public health and social measures between countries is evident in terms of widely differing disease burdens and levels of disruption to public health systems. Despite Thailand being the first country outside China to report a positive case of COVID-19, the subsequent number of cases and deaths has been much lower than in many other countries. As of 7 January 2021, the number of confirmed COVID-19-positive cases in Thailand was 9636 (138 per million population) and the number of deaths was 67 (1 per million population). We describe the nature of the health workforce and function that facilitated the capacity to respond to this pandemic. We also describe the public health policies (laboratory testing, test-and-trace system and mandatory 14-day quarantine of cases) and social interventions (daily briefings, restriction of mobility and social gatherings, and wearing of face masks) that allowed the virus to be successfully contained. To enhance the capacity of health-care workers to respond to the pandemic, the government (i) mobilized staff to meet the required surge capacity; (ii) developed and implemented policies to protect occupational safety; and (iii) initiated packages to support morale and well-being. The results of the policies that we describe are evident in the data: of the 66 countries with more than 100 COVID-19-positive cases in health-care workers as at 8 May 2020, Thailand ranked 65th.

Depuis janvier 2020, la pandémie de maladie à coronavirus (COVID-19) a eu un impact considérable sur la morbidité et la mortalité à l'échelle globale. Les degrés de mise en œuvre des mesures sociales et sanitaires, qui varient d'un pays à l'autre, ont des conséquences évidentes, notamment sur les différences de charge que représente la maladie et sur l'ampleur des perturbations touchant les systèmes de santé publique. Même si la Thaïlande est, après la Chine, la première nation à avoir signalé un cas positif de COVID-19, le nombre de cas et de décès qui ont suivi a été nettement moins élevé que dans de nombreux autres pays. Au 7 janvier 2021, la Thaïlande comptait 9636 cas positifs confirmés de COVID-19 (138 par million d'habitants) et 67 décès (1,0 par million d'habitants). Dans le présent document, nous décrivons la nature des professionnels de santé et des fonctions qui ont renforcé les capacités de réaction face à cette pandémie. Nous détaillons également les politiques de santé publique (tests en laboratoire, système de dépistage et de suivi, quarantaine obligatoire de 14 jours pour les cas détectés) et les interventions sociales (séances d'information quotidiennes, restriction des déplacements et des rassemblements, port du masque) qui ont permis de contenir le virus avec succès. Afin d'aider les soignants à lutter contre la pandémie, le gouvernement (i) a mobilisé du personnel pour fournir les capacités d'intervention requises; (ii) a développé et appliqué des mesures de protection pour garantir la sécurité au travail; et enfin, (iii) a proposé des programmes de soutien au moral et au bien-être. Les politiques que nous évoquons se traduisent par des résultats sans équivoque: sur les 66 pays dépassant les 100 cas positifs de COVID-19 chez les professionnels de santé au 8 mai 2020, la Thaïlande se classait à la 65e place.

Desde enero de 2020, la pandemia de la enfermedad por coronavirus (COVID-19) ha tenido un impacto de gran alcance en la morbilidad y la mortalidad mundial. Los efectos de los diferentes grados de aplicación de las medidas sociales y de salud pública entre los países son evidentes en términos de cargas virales muy diferentes y niveles de perturbación de los sistemas de salud pública. A pesar de que Tailandia fue el primer país fuera de China en notificar un caso positivo de COVID-19, el número posterior de casos y muertes ha sido mucho menor que en muchos otros países. Hasta el 7 de enero de 2021, el número de casos positivos confirmados de COVID-19 en Tailandia era de 9.636 (138 por millón de población) y el número de muertes era de 67 (1,0 por millón de población). Describimos la naturaleza del personal sanitario y la función que facilitó la capacidad de respuesta a esta pandemia. También describimos las políticas de salud pública (pruebas de laboratorio, sistema de prueba y rastreo y cuarentena obligatoria de 14 días), así como las intervenciones sociales (sesiones informativas diarias, restricción de la movilidad y de las reuniones sociales, uso de mascarillas, etc.) que permitieron contener el virus con éxito. Para mejorar la capacidad de los trabajadores sanitarios para responder a la pandemia, el gobierno (i) movilizó al personal para satisfacer la capacidad de respuesta requerida; (ii) desarrolló y aplicó políticas para proteger la seguridad laboral; y (iii) puso en marcha paquetes para apoyar la moral y el bienestar de la población. Los resultados de las políticas que describimos son evidentes en los datos: de los 66 países con más de 100 casos positivos de COVID-19 en trabajadores sanitarios a 8 de mayo de 2020, Tailandia ocupaba el puesto 65.

Annual prevalence of unmet healthcare need in Thailand: evidence from national household surveys between 2011 and 2019.

BACKGROUND: Extending Universal Health Coverage (UHC) requires identifying and addressing unmet healthcare need and its causes to improve access to essential health services. Unmet need is a useful monitoring indicator to verify if low incidence of catastrophic health spending is not a result of foregone services due to unmet needs. This study assesses the trend, between 2011 and 2019, of prevalence and reasons of unmet healthcare need and identifies population groups who had unmet needs. METHOD: The unmet healthcare need module in the Health and Welfare Survey (HWS) 2011-2019 was used for analysis. HWS is a nationally representative household survey conducted by the National Statistical Office biennially. There are more than 60,000 respondents in each round of survey. The Organisation for Economic Co-operation and Development (OECD) standard questions on unmet need and reasons behind were applied for outpatient (OP), inpatient (IP) and dental services in the past 12 months. Data from samples were weighted to represent the Thai population. Univariate analysis was applied to assess unmet need across socioeconomic profiles. RESULTS: The annual prevalence of unmet need between 2011 and 2019 was lower than 3%. The prevalence was 1.3-1.6% for outpatient services, 0.9% - 1.1% for dental services, and lower than 0.2% for inpatient care. A small increasing trend was observed on dental service unmet need, from 0.9% in 2011 to 1.1% in 2019. The poor, the elderly and people living in urban areas had higher unmet needs than their counterparts. Long waiting times was the main reason for unmet need, while cost of treatment was not an issue. CONCLUSION: The low level of unmet need at less than 3% was lower than OECD average (28%), and was the result of UHC since 2002. Regular monitoring using the national representative household survey to estimate annual prevalence and reasons for unmet need can guide policy to sustain and improve access by certain population groups.

Population knowledge and awareness of antibiotic use and antimicrobial resistance: results from national household survey 2019 and changes from 2017.

BACKGROUND: Lack of knowledge and awareness on antimicrobial resistance (AMR) can result in irrational use of antibiotics, which is one of the major drivers of AMR. One goal of the Thailand National Strategic Plan on AMR (2017-2021) is a 20% increase in public knowledge and awareness of antibiotic use and AMR by 2021. This study assesses antibiotic use, level of knowledge and awareness of antibiotic use and AMR and the factors associated with their knowledge and awareness in the Thai population in 2019. It compares findings with a similar national survey in 2017. METHODS: An AMR module was integrated into the Health and Welfare Survey, a biennial national household survey conducted by the National Statistical Office since 2017. The 2019 survey took place in March, through face-to-face interviews with 27,900 Thai adults aged 15 years or above who participated in the survey and compares 2019 findings with those from 2017. RESULTS: One month prior to the survey, 6.3% of population reported use of antibiotics (reduced from 7.9% to 2017), of which 98.1% received antibiotics through healthcare professionals and almost half (43.2%) for flu symptoms. During the last 12 months, 21.5% of Thai adults received information on the appropriate use of antibiotics and AMR (increased from 17.8% to 2017); mostly through health professionals (82.7%). On knowledge, 24.3% of adults gave correct answers to more than three out of six statements (three true and three false statements) (increased from 23.7% to 2017). The overall mean score of awareness of appropriate antibiotic use and AMR is 3.3 out of total score of 5. CONCLUSIONS: Although progress was made on knowledge and awareness between 2017 and 2019, certain practices, such as use of antibiotics for flu symptoms and receiving information about antibiotic use and AMR, are inappropriate and inadequate. These findings require significant action, notably strengthening health professionals' ability to prescribe and dispense antibiotics appropriately and effective communication with patients. The government should promote specific information on rational use of antibiotics and AMR to specific target groups.

Healthcare providers' perspectives on integrating NCDs into primary healthcare in Thailand: a mixed method study.

BACKGROUND: In response to an increased health burden from non-communicable diseases (NCDs), primary health care (PHC) is effective platform to support NCDs prevention and control. This study aims to assess Thailand's PHC capacity in providing NCDs services, identify enabling factors and challenges and provide policy recommendations for improvement. METHODS: This cross-sectional mixed-method study was conducted between October 2019 and May 2020. Two provinces, one rich and one poor, were randomly selected and then a city and rural district from each province were randomly selected. From these 4 sites in the 2 provinces, all 56 PHC centres responded to a self-administrative questionnaire survey on their capacities and practices related to NCDs. A total of 79 participants from Provincial and District Health Offices, provincial and district hospitals, and PHC centres who are involved with NCDs participated in focus group discussions or in-depth interviews. RESULTS: Strong health infrastructure, competent staff (however not with increased workload), essential medicines and secured budget boost PHC capacity to address NCDs prevention, control, case management, referral and rehabilitation. Community engagement through village health volunteers improves NCDs awareness, supports enrolment in screening and raises adherence to interventions. Village health volunteers, the crucial link between the health system and the community, are key in supporting health promotion and NCDs prevention and control. Collaboration between provincial and district hospitals in providing resources and technical support enhance the capacity of PHC centres to provide NCDs services. However, inconsistent national policy directions and uncertainty related to key performance indicators hamper progress in NCDs management at the operational level. The dynamic of urbanization and socialization, especially living in obesogenic environments, is one of the greatest challenges for dealing with NCDs. CONCLUSION: PHC centres play a vital role in NCDs prevention and control. Adequate human and financial resources and policy guidance are required to improve PHC performance in managing NCDs. Implementing best buy measures at national level provides synergies for NCDS control at PHC level.

Developing a Thai national critical care allocation guideline during the COVID-19 pandemic: a rapid review and stakeholder consultation.

BACKGROUND: At the height of the COVID-19 pandemic, Thailand had almost depleted its critical care resources, particularly intensive care unit (ICU) beds and ventilators. This prompted the necessity to develop a national guideline for resource allocation. This paper describes the development process of a national guideline for critical resource allocation in Thailand during the COVID-19 pandemic. METHODS: The guideline development process consisted of three steps: (1) rapid review of existing rationing guidelines and literature; (2) interviews of Thai clinicians experienced in caring for COVID-19 cases; and (3) multi-stakeholder consultations. At steps 1 and 2, data was synthesized and categorized using a thematic and content analysis approach, and this guided the formulation of the draft guideline. Within step 3, the draft Thai critical care allocation guideline was debated and finalized before entering the policy-decision stage. RESULTS: Three-order prioritization criteria consisting of (1) clinical prognosis using four tools (Charlson Comorbidity Index, Sequential Organ Failure Assessment, frailty assessment and cognitive impairment assessment), (2) number of life-years saved and (3) social usefulness were proposed by the research team based on literature reviews and interviews. At consultations, stakeholders rejected using life-years as a criterion due to potential age and gender discrimination, as well as social utility due to a concern it would foster public distrust, as this judgement can be arbitrary. It was agreed that the attending physician is required to be the decision-maker in the Thai medico-legal context, while a patient review committee would play an advisory role. Allocation decisions are to be documented for transparency, and no appealing mechanism is to be applied. This guideline will be triggered only when demand exceeds supply after the utmost efforts to mobilize surge capacity. Once implemented, it is applicable to all patients, COVID-19 and non-COVID-19, requiring critical care resources prior to ICU admission and during ICU stay. CONCLUSIONS: The guideline development process for the allocation of critical care resources in the context of the COVID-19 outbreak in Thailand was informed by scientific evidence, medico-legal context, existing norms and societal values to reduce risk of public distrust given the sensitive nature of the issue and ethical dilemmas of the guiding principle, though it was conducted at record speed. Our lessons can provide an insight for the development of similar prioritization guidelines, especially in other low- and middle-income countries.

Primary health care and sustainable development goals.

We examine the potential and limitations of primary health care in contributing to the achievement of the health-related sustainable development goals (SDGs), and recommend policies to enable a functioning primary health-care system. Governments have recently reaffirmed their commitment to the SDGs through the 2018 Declaration of Astana, which redefines the three functions of primary health care as: service provision, multisectoral actions and the empowerment of citizens. In other words, the health-related SDGs cannot be achieved by the provision of health-care services alone. Some health issues are related to environment, necessitating joint efforts between local, national and international partners; other issues require public awareness (health literacy) of preventable illnesses. However, the provision of primary health care, and hence achievement of the SDGs, is hampered by several issues. First, inadequate government spending on health is exacerbated by the small proportions allocated to primary health care. Second, the shortage and maldistribution of the health workforce, and chronic absenteeism in some countries, has led to a situation in which staffing levels are inversely related to poverty and need. Third, the health workforce is not trained in multisectoral actions, and already experiences workloads of an overwhelming nature. Finally, health illiteracy is common among the population, even in developed countries. We recommend that governments increase spending on health and primary health care, implement interventions to retain the rural health workforce, and update the pre-service training curricula of personnel to include skills in multisectoral collaboration and enhanced community engagement.

Dans le présent document, nous étudions le potentiel et les limites des soins de santé primaires en matière de réalisation des objectifs de développement durable (ODD) liés à la santé. Nous formulons également des recommandations politiques pour l'instauration d'un système de soins de santé primaires efficace. Les gouvernements ont récemment réaffirmé leur engagement envers les ODD en 2018 par le biais de la Déclaration d'Astana, qui redéfinit les trois fonctions des soins de santé primaires comme suit: fourniture de services, actions multidisciplinaires et implication des citoyens. En d'autres termes, les ODD liés à la santé ne peuvent être atteints uniquement en proposant des services médicaux. Certains problèmes de santé sont inhérents à l'environnement et requièrent les efforts conjoints des partenaires locaux, nationaux et internationaux; d'autres nécessitent de sensibiliser le public (médecine préventive) aux maladies évitables. Cependant, la fourniture de soins de santé primaires, et par conséquent la réalisation des ODD, rencontre de nombreux obstacles. Tout d'abord, les dépenses inadéquates des gouvernements en matière de santé sont aggravées par le faible pourcentage octroyé aux soins de santé primaires. Ensuite, la pénurie et les inégalités de répartition des professionnels de la santé ainsi que l'absentéisme chronique dans certains pays ont débouché sur une situation où le niveau des effectifs est inversement proportionnel au niveau de pauvreté et aux besoins. Par ailleurs, le personnel soignant n'est pas formé aux actions multidisciplinaires et subit déjà une charge de travail écrasante. Et enfin, la méconnaissance des bases sanitaires est fréquente au sein de la population, même dans les pays développés. Nous conseillons aux gouvernements d'accroître leurs dépenses en soins de santé et soins de santé primaires, d'intervenir pour encourager les soignants à rester dans les régions rurales, et de mettre à jour les programmes de formation initiale du personnel pour y inclure des compétences en collaboration multidisciplinaire et en amélioration de l'engagement communautaire.

Se analizan las posibilidades y las limitaciones de la atención primaria de salud para contribuir al logro de los objetivos de desarrollo sostenible (los ODS) relacionados con la salud, y se recomiendan políticas que permitan el funcionamiento del sistema de atención primaria de salud. Recientemente, los gobiernos reiteraron su compromiso con los ODS en la Declaración de Astaná de 2018, en la que se redefinen las tres funciones de la atención primaria de salud, a saber: la prestación de servicios, las medidas multisectoriales y una mayor participación de los ciudadanos. Es decir, los ODS relacionados con la salud no se pueden cumplir tan solo con la prestación de servicios de atención de la salud. Algunos temas de salud están relacionados con el medio ambiente, lo que requiere esfuerzos conjuntos entre los asociados locales, nacionales e internacionales; otros temas requieren la concienciación del público (conocimientos sobre la salud) acerca de las enfermedades que se pueden evitar. Sin embargo, la prestación de atención primaria de salud, y por consiguiente el logro de los ODS, presenta diversas dificultades. En primer lugar, el gasto público inadecuado en salud empeora debido a los porcentajes tan reducidos que se asignan a la atención primaria de salud. En segundo lugar, la escasez y la mala distribución del personal sanitario, así como el absentismo crónico en algunos países, han creado una situación en la que los niveles de personal están relacionados de manera inversa con la pobreza y la necesidad. En tercer lugar, el personal sanitario no está capacitado para emprender medidas multisectoriales, además de que ya tiene una carga de trabajo abrumadora. Por último, la falta de conocimientos sobre salud es común entre la población, incluso en los países desarrollados. Se recomienda a los gobiernos que aumenten el gasto en salud y en atención primaria de la salud, que implementen intervenciones para fidelizar al personal sanitario de las zonas rurales y que actualicen los programas de capacitación del personal previa a la prestación de servicios para integrar las habilidades en la colaboración multisectorial y el aumento de la participación de la comunidad.

Legislating for public accountability in universal health coverage, Thailand.

Sustaining universal health coverage requires robust active public participation in policy formation and governance. Thailand's universal coverage scheme was implemented nationwide in 2002, allowing Thailand to achieve full population coverage through three public health insurance schemes and to demonstrate improved health outcomes. Although Thailand's position on the World Bank worldwide governance indicators has deteriorated since 1996, provisions for voice and accountability were embedded in the legislation and design of the universal coverage scheme. We discuss how legislation related to citizens' rights and government accountability has been implemented. Thailand's constitution allowed citizens to submit a draft bill in which provisions on voice and accountability were successfully embedded in the legislative texts and adopted into law. The legislation mandates registration of beneficiaries, a 24/7 helpline, annual public hearings and no-fault financial assistance for patients who have experienced adverse events. Ensuring the right to health services, and that citizens' voices are heard and action taken, requires the institutional capacity to implement legislation. For example, Thailand needed the capacity to register 47 million people and match them with the health-care provider network in the district where they live, and to re-register members who move out of their districts. Annual public hearings need to be inclusive of citizens, health-care providers, civil society organizations and stakeholders such as local governments and patient groups. Subsequent policy and management responses are important for building trust in the process and citizens' ownership of the scheme. Annual public reporting of outcomes and performance of the scheme fosters transparency and increases citizens' trust.

Maintenir la couverture sanitaire universelle exige une forte participation publique à l'élaboration des politiques et à la gouvernance. En Thaïlande, le régime de couverture universelle a été mis en œuvre dans tout le pays en 2002, permettant de couvrir l'ensemble de la population grâce à trois régimes publics d'assurance maladie et d'améliorer les résultats de santé. Bien que la position de la Thaïlande concernant les Indicateurs de gouvernance mondiaux de la Banque mondiale se soit détériorée depuis 1996, des dispositions en matière d'expression et de reddition de comptes ont été intégrées à la législation et à la structure du régime de couverture universelle. Nous discutons ici de la mise en œuvre de la législation relative aux droits des citoyens et à la reddition de comptes du gouvernement. En vertu de la constitution de la Thaïlande, les citoyens ont pu soumettre un projet de loi dont les dispositions en matière d'expression et de reddition de comptes ont été intégrées aux textes législatifs et transposées dans la loi. La législation rend obligatoire l'enregistrement des bénéficiaires, une assistance téléphonique 24h/24 et 7 j/7, des auditions publiques annuelles et une aide financière systématique pour les patients qui ont été victimes d'événements indésirables. Pour garantir le droit à des services de santé, permettre aux citoyens de faire entendre leur voix et s'assurer que des mesures soient prises, les institutions doivent être en mesure d'appliquer la législation. Par exemple, la Thaïlande devait pouvoir enregistrer 47 millions de personnes et les rattacher au réseau de prestataires de soins du district où elles vivaient, et réenregistrer les personnes qui changeaient de district. Les auditions publiques annuelles doivent faire participer les citoyens, les prestataires de soins, les organisations de la société civile et les parties prenantes telles que les collectivités locales et les groupes de patients. Les réponses qui en découlent au point de vue des politiques et de la gestion sont importantes pour instaurer la confiance dans le processus et permettre aux citoyens de se l'approprier. Les rapports annuels publics sur les résultats du régime de couverture permettent d'accroître la transparence et de renforcer la confiance des citoyens.

Para mantener la cobertura sanitaria universal se requiere una sólida participación activa del público en la formulación de políticas y la gobernanza. El plan de cobertura universal de Tailandia se implementó en todo el país en 2002, lo que permitió a Tailandia lograr una cobertura completa de la población a través de tres planes de seguro médico público y demostrar mejores resultados en materia de salud. Aunque la posición de Tailandia respecto de los Indicadores mundiales de gobernanza del Banco Mundial ha disminuido desde 1996, las disposiciones relativas a la voz y la rendición de cuentas estaban incorporadas en la legislación y en el diseño del plan de cobertura universal. Se discute cómo se ha implementado la legislación relacionada con los derechos de los ciudadanos y la rendición de cuentas del gobierno. La Constitución de Tailandia permitía a los ciudadanos presentar un proyecto de ley en el que las disposiciones sobre la voz y la rendición de cuentas se incorporaban con éxito en los textos legislativos y se aprobaban como ley. La legislación exige el registro de los beneficiarios, una línea telefónica de ayuda 24 horas al día los 7 días de la semana, audiencias públicas anuales y asistencia financiera gratuita para los pacientes que han sufrido eventos adversos. Para garantizar el derecho a los servicios de salud y que se escuche la voz de los ciudadanos y se adopten medidas, es necesario contar con la capacidad institucional para aplicar la legislación. Por ejemplo, Tailandia necesitaba la capacidad de inscribir a 47 millones de personas y ponerlas en contacto con la red de proveedores de servicios de salud del distrito en el que viven, y de volver a inscribir a los miembros que se trasladan fuera de sus distritos. Las audiencias públicas anuales deben incluir a los ciudadanos, los proveedores de servicios de salud, las organizaciones de la sociedad civil y las partes interesadas, como los gobiernos locales y los grupos de pacientes. Las respuestas políticas y de gestión subsiguientes son importantes para generar confianza en el proceso y en la apropiación del plan por parte de los ciudadanos. El informe público anual sobre los resultados y el rendimiento del plan fomenta la transparencia y aumenta la confianza de los ciudadanos.

Political economy of Thailand's tax-financed universal coverage scheme.

PROBLEM: The challenge of implementing contributory health insurance among populations in the informal sector was a barrier to achieving universal health coverage (UHC) in Thailand. APPROACH: UHC was a political manifesto of the 2001 election campaign. A contributory system was not a feasible option to honour the political commitment. Given Thailand's fiscal capacity and the moderate amount of additional resources required, the government legislated to use general taxation as the sole source of financing for the universal coverage scheme. LOCAL SETTING: Before 2001, four public health insurance schemes covered only 70% (44.5 million) of the 63.5 million population. The health ministry received the budget and provided medical welfare services for low-income households and publicly subsidized voluntary insurance for the informal sector. The budgets for supply-side financing of these schemes were based on historical figures which were inadequate to respond to health needs. The finance ministry used its discretionary power in budget allocation decisions. RELEVANT CHANGES: Tax became the sole source of financing the universal coverage scheme. Transparency, multistakeholder engagement and use of evidence informed budgetary negotiations. Adequate funding for UHC was achieved, providing access to services and financial protection for vulnerable populations. Out-of-pocket expenditure, medical impoverishment and catastrophic health spending among households decreased between 2000 and 2015. LESSONS LEARNT: Domestic government health expenditure, strong political commitment and historical precedence of the tax-financed medical welfare scheme were key to achieving UHC in Thailand. Using evidence secures adequate resources, promotes transparency and limits discretionary decision-making in budget allocation.

Financial risk protection of Thailand's universal health coverage: results from series of national household surveys between 1996 and 2015.

BACKGROUND: Thailand, an upper-middle income country, has demonstrated exemplary outcomes of Universal Health Coverage (UHC). The country achieved full population coverage and a high level of financial risk protection since 2002, through implementing three public health insurance schemes. UHC has two explicit goals of improved access to health services and financial protection where use of these services does not create financial hardship. Prior studies in Thailand do not provide evidence of long-term UHC financial risk protection. This study assessed financial risk protection as measured by the incidence of catastrophic health spending and impoverishment in Thai households prior to and after UHC in 2002. METHODS: We used data from a 15-year series of annual national household socioeconomic surveys (SES) between 1996 and 2015, which were conducted by the National Statistic Office (NSO). The survey covered about 52,000 nationally representative households in each round. Descriptive statistics were used to assess the incidence of catastrophic payment as measured by the share of out-of-pocket payment (OOP) for health by households exceeding 10 and 25% of household total consumption expenditure, and the incidence of impoverishment as determined by the additional number of non-poor households falling below the national and international poverty lines after making health payments. RESULTS: Using the 10% threshold, the incidence of catastrophic spending dropped from 6.0% in 1996 to 2% in 2015. This incidence reduced more significantly when the 25% threshold was applied from 1.8 to 0.4% during the same period. The incidence of impoverishment against the national poverty line reduced considerably from 2.2% in 1996 to approximately 0.3% in 2015. When the international poverty line of US$ 3.1 per capita per day was applied, the incidence of impoverishment was 1.4 and 0.4% in 1996 and 2015 respectively; and when US$ 1.9 per day was applied, the incidence was negligibly low. CONCLUSION: The significant decline in the incidence of catastrophic health spending and impoverishment was attributed to the deliberate design of Thailand's UHC, which provides a comprehensive benefits package and zero co-payment at point of services. The well-founded healthcare delivery system and favourable benefits package concertedly support the achievement of UHC goals of access and financial risk protection.

Performance of Thailand's universal health coverage scheme: Evaluating the effectiveness of annual public hearings.

BACKGROUND: Legislative provisions in Thailand's National Health Security Act 2002 mandate annual public hearings for providers, beneficiaries and other stakeholders in order to improve the performance of the Universal Health Coverage Scheme (UCS). OBJECTIVE: This study aims to explore the annual public hearing process, evaluate its effectiveness and propose recommendations for improvement. METHOD: In-depth interviews were conducted with 29 key informants from various stakeholder groups involved in annual public hearings. RESULTS: The evaluation showed that the public hearings fully met the criteria of influence over policy decision and partially met the criteria of appropriate participation approach and social learning. However, there are rooms for improvement on public hearing's inclusiveness and representativeness of participants, adequacy of information and transparency. CONCLUSIONS: Three recommendations were proposed a) informing stakeholders in advance of the agenda and hearing process to enable their active participation; b) identifying experienced facilitators to navigate the discussions across stakeholders with different or conflicting interests, in order to reach consensus and prioritize recommendations; and c) communicating policy and management responses as a result of public hearings to all stakeholders in a timely manner.

Prioritizing critical-care resources in response to COVID-19: lessons from the development of Thailand's Triage protocol.

As COVID-19 ravages the world, many countries are faced with the grim reality of not having enough critical-care resources to go around. Knowing what could be in store, the Thai Ministry of Public Health called for the creation of an explicit protocol to determine how these resources are to be rationed in the situation of demand exceeding supply. This paper shares the experience of developing triage criteria and a mechanism for prioritizing intensive care unit resources in a middle-income country with the potential to be applied to other low- and middle-income countries (LMICs) faced with a similar (if not more of a) challenge when responding to the global pandemic. To the best of our knowledge, this locally developed guideline would be among the first of its kind from an LMIC setting. In summary, the experience from the Thai protocol development highlights three important lessons. First, stakeholder consultation and public engagement are crucial steps to ensure the protocol reflects the priorities of society and to maintain public trust in the health system. Second, all bodies and actions proposed in the protocol must not conflict with existing laws to ensure smooth implementation and adherence by professionals. Last, all components of the protocol must be compatible with the local context including medical culture, physician-patient relationship, and religious and societal norms.

Framework for Managing the COVID-19 Infodemic: Methods and Results of an Online, Crowdsourced WHO Technical Consultation.

BACKGROUND: An infodemic is an overabundance of information-some accurate and some not-that occurs during an epidemic. In a similar manner to an epidemic, it spreads between humans via digital and physical information systems. It makes it hard for people to find trustworthy sources and reliable guidance when they need it. OBJECTIVE: A World Health Organization (WHO) technical consultation on responding to the infodemic related to the coronavirus disease (COVID-19) pandemic was held, entirely online, to crowdsource suggested actions for a framework for infodemic management. METHODS: A group of policy makers, public health professionals, researchers, students, and other concerned stakeholders was joined by representatives of the media, social media platforms, various private sector organizations, and civil society to suggest and discuss actions for all parts of society, and multiple related professional and scientific disciplines, methods, and technologies. A total of 594 ideas for actions were crowdsourced online during the discussions and consolidated into suggestions for an infodemic management framework. RESULTS: The analysis team distilled the suggestions into a set of 50 proposed actions for a framework for managing infodemics in health emergencies. The consultation revealed six policy implications to consider. First, interventions and messages must be based on science and evidence, and must reach citizens and enable them to make informed decisions on how to protect themselves and their communities in a health emergency. Second, knowledge should be translated into actionable behavior-change messages, presented in ways that are understood by and accessible to all individuals in all parts of all societies. Third, governments should reach out to key communities to ensure their concerns and information needs are understood, tailoring advice and messages to address the audiences they represent. Fourth, to strengthen the analysis and amplification of information impact, strategic partnerships should be formed across all sectors, including but not limited to the social media and technology sectors, academia, and civil society. Fifth, health authorities should ensure that these actions are informed by reliable information that helps them understand the circulating narratives and changes in the flow of information, questions, and misinformation in communities. Sixth, following experiences to date in responding to the COVID-19 infodemic and the lessons from other disease outbreaks, infodemic management approaches should be further developed to support preparedness and response, and to inform risk mitigation, and be enhanced through data science and sociobehavioral and other research. CONCLUSIONS: The first version of this framework proposes five action areas in which WHO Member States and actors within society can apply, according to their mandate, an infodemic management approach adapted to national contexts and practices. Responses to the COVID-19 pandemic and the related infodemic require swift, regular, systematic, and coordinated action from multiple sectors of society and government. It remains crucial that we promote trusted information and fight misinformation, thereby helping save lives.

Contributions of information and communications technology to future health systems and Universal Health Coverage: application of Japan's experiences.

BACKGROUND: Demographic changes in the pattern of disease burden, escalating health expenditures and inequitable access to healthcare are global challenges. Irrespective of their level of development, all countries need to reform their health systems to prepare for the future emerging health needs, in order to meet their commitments of health systems strengthening, universal health coverage (UHC) and explicit targets in the Sustainable Development Goals (SDGs). We propose three core principles for the future health system as described herein. A health system is not simply a 'cure delivery machine' but part of a 'social security system' that engages all stakeholders through a shared vision and value of health and well-being, not merely an absence of diseases. The future health system shall provide people-centred, affordable care, tailored to the individual's needs, accessible at any time and any place, and reflect the notion of leaving no one behind through a life course approach - underpinned by the SDGs. Information and communications technology (ICT) offers the potential to facilitate the realisation of these principles by improving the information flow between different parts of the health system through electronic means. We introduce Japan's new data platform - Person-centred Open PLatform for wellbeing (PeOPLe) - planned to be introduced in 2020 as one example of an ICT-based intervention to realise the three proposed principles. PeOPLe integrates data collected throughout the life course to enable all people to receive affordable, personalised health and social care at any time and any place throughout their lifetime. Furthermore, we discuss the applicability of these principles and PeOPLe to the health systems context of Thailand and the Philippines, including elaborations on ICT transformation challenges. CONCLUSION: Current rising momentum and scale for ICTs in the UHC era offers a great opportunity to make a difference for countries. The PeOPLe concept is not only relevant to resource-rich countries; its applicability to other Asian countries could be feasible though it will need to be adapted to the various country contexts. We hope that this paper contributes to wider discussion around policy choices of ICT application for future health systems strengthening and UHC in order to achieve the SDGs.