Modelling cost-effectiveness of replacement strategies for ambulance services in the Ministry of Health Malaysia.

BACKGROUND: Emergency Medical Service (EMS) is a very crucial aspect of the healthcare system in providing urgent management and transportation of patients during emergencies. The sustainability of the services is however greatly impacted by the quality and age of ambulances. While this has led to numerous replacement policy recommendations, the implementations are often limited due to a lack of evidence and financial constraints. This study thus aims to develop a cost-effectiveness model and testing the model by evaluating the cost-effectiveness of 10-year and 15-year compulsory ambulance replacement strategies in public healthcare for the Malaysian Ministry of Health (MOH). METHODS: A Markov model was developed to estimate the cost and outcomes ambulance replacement strategies over a period of 20 years. The model was tested using two alternative strategies of 10-year and 15-year. Model inputs were derived from published literature and local study. Model development and economic analysis were accomplished using Microsoft Excel 2016. The outcomes generated were costs per year, the number of missed trips and the number of lives saved, in addition to the Incremental Cost-Effectiveness Ratio (ICER). One-Way Deterministic Sensitivity Analysis (DSA) and Probabilistic Sensitivity Analysis (PSA) were conducted to identify the key drivers and to assess the robustness of the model. RESULTS: Findings showed that the most expensive strategy, which is the implementation of 10 years replacement strategy was more cost-effective than 15 years ambulance replacement strategy, with an ICER of MYR 11,276.61 per life saved. While an additional MYR 13.0 million would be incurred by switching from a 15- to 10-year replacement strategy, this would result in 1,157 deaths averted or additional live saved per year. Sensitivity analysis showed that the utilization of ambulances and the mortality rate of cases unattended by ambulances were the key drivers for the cost-effectiveness of the replacement strategies. CONCLUSIONS: The cost-effectiveness model developed suggests that an ambulance replacement strategy of every 10 years should be considered by the MOH in planning sustainable EMS. While this model may have its own limitation and may require some modifications to suit the local context, it can be used as a guide for future economic evaluations of ambulance replacement strategies and further exploration of alternative solutions.

Cost Estimates of Postnatal Care in Public Primary Care Facilities in Negeri Sembilan, Malaysia.

Background: Postnatal care (PNC) in Malaysia is believed to have played a role in reducing maternal and child mortality. A pilot study was thereby conducted to estimate the cost of PNC in public primary care facilities in Negeri Sembilan from the perspective of healthcare providers. Methods: This study employed a cross-sectional design that involved six public primary care facilities in Negeri Sembilan, Malaysia. The PNC-related costs data were collected between May and July 2017, utilising cost data for the year 2016 and involving 287 eligible mothers. The PNC costs were calculated using mixed top-down and activity-based costing (ABC) approaches. Results: The mean cost of PNC per patient was RM165.65 (median, RM167.12). Personnel cost was the main cost driver for PNC, which accounted for the most significant proportion of the total cost at 94.2%. Education level, type of health facilities and postnatal visits were positively associated with the total PNC cost. Conclusion: This study highlighted the average cost of PNC in the public primary care facilities in Negeri Sembilan. The cost of PNC was revealed to be primarily driven by personnel cost. The findings of this pilot study could add to the evidence base of PNC and serve as a vital reference for improving future estimates to better allocate scarce resources.

Analysis of costs and utilization of ambulance services in the ministry of health facilities, Malaysia.

BACKGROUND: Despite emergency ambulance services playing a pivotal role in accessibility to life-saving treatments in Malaysia, there are still numerous gaps in knowledge in terms of their utilization and cost. This leads to current policies on procurement, maintenance, and allocation being predicated on historical evidence and expert opinions. This study thus aims to analyse the cost and utilization of ambulance services in selected public health facilities in Malaysia. METHODS: A cross-sectional study was employed involving 239 ambulances from selected hospitals and clinics. Ambulance service utilization was based on the number of trips, distance and duration of travel obtained from travel logbooks. A mixed top-down and activity-based costing approach was used to estimate the monthly cost of ambulance services. This constituted personnel, maintenance, fuel, overhead, consumables, ambulance, and medical equipment costs. The utilization and costs of ambulance services were further compared between settings and geographical locations. RESULTS: The average total cost of ambulance services was MYR 11,410.44 (US$ 2,756.14) for hospitals and MYR 9,574.39 (US$ 2,312.65) for clinics, albeit not significantly different. Personnel cost was found to be the main contributor to the total cost, at around 44% and 42% in hospitals and clinics, respectively. There was however a significant difference in the total cost in terms of the type and age of ambulances, in addition to their location. In terms of service utilization, the median number of trips and duration of ambulance usage was significantly higher in clinics (31.88 trips and 58.58 hours) compared to hospitals (16.25 trips and 39.25 hours). CONCLUSIONS: The total cost of ambulance services was higher in hospitals compared to clinics, while its utilization showed a converse trend. The current findings evidence that despite the ambulance services being all under the MOH, their operating process and utilization reflected an inherent difference by setting.

The inequalities and determinants of Households' Distress Financing on Out-off-Pocket Health expenditure in Malaysia.

BACKGROUND: Out-of-pocket (OOP) payments for healthcare services potentially have severe consequences on households, especially among the poor. Under certain circumstances, healthcare payments are financed through selling household assets, or borrowings. This certainly could influence households' decision, which likely resorts to forgoing healthcare services. Thus, the focal point of this study is aimed to identify the inequalities and determinants of distress financing among households in Malaysia. METHODS: This study used secondary data from the National Health and Morbidity Survey (NHMS) 2019, a national cross-sectional household survey that used a two-stage stratified random sampling design involving 5,146 households. The concentration curve and concentration index were used to determine the economic inequalities in distress financing. Whereas, the determinants of distress financing were identified using the modified Poisson regression model. RESULTS: The prevalence of borrowing without interest was the highest (13.86%), followed by borrowing with interest (1.03%) while selling off assets was the lowest (0.87%). Borrowing without interest was highest among rural (16.21%) and poor economic status (23.34%). The distribution of distress financing was higher among the poor, with a concentration index of -0.245. The modified Poisson regression analysis revealed that the poor, middle, rich, and richest had 0.57, 0.58, 0.40 and 0.36 times the risk to develop distress financing than the poorest socio-economic group. Whereas, the presence of one and two or more elderly were associated with a 1.94 and 1.59 times risk of experiencing distress financing than households with no elderly members. The risk of developing distress financing was also 1.28 and 1.58 times higher among households with one and two members receiving inpatient care in the past 12 months compared to none. CONCLUSIONS: The findings implied that the improvement of health coverage should be emphasized to curtail the prevalence of distress financing, especially among those caring for the elderly, requiring admission to hospitals, and poor socio-economic groups. This study could be of interest to policymakers to help achieve and sustain health coverage for all.

Cost-effectiveness and budget impact analysis of PPV23 vaccination for the Malaysian Hajj pilgrims.

The potential occurrence of disease outbreaks during the hajj season is of great concern due to extreme congestion in a confined space. This promotes the acquisition, spread and transmission of pathogenic microorganisms and pneumococcal disease are one of the most frequent infections among Hajj pilgrims. This study aimed to assess the cost-effectiveness and budget impact of introducing the PPV23 to Malaysian Hajj pilgrims. A decision tree framework with a 1-year cycle length was adapted to evaluate the cost-effectiveness of a PPV23 vaccination program with no vaccination. The cost information was retrieved from the Lembaga Tabung Haji Malaysia (LTH) database. Vaccine effectiveness was based on the locally published data and the disease incidence specifically related to Streptococcus pneumoniae was based on a literature search. Analyses were conducted from the perspective of the provider: Ministry of Health and LTH Malaysia. The incremental cost-effectiveness ratios (ICER), cases averted, and net cost savings were estimated. Findings from this study showed that PPV23 vaccination for Malaysian Hajj pilgrims was cost-effective. The PPV23 vaccination programme has an ICER of MYR -449.3 (US$-110.95) per case averted. Based on the national threshold value of US$6,200-US$8,900 per capita, the base-case result shows that introduction of the PPV23 vaccine for Malaysian Hajj pilgrims is very cost-effective. Sensitivity analysis revealed parameters related to annual incidence and hospitalised cost of septicemia and disease without vaccination as the key drivers of the model outputs. Compared with no vaccination, the inclusion of PPV23 vaccination for Malaysian Hajj pilgrims was projected to result in a net cost saving of MYR59.6 million and 109,996 cases averted over 5 years period. The PPV23 vaccination program could substantially offer additional benefits in reducing the pneumococcal disease burden and healthcare cost. This could be of help for policymakers to consider the implementation of PPV23 vaccination for Malaysian performing hajj.

Data envelopment analysis for ambulance services of different service providers in urban and rural areas in Ministry of Health Malaysia.

Introduction: Ambulance services are pivotal in any country's healthcare system. An efficient ambulance service not only decreases patient mortality rate but also allows resource prioritization for better outputs. This study aims to measure the efficiency of ambulance services provided by health facilities in the Ministry of Health (MOH), Malaysia. Methods: This cross-sectional study analyzed the efficiency of 76 Decision-Making Units (DMUs) or health facilities, consisting of 62 health clinics and 14 hospitals. Data Envelopment Analysis (DEA) was used for computing efficiency scores while adopting the Variable Return to Scale (VRS) approach. The analysis was based on input orientation. The input was the cost of ambulance services, while the output for this analysis was the distance coverage (in km), the number of patients transferred, and hours of usage (in hours). Subsequent analysis was conducted to test the Overall Technical Efficiency (OTE), the Pure Technical Efficiency (PTE), the Scale Efficiency (SE), and the Return to Scale with the type of health facilities and geographical areas using a Mann-Whitney U-test and a chi-square test. Results: The mean scores of OTE, PTE, and SE were 0.508 (±0.207), 0.721 (±0.185), and 0.700 (±0.200), respectively. Approximately, 14.47% of the total health facilities were PTE. The results showed a significant difference in OTE and SE between ambulance services in hospitals and health clinics (p < 0.05), but no significant difference in PTE between hospitals and clinics (p>0.05). There was no significant difference in efficiency scores between urban and rural health facilities in terms of ambulance services except for OTE (p < 0.05). Discussion: The ambulance services provided in healthcare facilities in the MOH Malaysia operate at 72.1% PTE. The difference in OTE between hospitals and health clinics' ambulance services was mainly due to the operating size rather than PTE. This study will be beneficial in providing a guide to the policymakers in improving ambulance services through the readjustment of health resources and improvement in the outputs.

Cost-Effectiveness Analysis of High-Risk Groups Tuberculosis Screening in Malaysia.

Screening of high-risk groups for Tuberculosis (TB) is considered as the cornerstone for TB elimination but the measure of cost-effectiveness is also crucial in deciding the strategy for TB screening. This study aims to measure the cost-effectiveness of TB screening between the various high-risk groups in Malaysia. A decision tree model was developed to assess the cost-effectiveness of TB screening among the high-risk groups from a provider perspective using secondary data from the year 2016 to 2018. The results are presented in terms of an Incremental Cost-Effectiveness Ratio (ICER), expressed as cost per TB case detected. Deterministic and Probabilistic Sensitivity Analysis was also performed to measure the robustness of the model. TB screening among Person Living with Human Immunodeficiency Virus (PL HIV) was the most cost-effective strategy, with MYR 2,597.00 per TB case detected. This was followed by elderly, prisoners and smokers with MYR 2,868.62, MYR 3,065.24, and MYR 4,327.76 per one TB case detected, respectively. There was an incremental cost of MYR 2.49 per screening, and 3.4 TB case detection per 1,000 screening for TB screening among PL HIV in relation to TB screening among prisoners. The probability of symptomatic cases diagnosed as TB was the key driver for increasing cost-effectiveness efficacy among PL HIV. Results of the study suggest prioritization of high-risk group TB screening program by focusing on the most cost-effective strategy such as screening among PL HIV, prisoners and elderly, which has a lower cost per TB case detected.