Measuring health equity in the ASEAN region: conceptual framework and assessment of data availability.

BACKGROUND: Existing research on health equity falls short of identifying a comprehensive set of indicators for measurement across health systems. Health systems in the ASEAN region, in particular, lack a standardised framework to assess health equity. This paper proposes a comprehensive framework to measure health equity in the ASEAN region and highlights current gaps in data availability according to its indicator components. METHODS: A comprehensive literature review was undertaken to map out a core set of indicators to evaluate health equity at the health system level. Secondary data collection was subsequently conducted to assess current data availability for ASEAN states in key global health databases, national health accounts, and policy documents. RESULTS: A robust framework to measure health equity was developed comprising 195 indicators across Health System Inputs and Processes, Outputs, Outcomes, and Contextual Factors. Total indicator data availability equated to 72.9% (1423/1950). Across the ASEAN region, the Inputs and Processes sub-component of Health Financing had complete data availability for all indicators (160/160, 100%), while Access to Essential Medicine had the least data available (6/30, 20%). Under Outputs and Outcomes, Coverage of Selected Interventions (161/270, 59.63%) and Population Health (350/350, 100%) respectively had the most data available, while other indicator sub-components had little to none (≤ 38%). 72.145% (384/530) of data is available for all Contextual Factors. Out of the 10 ASEAN countries, the Philippines had the highest data availability overall at 77.44% (151/195), while Brunei Darussalam and Vietnam had the lowest data availability at 67.18% (131/195). CONCLUSIONS: The data availability gaps highlighted in this study underscore the need for a standardised framework to guide data collection and benchmarking of health equity in ASEAN. There is a need to prioritise regular data collection for overlooked indicator areas and in countries with low levels of data availability. The application of this indicator framework and resulting data availability analysis could be conducted beyond ASEAN to enable cross-regional benchmarking of health equity.

Dynamics of colorectal cancer screening in low and middle-income countries: A modeling analysis from Thailand.

BACKGROUND: Low and middle-income countries face constraints for early colorectal cancer (CRC) detection, including restricted access to care and low colonoscopy capacity. Considering these constraints, we studied strategies for increasing access to early CRC detection and reducing CRC progression and mortality rates in Thailand. METHODS: We developed a system dynamics model to simulate CRC death and progression trends. We analyzed the impacts of increased access to screening via fecal immunochemical test and colonoscopy, improving access to CRC diagnosis among symptomatic individuals, and their combination. RESULTS: Projecting the status quo (2023-2032), deaths per 100K people increase from 87.5 to 115.4, and CRC progressions per 100K people rise from 131.8 to 159.8. In 2032, improved screening access prevents 2.5 CRC deaths and 2.5 progressions per 100K people, with cumulative prevented 7K deaths and 9K progressions, respectively. Improved symptom evaluation access prevents 7.5 CRC deaths per 100K with no effect on progression, totaling 35K saved lives. A combined approach prevents 9.3 deaths and 1.8 progressions per 100K, or 41K and 7K cumulatively. The combined strategy prevents most deaths; however, there is a tradeoff: It prevents fewer CRC progressions than screening access improvement. Increasing the current annual colonoscopy capacity (200K) to sufficient capacity (681K), the combined strategy achieves the best results, preventing 15.0 CRC deaths and 10.3 CRC progressions per 100K people, or 54K and 30K cumulatively. CONCLUSION: Until colonoscopy capacity increases, enhanced screening and symptom evaluation are needed simultaneously to curb CRC deaths, albeit not the best strategy for CRC progression prevention.

Cost-Effectiveness and Cost-Utility Analyses in Thailand of Continuous Intrathecal Morphine Infusion Compared with Conventional Therapy in Cancer Pain: A 10-year Multicenter Retrospective Study.

Background: Because of the high initial cost of intrathecal drug delivery (ITDD) therapy, this study investigated the cost-effectiveness and cost-utility of ITDD therapy in refractory cancer pain management in Thailand over the past 10 years. Methods: The retrospective study was conducted in patients with cancer pain who underwent ITDD therapy from January 2011 to 2021 at three university hospitals. Clinical outcomes included the numerical rating scale (NRS), Palliative Performance Scale, and the EQ-5D. The direct medical and nonmedical as well as indirect costs were also recorded. Cost-effectiveness and cost-utility analyses were performed comparing ITDD therapy with conventional therapy (extrapolated from costs of the same patient before ITDD therapy) from a societally oriented economic evaluation. Results: Twenty patients (F:M: 10:10) aged 60 ± 15 years who underwent implantation of an intrathecal percutaneous port (IT port; n = 15) or programmable intrathecal pump (IT pump; n = 5) were included. The median survival time was 78 (interquartile range = 121-54) days after ITDD therapy. At 2-month follow-up, the incremental cost-effectiveness ratio (ICER)/pain reduction of an IT port (US$2065.36 (CA$2829.54)/2-point NRS reduction/lifetime) was lower than for patients with an IT pump (US$5479.26 (CA$7506.58)/2-point NRS reduction/lifetime) compared with continued conventional therapy. The ICER/quality-adjusted life years (QALYs) gained for an IT port compared with conventional treatment was US$93,999.31(CA$128,799.06)/QALY gained, which is above the cost-effectiveness threshold for Thailand. Conclusion: The cost-effectiveness and cost-utility of IT port therapy for cancer pain was high relative to the cost of living in Thailand, above the cost-effectiveness threshold. Prospective cost analysis studies enrolling more patients with diverse cancers that investigate the benefit of early ITDD therapy with devices over a range of prices are warranted.

Contexte: En raison du coût initial élevé du traitement par administration intrathécale de médicaments (AIM), cette étude a étudié le rapport coût-efficacité et le rapport coût-utilité du traitement par AIM dans la prise en charge de la douleur cancéreuse réfractaire en Thaïlande au cours des 10 dernières années.Méthodes: L'étude rétrospective a été menée auprès de patients souffrant de douleur cancéreuse ayant subi un traitement par AIM de janvier 2011 et 2021 dans trois hôpitaux universitaires. Les résultats cliniques comprenaient l'échelle d'évaluation numérique (EEN), l'échelle de performance palliative et l'EQ-5D. Les coûts médicaux et non médicaux directs et indirects ont également été consignés. Les analyses coûts-efficacité et coût-utilité ont été effectuées en comparant le traitement par AIM au traitement conventionnel (extrapolé à partir des coûts pour le même patient avant le traitement par AIM) à partir d'une évaluation économique sociétale.Résultats: Vingt patients (F : M : 10 : 10) âgés de 60 ± 15 ans ayant subi l'implantation d'un port percutané intrathécal (port IT; n = 15) ou d'une pompe intrathécale programmable (pompe IT; n = 5) ont été inclus. Le temps de survie médian était de 78 jours (intervalle interquartile = 121­54) après le traitement par AIM. À deux mois de suivi, le ratio coût-efficacité incrémental (RCEI/réduction de la douleur d'un port IT (2 065,36 $ US (2 829,54 $ CA) /réduction de 2 points sur l'EEN/durée de vie) était inférieur à celui des patients avec une pompe IT (5479,26 $ US (7506,58 $ CA) /réduction de 2 points sur l'EEN/durée de vie) comparativement au traitement conventionnel en continu. Le RCEI/année de vie pondérée par la qualité (AVPQ) gagnée pour un port IT comparativement au traitement conventionnel était de 93 999,31 $ US (128 799,06 $ CA) /AVPQ gagné, ce qui est au-dessus du seuil de rentabilité pour la Thaïlande.Conclusion: Le rapport coût-efficacité et le rapport coût-utilité du traitement par port IT pour la douleur cancéreuse étaient élevés par rapport au coût de la vie en Thaïlande, soit au-dessus du seuil de rentabilité. Les études d'analyse de coût prospectives portant sur un plus grand nombre de patients atteints de divers cancers qui étudient les avantages des traitements par AIM précoces à l'aide d'appareils de prix différents sont justifiées.

Associations between the stringency of COVID-19 containment policies and health service disruptions in 10 countries.

BACKGROUND: Disruptions in essential health services during the COVID-19 pandemic have been reported in several countries. Yet, patterns in health service disruption according to country responses remain unclear. In this paper, we investigate associations between the stringency of COVID-19 containment policies and disruptions in 31 health services in 10 low- middle- and high-income countries in 2020. METHODS: Using routine health information systems and administrative data from 10 countries (Chile, Ethiopia, Ghana, Haiti, Lao People's Democratic Republic, Mexico, Nepal, South Africa, South Korea, and Thailand) we estimated health service disruptions for the period of April to December 2020 by dividing monthly service provision at national levels by the average service provision in the 15 months pre-COVID (January 2019-March 2020). We used the Oxford COVID-19 Government Response Tracker (OxCGRT) index and multi-level linear regression analyses to assess associations between the stringency of restrictions and health service disruptions over nine months. We extended the analysis by examining associations between 11 individual containment or closure policies and health service disruptions. Models were adjusted for COVID caseload, health service category and country GDP and included robust standard errors. FINDINGS: Chronic disease care was among the most affected services. Regression analyses revealed that a 10% increase in the mean stringency index was associated with a 3.3 percentage-point (95% CI -3.9, -2.7) reduction in relative service volumes. Among individual policies, curfews, and the presence of a state of emergency, had the largest coefficients and were associated with 14.1 (95% CI -19.6, 8.7) and 10.7 (95% CI -12.7, -8.7) percentage-point lower relative service volumes, respectively. In contrast, number of COVID-19 cases in 2020 was not associated with health service disruptions in any model. CONCLUSIONS: Although containment policies were crucial in reducing COVID-19 mortality in many contexts, it is important to consider the indirect effects of these restrictions. Strategies to improve the resilience of health systems should be designed to ensure that populations can continue accessing essential health care despite the presence of containment policies during future infectious disease outbreaks.

Tracking health system performance in times of crisis using routine health data: lessons learned from a multicountry consortium.

COVID-19 has prompted the use of readily available administrative data to track health system performance in times of crisis and to monitor disruptions in essential healthcare services. In this commentary we describe our experience working with these data and lessons learned across countries. Since April 2020, the Quality Evidence for Health System Transformation (QuEST) network has used administrative data and routine health information systems (RHIS) to assess health system performance during COVID-19 in Chile, Ethiopia, Ghana, Haiti, Lao People's Democratic Republic, Mexico, Nepal, South Africa, Republic of Korea and Thailand. We compiled a large set of indicators related to common health conditions for the purpose of multicountry comparisons. The study compiled 73 indicators. A total of 43% of the indicators compiled pertained to reproductive, maternal, newborn and child health (RMNCH). Only 12% of the indicators were related to hypertension, diabetes or cancer care. We also found few indicators related to mental health services and outcomes within these data systems. Moreover, 72% of the indicators compiled were related to volume of services delivered, 18% to health outcomes and only 10% to the quality of processes of care. While several datasets were complete or near-complete censuses of all health facilities in the country, others excluded some facility types or population groups. In some countries, RHIS did not capture services delivered through non-visit or nonconventional care during COVID-19, such as telemedicine. We propose the following recommendations to improve the analysis of administrative and RHIS data to track health system performance in times of crisis: ensure the scope of health conditions covered is aligned with the burden of disease, increase the number of indicators related to quality of care and health outcomes; incorporate data on nonconventional care such as telehealth; continue improving data quality and expand reporting from private sector facilities; move towards collecting patient-level data through electronic health records to facilitate quality-of-care assessment and equity analyses; implement more resilient and standardized health information technologies; reduce delays and loosen restrictions for researchers to access the data; complement routine data with patient-reported data; and employ mixed methods to better understand the underlying causes of service disruptions.

COVID-19 and resilience of healthcare systems in ten countries.

Declines in health service use during the Coronavirus Disease 2019 (COVID-19) pandemic could have important effects on population health. In this study, we used an interrupted time series design to assess the immediate effect of the pandemic on 31 health services in two low-income (Ethiopia and Haiti), six middle-income (Ghana, Lao People's Democratic Republic, Mexico, Nepal, South Africa and Thailand) and high-income (Chile and South Korea) countries. Despite efforts to maintain health services, disruptions of varying magnitude and duration were found in every country, with no clear patterns by country income group or pandemic intensity. Disruptions in health services often preceded COVID-19 waves. Cancer screenings, TB screening and detection and HIV testing were most affected (26-96% declines). Total outpatient visits declined by 9-40% at national levels and remained lower than predicted by the end of 2020. Maternal health services were disrupted in approximately half of the countries, with declines ranging from 5% to 33%. Child vaccinations were disrupted for shorter periods, but we estimate that catch-up campaigns might not have reached all children missed. By contrast, provision of antiretrovirals for HIV was not affected. By the end of 2020, substantial disruptions remained in half of the countries. Preliminary data for 2021 indicate that disruptions likely persisted. Although a portion of the declines observed might result from decreased needs during lockdowns (from fewer infectious illnesses or injuries), a larger share likely reflects a shortfall of health system resilience. Countries must plan to compensate for missed healthcare during the current pandemic and invest in strategies for better health system resilience for future emergencies.

System dynamics modelling of health workforce planning to address future challenges of Thailand's Universal Health Coverage.

BACKGROUND: System dynamics (SD) modelling can inform policy decisions under Thailand's Universal Health Coverage. We report on this thinking approach to Thailand's strategic health workforce planning for the next 20 years (2018-2037). METHODS: A series of group model building (GMB) sessions involving 110 participants from multi-sectors of Thailand's health systems was conducted in 2017 and 2018. We facilitated policymakers, administrators, practitioners and other stakeholders to co-create a causal loop diagram (CLD) representing a shared understanding of why the health workforce's demands and supplies in Thailand were mismatched. A stock and flow diagram (SFD) was also co-created for testing the consequences of policy options by simulation modelling. RESULTS: The simulation modelling found hospital utilisation created a vicious cycle of constantly increasing demands for hospital care and a constant shortage of healthcare providers. Moreover, hospital care was not designed for effectively dealing with the future demands of ageing populations and prevalent chronic illness. Hence, shifting emphasis to professions that can provide primary care, intermediate care, long-term care, palliative care, and end-of-life care can be more effective. CONCLUSIONS: Our SD modelling confirmed that shifting the care models to address the changing health demands can be a high-leverage policy of health workforce planning, although very difficult to implement in the short term. of health workforce planning, although very difficult to implement in the short term.

Breast cancer in Thailand: policy and health system challenges to universal healthcare.

Thailand has successfully implemented Universal Health Coverage (UHC) and embedded the 2030 Agenda for Sustainable Development into its Thailand 4.0 policy. Breast cancer is a growing challenge in Thailand, as it is globally. It serves as a perfect medium through which to interrogate UHC and demonstrate areas of the health system which require further strengthening if UHC is to be sustainable in the longer term. We conducted a situation analysis and used a Systemic Rapid Assessment (SYSRA) framework to examine the challenges posed to UHC through the lens of breast cancer. We identified a number of challenges facing UHC including (1) continued political commitment; (2) the need for coordinated scale-up of strategic investments involving increased financing and fine-tuning of the allocation of resources according to health needs; (3) reducing inequities between health insurance schemes; (4) investing in innovation of technologies, and more critically, in technology transfer and capacity building; (5) increasing capacity, quality and confidence in the whole primary healthcare team but especially family medicine doctors. This would subsequently increase both efficiency and effectiveness of the patient pathway, as well as allow patients wherever possible to be treated close to their homes, work and family; (6) developing and connecting information systems to facilitate understanding of what is working, where needs are and track trends to monitor improvements in patient care. Our findings add to an existing body of evidence which suggest, in light of changing disease burden and increasing costs of care, a need for broader health system reforms to create a more enabling platform for integrated healthcare as opposed to addressing individual challenging elements one vertical system at a time. As low- and middle-income countries look to realize the 2015 Sustainable Development Goals and sustainable UHC this analysis may provide input for policy discussion at national, regional and community levels and have applicability beyond breast cancer services alone and beyond Thailand.

Assessing system-based trainings for primary care teams and quality-of-life of patients with multimorbidity in Thailand: patient and provider surveys.

BACKGROUND: Strengthening primary care is considered a global strategy to address non-communicable diseases and their comorbidity. However, empirical evidence of the longer-term benefits of capacity building programmes for primary care teams contextualised for low- and middle-income countries is scanty. In Thailand, a series of system-based capacity building programmes for primary care teams have been implemented for a decade. An analysis of the relationship between these systems-based trainings in diverse settings of primary care and quantified patient outcomes was needed. METHODS: Facility-based and community-based cross-sectional surveys were used to obtain data on exposure of primary care team members to 11 existing training programmes in Thailand, and health profiles and health-related quality of life of their patients measured in EuroQol-5 Dimension (EQ-5D) scale. Using a multilevel modelling, the associations between primary care provider's training and patient's EQ-5D score were estimated by a generalized linear mixed model (GLMM). RESULTS: While exposure to training programmes varied among primary care teams nationwide, District Health Management Learning (DHML) and Contracting Unit of Primary Care (CUP) Leadership Training Programmes, which put more emphasis on bundling of competencies and contextualising of applying such competencies, were positively associated with better health-related quality of life of their multimorbid patients. CONCLUSIONS: Our report provides systematic feedback to a decade-long investment on system-based capacity building for primary care teams in Thailand, and can be considered as new evidence on the value of human resource development in primary care systems in low- and middle-income countries. Building multiple competencies helps members of primary care teams collaboratively manage district health systems and address complex health problems in different local contexts. Coupling contextualised training with ongoing programme implementation could be a key entity to the sustainable development of primary care teams in low and middle income countries which can then be a leverage for improving patients outcomes.

Pain experiences and intrapersonal change among patients with chronic non-cancer pain after using a pain diary: a mixed-methods study.

OBJECTIVE: Pain diaries are a valuable self-assessment tool; however, their use in chronic non-cancer pain has received limited attention. In this study, we examined the effect of pain diary use on pain intensity, interference, and intrapersonal change in patients with chronic non-cancer pain. METHOD: A convergent mixed-methods design was used to prospectively evaluate a cohort of 72 patients. Daily pain intensity and weekly pain-interference were self-reported using pain diaries for a 4-week period. Outcomes were assessed by examining changes in pain scores (primary outcome) as well as the Brief Pain Inventory and Short-form McGill Pain Questionnaire-2. In addition, qualitative data obtained from pain diary entries and focus-group interviews were analyzed using thematic content analysis. RESULTS: Pain intensity and average pain scores were significantly lower after using the diaries. Participants reported less pain interference in mood, walking ability, normal work, and enjoyment of life. No differences were found in SF-MPQ-2 scores. Qualitative analysis indicated that better pain recognition and more effective communication with care providers led to improved self-management and more effectual treatment plans. CONCLUSION: Use of a pain diary in patients with chronic non-cancer pain was associated with reduced pain intensity and improved mood as well as function. Further controlled trials examining the long-term effects of pain diaries are warranted.

Comparison of Superficial Surgical Site Infection Between Delayed Primary Versus Primary Wound Closure in Complicated Appendicitis: A Randomized Controlled Trial.

OBJECTIVE: To compare superficial surgical site infection (SSI) rates between delayed primary wound closure (DPC) and primary wound closure (PC) for complicated appendicitis. BACKGROUND: SSI is common in appendectomy for complicated appendicitis. DPC is preferentially used over PC, but its efficacy is still controversial. METHODS: A multicenter randomized controlled trial was conducted in 6 hospitals in Thailand, enrolling patients with gangrenous and ruptured appendicitis. Patients were randomized to PC (ie, immediately wound closure) or DPC (ie, wound closure at postoperative days 3-5). Superficial SSI was defined by the Center for Disease Control criteria. Secondary outcomes included postoperative pain, length of stay, recovery time, quality of life, and cost of treatment. RESULTS: In all, 303 and 304 patients were randomized to PC and DPC groups, and 5 and 4 patients were lost to follow-up, respectively, leaving 300 and 298 patients in the modified intention-to-treat analysis. The superficial SSI rate was lower in the PC than DPC groups [ie, 7.3% (95% confidence interval 4.4, 10.3) vs 10% (95% CI 6.6, 13.3)] with a risk difference (RD) of -2.7% (-7.1%, 1.9%), but this RD was not significant. Postoperative pain, length of stay, recovery times, and quality of life were nonsignificantly different with corresponding RDs of 0.3 (-2.5, 3.0), -0.1 (-0.5, 0.3), -0.2 (-0.8, 0.4), and 0.02 (-0.01, 0.04), respectively. However, costs for PC were 2083 (1410, 2756) Baht cheaper than DPC (∼$60 USD). CONCLUSIONS: Superficial SSI rates for the PC group were slightly lower than DPC group, but this did not reach statistical significance. Costs were significantly lower for the PC group.

Do electronic medical records improve diabetes quality in physician practices?

OBJECTIVES: To measure the effect of electronic medical records (EMRs) on a publicly reported composite measure indicating optimal diabetes care (ODC) rates in ambulatory settings. STUDY DESIGN: Data from Minnesota Community Measurement on 557 clinics were used, including information on ODC, EMR adoption, and clinic characteristics. METHODS: A difference-in-differences strategy was used to estimate the impact of EMR adoption on patient outcomes while controlling for observed and unobserved clinic characteristics. Results were compared with a cross-sectional analysis of the same data. RESULTS: EMRs had no observable effect on ODC for the average clinic during the first 2 years postadoption. EMRs may, however, generate modest (+4 percentage point) ODC increases for clinics in large, multisite practices. Cross-sectional analysis likely overestimates the effect of EMRs on quality. CONCLUSIONS: There is little evidence that EMR adoption improves diabetes care during the first 2 years postadoption. This is notable as diabetes is a condition for which information technology has the potential to improve care management. The results suggest that policy makers should not expect public sector EMR investments to yield significant short-term improvements in publicly reported measures.