Reliable mortality statistics in Myanmar: a qualitative assessment of challenges in two townships

Background

The vital registration system is universally recognized as the main source of mortality data which is essential for policy formulation, proper interventions and resource allocation to address priority health challenges. To improve availability and quality of mortality statistics by strengthening the vital registration system, understanding the current vital registration system is essential. This study identified challenges in generating reliable mortality statistics in the vital registration system of Myanmar.

Methods

Qualitative methods were used to collect data in two selected townships of Mandalay Region. Grey literature related to the management of mortality registration was reviewed; in-depth interviews of sixteen key informants and fourteen focus group discussions were conducted with those involved in death registration at the local level, such as healthcare providers, local administrators and knowledgeable adults in households where deaths occurred during the past three years. Thematic analysis was performed to identify system barriers in the death registration process.

Results

Weaknesses in the death registration system are classified in three areas: a) administrative which includes the lack of enforcement of mandatory death registration, limited issuance of death certificates and no formal mandatory notification of death events by households and; b) technical which includes absence of proper and regular on-the-job trainings, ineffective cause-of-death certification practice for deaths in the communities and the absence of routine data plausibility checks at the local level; and c) societal which includes poor community awareness and inadequate participation in death registration.

Conclusion

The study highlighted challenges in the death registration system at the operational level, which undermines the achievement of a satisfactory level of completeness and accuracy of mortality data. We recommend establishing a strong legal framework, improving technical capacities and raising public awareness and cooperation to strengthen the system that can generate reliable mortality statistics.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6671-y) contains supplementary material, which is available to authorized users.

Assessment of the stated policies of prominent food companies related to obesity and non-communicable disease (NCD) prevention in Thailand

Objective

To review the publicly available policies and commitments of selected food companies in Thailand relating to obesity and non-communicable diseases (NCDs) prevention, and to assess these stated policies and commitments against global recommendations.

Methods

Nineteen food and beverage companies, including 13 packaged food, three non-alcoholic beverage, two food retailer, and one fast food company were selected, based on their market share by sector and food category. A review of publicly available policies and commitments related to four domains (product reformulation, food marketing, nutrition information and food accessibility) was carried out for each company. Content analysis of all data was conducted, including a comparison of policy content against global recommendations in each domain.

Results

Eleven companies (58%) reported at least one policy or commitment across the four domains. The packaged food companies reported policies in all four domains while the beverage companies committed to implement policies in all except the accessibility domain. The food retailers and fast food company only had policies in the reformulation and nutrition information domains. Very few of the policies and commitments covered all of the recommended components in each domain, and most lacked sufficient specificity to allow detailed monitoring and evaluation.

Conclusion

A small number of the most prominent food companies in Thailand have several nutrition-related policies in place. However, these policies do not sufficiently cover recommended areas for NCD and obesity prevention. Moreover, the extent to which policy statements translate to implementation has yet to be evaluated. Successful implementation of nutrition-related policies by the food industry in Thailand will likely require concrete, measurable indicators to guide both corporate policy making as well as public monitoring. The Thailand Government requires greater capacity to establish effective multi-sector platforms for NCD prevention, and to evaluate food companies’ policies and enforce compliance both with regulations and voluntary commitments.

Childhood stunting in Thailand: when prolonged breastfeeding interacts with household poverty

BACKGROUND

Childhood stunting, defined as the height-for-age standardized score lower than minus two, is one of the key indicators for assessing well-being and health of a child; and can be used for monitoring child health inequalities. Thailand has been successful in improving health and providing financial protection for its population. A better understanding of the determinants of stunting will help fill both knowledge and policy gaps which promote children's health and well-being. This study assesses the factors contributing to stunting among Thai children aged less than five years.

METHODS

This study obtained data from the Multiple Indicator Cluster Survey Round 4 (MICS4), conducted in Thailand in 2012. Data analysis consisted of three steps. First, descriptive statistics provided an overview of data. Second, a Chi-square test determined the association between each covariate and stunting. Finally, multivariable logistic regression assessed the likelihood of stunting from all independent variables. Interaction effects between breastfeeding and household economy were added in the multivariable logistic regression.

RESULTS

In the analysis without interaction effects, while the perceived size of children at birth as 'small' were positively associated with stunting, children in the well-off households were less likely to experience stunting. The analysis of the interactions between 'duration of breastfeeding' and 'household's economic level' found that the odds of stunting in children who were breastfed longer than 12 months in the poorest household quintile were 1.8 fold (95% Confidence interval: 1.3-2.6) higher than the odds found in mothers from the same poorest quintiles, but without prolonged breastfeeding. However prolonged breastfeeding in most well-off households (those between the second quintile and the fifth wealth quintile) did not show a tendency towards stunting.

CONCLUSIONS

Childhood stunting was significantly associated with several factors. Prolonged breastfeeding beyond 12 months when interacting with poor economic status of a household potentiated stunting. Children living in the least well-off households were more prone to stunting than others. We recommend that the MICS survey questionnaire be amended to capture details on quantity, quality and practices of supplementary feeding. Multi-sectoral nutrition policies targeting poor households are required to address stunting challenges.

Implementation of national action plans on noncommunicable diseases, Bhutan, Cambodia, Indonesia, Philippines, Sri Lanka, Thailand and Viet Nam

By 2016, Member States of the World Health Organization (WHO) had developed and implemented national action plans on noncommunicable diseases in line with the Global action plan for the prevention and control of noncommunicable diseases (2013–2020). In 2018, we assessed the implementation status of the recommended best-buy noncommunicable diseases interventions in seven Asian countries: Bhutan, Cambodia, Indonesia, Philippines, Sri Lanka, Thailand and Viet Nam. We gathered data from a range of published reports and directly from health ministries. We included interventions that addressed the use of tobacco and alcohol, inadequate physical activity and high salt intake, as well as health-systems responses, and we identified gaps and proposed solutions. In 2018, progress was uneven across countries. Implementation gaps were largely due to inadequate funding; limited institutional capacity (despite designated noncommunicable diseases units); inadequate action across different sectors within and outside the health system; and a lack of standardized monitoring and evaluation mechanisms to inform policies. To address implementation gaps, governments need to invest more in effective interventions such as the WHO-recommended best-buy interventions, improve action across different sectors, and enhance capacity in monitoring and evaluation and in research. Learning from the Framework Convention on Tobacco Control, the WHO and international partners should develop a standardized, comprehensive monitoring tool on alcohol, salt and unhealthy food consumption, physical activity and health-systems response.

Lessons from the Thai Health Promotion Foundation

To facilitate the policy response to noncommunicable diseases in Thailand, parliament adopted the Health Promotion Foundation Act in 2001. This Act led to the establishment of an autonomous government body, the Thai Health Promotion Foundation, called ThaiHealth. The foundation receives its revenue from a 2% surcharge of excise taxes on tobacco and alcohol. The fund supports evidence generation, campaigns and social mobilization to address noncommunicable disease risk factors, such as tobacco-use, harmful use of alcohol and sedentary behaviour. On average, its annual revenue is 120 million United States dollars (US$). Some notable ThaiHealth-supported public campaigns are for schools free of sweetened carbonated beverages; alcohol abstinence during three-month Buddhist lent; and nationwide physical activity. The percentage of people using tobacco decreased from 22.5% in 2001 to 18.2% in 2014. The annual per capita alcohol consumption decreased from 8.1 litres pure alcohol in 2005 to 6.9 litres in 2014. The percentage of the adult population doing at least 150 minutes of moderate-intensity or 75 minutes high-intensity aerobic exercise per week, increased from 66.3% in 2012 to 72.9% in 2017. A dedicated funding mechanism, a transparent and accountable organization, and the engagement of civil society organizations and other government agencies have enabled ThaiHealth to run these campaigns.

Reshaping public hospitals: an agenda for reform in Asia and the Pacific

Hospitals in the Asia-Pacific today face the 'triple aim' challenge, proposed by the Institute for Healthcare Improvement, of how to improve quality of care and population health, while at the same time controlling healthcare costs. Yet, pursuing these challenges in combination is presently a remote prospect for many hospitals and, indeed, in a majority of countries in the region. The roles and functions of the public hospital sector within local health systems need redefinition and reform in the context of demographic and epidemiological transitions. Policymakers, managers and health professionals have an obligation to reshape the future of public hospitals. This article outlines actions for how public hospitals can be reshaped from a health system perspective. First, hospitals should be integrated into the fabric of the local health system; they can lead in this through working in alliances with other healthcare facilities, including primary care and private hospitals. Policymakers have a role in facilitating this as it contributes to health improvement of the population. Second, investments in system innovation, management improvement and information systems are required and their impact assessed. Such investments can contribute to cost control and efficiency. Public hospital sector investments should be strategic, efficient and should not bias investment in broader determinants of health. Third, reorienting health workforce competencies and appropriate skills should be central to hospital sector reforms, from policy to frontline services delivery. Creative thinking is needed to build and support flexible care delivery arrangements for services designed to respond to patients ' and providers' needs. Pivotal to achievement of each of these three areas of reform is good governance and leadership.

Corporate political activity of major food companies in Thailand: an assessment and policy recommendations

BACKGROUND

The food industry can influence individual and population level food consumption behaviours, shape public preferences and interfere with government policy on obesity prevention and NCDs. This paper identifies the Corporate Political Activity (CPA) of major food companies in Thailand which relate to obesity and NCDs.

METHODS

Using the INFORMAS framework to classify CPA, we reviewed publicly available information by 12 food companies between August 2011 and July 2016 in order to identify, analyse and classify the CPA contents. Semi-structured interviews with 17 key stakeholders who are experts in this field supplemented evidence from the document review. Data analysis applied a thematic approach.

RESULTS

Food industry in Thailand applied a variety of CPA strategies and practices. The two most common strategies were constituency building and information and messaging.

CONCLUSION

The diverse range of CPA strategies which influence government policy and public opinion can undermine efforts to prevent obesity and diet-related NCDs. We recommend systematic monitoring of their CPA, strengthening mechanisms to hold the food industry accountable for their role in protecting and promoting the nutrition and health of the population, introducing mandatory registration of lobbyists, mandatory disclosure of political donations, and stronger oversight of conflicts of interest among the government actors.

Addressing the threat of antibiotic resistance in Thailand: monitoring population knowledge and awareness

The 2015 Global action plan on antimicrobial resistance (GAP-AMR) highlights the key importance of improving awareness and understanding of antimicrobial resistance among consumers. While low levels of awareness are not exclusive to consumers in low- and middle-income countries, the challenges to improving understanding are compounded in these settings, by factors such as higher rates of antibiotic self-medication and availability through informal suppliers. In 2016, Thailand set an ambitious target to increase, by 2021, public knowledge of antibiotic resistance and awareness of appropriate use of antibiotic by 20%. This involved first establishing baseline data by incorporating a module on antibiotic awareness into the 2017 national Health and Welfare Survey conducted by the National Statistical Office. The benefit of this approach is that the data from the antibiotic module are collected in parallel with data on socioeconomic, demographic and geospatial parameters that can inform targeted public communications. The module was developed by review of existing tools that have been used to measure public awareness of antibiotics, namely those of the Eurobarometer project of the European Union and a questionnaire developed by the World Health Organization. The Thai module was constructed in such a way that results could be benchmarked against those of the other survey tools, to allow international comparison. The Thai experience showed that close collaboration between the relevant national authorities allowed smooth integration of a module on antibiotic awareness into the national household survey. To date, evidence from the module has informed the content and strategy of public communications on antibiotic use and misuse. Work is under way to select the most robust indicators to use in monitoring progress. The other Member States of the World Health Organization South-East Asia Region can benefit from Thailand's experiences in improvement of monitoring population knowledge and awareness.

Improving access to assistive technologies: challenges and solutions in low- and middle-income countries

Assistive technologies can benefit a wide range of people, including those with disabilities; those with age-related frailties; those affected by noncommunicable diseases; and those requiring rehabilitation. Access to these technologies is limited in low- and middle-income countries but the already-high need will inevitably rise further because of demographic and epidemiological transitions. Four key gaps contribute to limited access. First, although need is high, demand is low, not least because of widespread lack of awareness among potential beneficiaries, their caregivers, and their health-care providers. Second, product designs are insufficiently informed by users' and caregivers' preferences and environments, and transfer of technologies to low-resource settings is limited. Third, barriers to supply include low production quality, financial constraints and a scarcity of trained personnel. Fourth, there is a dearth of high-quality evidence on the effectiveness of different types of technology. Adoption of the World Health Assembly Resolution WHA71.8 in 2018 marked convergence of, commitment to and strengthening of efforts to close these gaps and improve access to assistive devices. The Global Cooperation on Assistive Technology workplan identifies four overarching, interlinked solutions for countries to improve access. First, a national policy framework for assistive technology is needed. Second, product development should be encouraged through incentive schemes that support and promote affordable assistive products. Third, capacity-building of personnel is needed, through undergraduate and in-service training. Fourth, provision needs to be enhanced, especially through integration of services with the health system. These actions need to be underpinned by government leadership, a multisectoral approach and adequate funding.

Multisectoral governance for health: challenges in implementing a total ban on chrysotile asbestos in Thailand

INTRODUCTION

Interest in multisectoral governance for health has grown in recent years in response to the limitations of government-centric policy formulation and implementation. This study describes multisectoral governance associated with policy formulation and implementation of a total ban on chrysotile asbestos in Thailand.

METHODS

Qualitative methods were applied, including analysis of related literature and media, and in-depth interviews with key informants. Consent was obtained for interview and tape recording; protection of confidentiality was fully assured.

RESULTS

An agenda on total ban of chrysotile asbestos was proposed to the National Health Assembly, where a resolution was adopted in 2010. The resolution was endorsed by the Cabinet in 2011, which mandated the Ministry of Industry to implement the ban immediately. There was uneven interest and ownership by stakeholders in the policy formulation process. Long delays in implementation have been observed. Furthermore, while the policy is likely to affect relatively few industries there has been misinformation on the safe use of chrysotile, and delaying tactics and pressure from major chrysotile-exporting countries.

CONCLUSION

The National Health Assembly is a useful platform for policy formulation on complex policy issues requiring multisectoral action. However, policy implementation is challenging due to lack of clear policy across sectors. Success in protecting people's health requires participatory policy-making and effective governance of multisectoral action throughout implementation. The Assembly is not designed to enforce implementation, especially when power and authority lie with state actors, but monitoring and public reporting would be powerful tools to drive this agenda.

Contributions of national and global health estimates to monitoring health-related Sustainable Development Goals in Thailand

The Millennium Development Goals (MDGs) triggered increased demand for data on child and maternal mortality for monitoring progress. With the advent of the Sustainable Development Goals (SDGs) and growing evidence of an epidemiological transition towards non-communicable diseases, policy makers need data on mortality and disease trends and distribution to inform effective policies and support monitoring progress. Where there are limited capacities to produce national health estimates (NHEs), global health estimates (GHEs) can fill gaps for global monitoring and comparisons. This paper draws lessons learned from Thailand’s burden of disease study (BOD) on capacity development for NHEs, and discusses the contributions and limitation of GHEs in informing policies at country level. Through training and technical support by external partners, capacities are gradually strengthened and institutionalized to enable regular updates of BOD at national and sub-national levels. Initially, the quality of cause of death reporting in the death certificates was inadequate, especially for deaths occurring in the community. Verbal autopsies were conducted, using domestic resources, to determine probable causes of deaths occurring in the community. This helped improve the estimation of years of life lost. Since the achievement of universal health coverage in 2002, the quality of clinical data on morbidities has also considerably improved. There are significant discrepancies between the 2010 Global Burden of Diseases (GBD) estimates for Thailand and the 1999 nationally generated BOD, especially for years of life lost due to HIV/AIDS, and the ranking of priority diseases. National ownership of NHEs and effective interfaces between researchers and decision makers contribute to enhanced country policy responses, while sub-national data are intended to be used by various sub-national-level partners. Though GHEs contribute to benchmarking country achievement compared with global health commitments, they may hamper development of NHE capacities. GHEs should encourage and support countries to improve their data systems and develop a data infrastructure that supports the production of empirical data needed to underpin estimation efforts.

An evaluation of health systems equity in Indonesia: study protocol

BACKGROUND

Many low and middle income countries are implementing reforms to support Universal Health Coverage (UHC). Perhaps one of the most ambitious examples of this is Indonesia's national health scheme known as the JKN which is designed to make health care available to its entire population of 255 million by end of 2019. If successful, the JKN will be the biggest single payer system in the world. While Indonesia has made steady progress, around a third of its population remains without cover and out of pocket payments for health are widespread even among JKN members. To help close these gaps, especially among the poor, the Indonesian government is currently implementing a set of UHC policy reforms that include the integration of remaining government insurance schemes into the JKN, expansion of provider networks, restructuring of provider payments systems, accreditation of all contracted health facilities and a range of demand side initiatives to increase insurance uptake, especially in the informal sector. This study evaluates the equity impact of this latest set of UHC reforms.

METHODS

Using a before and after design, we will evaluate the combined effects of the national UHC reforms at baseline (early 2018) and target of JKN full implementation (end 2019) on: progressivity of the health care financing system; pro-poorness of the health care delivery system; levels of catastrophic and impoverishing health expenditure; and self-reported health outcomes. In-depth interviews with stakeholders to document the context and the process of implementing these reforms, will also be undertaken.

DISCUSSION

As countries like Indonesia focus on increasing coverage, it is critically important to ensure that the poor and vulnerable - who are often the most difficult to reach - are not excluded. The results of this study will not only help track Indonesia's progress to universalism but also reveal what the UHC-reforms mean to the poor.

Unhealthy food and non-alcoholic beverage advertising on children's, youth and family free-to-air and digital television programmes in Thailand

Background

Food advertising is a key factor which influences children’s food preferences. This study assessed the rates, nutritional quality and contents of food and beverage advertising in children’s, youth and family television programmes in Thailand.

Methods

Free TV was recorded for two weeks in March 2014 from six to ten am and three to eight pm on weekends and three to eight pm on weekdays across all four channels; a total of 344 h recorded. Digital TV was recorded across three channels for one week for 24 h per day in October 2014; a total 504 h recorded.

Results

For Free TV, 1359 food advertisements were identified, with on average 2.9 non-core food advertisements per hour per channel. The most frequently advertised food products on free TV were sugar-sweetened drinks. The rates of advertisements containing promotional characters and premium offers were significantly higher for non-core than core foods, 1.2 versus 0.03 and 0.6 versus 0.0 per hour respectively. For Digital TV, 693 food advertisements were identified, with an average of one non-core food advertisement per hour per channel. The most frequently advertised food products on digital TV were baby and toddler milk formulae.

Conclusions

Food and beverage advertising on Thai television is predominantly unhealthy. Therefore, the Government and related agencies should introduce and enforce policies to address this issue. Current regulations should be adapted to control both the frequency and nature of unhealthy on-air food marketing to protect the health of Thai children.

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

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

Health systems development in Thailand: a solid platform for successful implementation of universal health coverage

Thailand's health development since the 1970s has been focused on investment in the health delivery infrastructure at the district level and below and on training the health workforce. Deliberate policies increased domestic training capacities for all cadres of health personnel and distributed them to rural and underserved areas. Since 1975, targeted insurance schemes for different population groups have improved financial access to health care until universal health coverage was implemented in 2002. Despite its low gross national income per capita in Thailand, a bold decision was made to use general taxation to finance the Universal Health Coverage Scheme without relying on contributions from members. Empirical evidence shows substantial reduction in levels of out-of-pocket payments, the incidence of catastrophic health spending, and in medical impoverishment. The scheme has also greatly reduced provincial gaps in child mortality. Certain interventions such as antiretroviral therapy and renal replacement therapy have saved the lives of adults. Well designed strategic purchasing contributed to efficiency, cost containment, and equity. Remaining challenges include preparing for an ageing society, primary prevention of non-communicable diseases, law enforcement to prevent road traffic mortality, and effective coverage of diabetes and tuberculosis control.

Surveillance of antimicrobial consumption in animal production sectors of low- and middle-income countries: Optimizing use and addressing antimicrobial resistance

In a policy forum, Daniel Schar and colleagues discuss the need for surveillance of antimicrobial consumption in animals in low- and middle-income countries and propose the establishment of antimicrobial consumption monitoring systems.

Managing In- and Out-Migration of Health Workforce in Selected Countries in South East Asia Region

Background: There is an increasing trend of international migration of health professionals from low- and middle- income countries to high-income countries as well as across middle-income countries. The WHO Global Code of Practice on the International Recruitment of Health Personnel was created to better address health workforce development and the ethical conduct of international recruitment. This study assessed policies and practices in 4 countries in South East Asia on managing the in- and out-migration of doctors and nurses to see whether the management has been in line with the WHO Global Code and has fostered health workforce development in the region; and draws lessons from these countries.

Methods: Following the second round of monitoring of the Global Code of Practice, a common protocol was developed for an in-depth analysis of (a) destination country policy instruments to ensure expatriate and local professional quality through licensing and equal practice, (b) source country collaboration to ensure the out-migrating professionals are equally treated by destination country systems. Documents on employment practice for local and expatriate health professionals were also reviewed and synthesized by the country authors, followed by a cross-country thematic analysis.

Results: Bhutan and the Maldives have limited local health workforce production capacities, while Indonesia and Thailand have sufficient capacities but are at risk of increased out-migration of nurses. All countries have mandatory licensing for local and foreign trained professionals. Legislation and employment rules and procedures are equally applied to domestic and expatriate professionals in all countries. Some countries apply mandatory renewal of professional licenses for local professionals that require continued professional development. Local language proficiency required by destination countries is the main barrier to foreign professionals gaining a license. The size of outmigration is unknown by these 4 countries, except in Indonesia where some formal agreements exist with other governments or private recruiters for which the size of outflows through these mechanisms can be captured.

Conclusion: Mandatory professional licensing, employment regulations and procedures are equally applied to domestic and foreign trained professionals, though local language requirements can be a barrier in gaining license. Source country policy to protect their out-migrating professionals by ensuring equal conditions of practice by destination countries is hampered by the fact that most out-migrating professionals leave voluntarily and are outside government to government agreements. This requires more international solidarity and collaboration between source and destination countries, for which the WHO Global Code is an essential and useful platform.

Antibiotic distribution channels in Thailand: results of key-informant interviews, reviews of drug regulations and database searches

Objective

To analyse how antibiotics are imported, manufactured, distributed and regulated in Thailand.

Methods

We gathered information, on antibiotic distribution in Thailand, in in-depth interviews - with 43 key informants from farms, health facilities, pharmaceutical and animal feed industries, private pharmacies and regulators- and in database and literature searches.

Findings

In 2016-2017, licensed antibiotic distribution in Thailand involves over 700 importers and about 24 000 distributors - e.g. retail pharmacies and wholesalers. Thailand imports antibiotics and active pharmaceutical ingredients. There is no system for monitoring the distribution of active ingredients, some of which are used directly on farms, without being processed. Most antibiotics can be bought from pharmacies, for home or farm use, without a prescription. Although the 1987 Drug Act classified most antibiotics as "dangerous drugs", it only classified a few of them as prescription-only medicines and placed no restrictions on the quantities of antibiotics that could be sold to any individual. Pharmacists working in pharmacies are covered by some of the Act's regulations, but the quality of their dispensing and prescribing appears to be largely reliant on their competences.

Conclusion

In Thailand, most antibiotics are easily and widely available from retail pharmacies, without a prescription. If the inappropriate use of active pharmaceutical ingredients and antibiotics is to be reduced, we need to reclassify and restrict access to certain antibiotics and to develop systems to audit the dispensing of antibiotics in the retail sector and track the movements of active ingredients.

Burden of musculoskeletal disorders among registered nurses: evidence from the Thai nurse cohort study

Background

Musculoskeletal disorders (MSDs) are a major public health problem among registered nurses (RNs) in Thailand. Information on their burdens at a national level is limited. This study estimated the prevalence of MSDs among RNs using the 2009 Thai Nurse Cohort, a nationally representative sample of RNs in Thailand.

Methods

This study is part of the first wave survey of the Thai Nurse Cohort Study (TNCS) conducted in 2009. Members of the cohort consisted of 18,756 RNs across Thailand. A 13-page self-administered questionnaire was sent to participants where MSDs were measured by self-reported answers to questions related to experiencing MSDs during a previous year. However, 1070 RNs were excluded from this study since they were unemployed during a previous year, therefore the final sample size was 17,686 RNs. A 12-month prevalence of MSDs and its 95% confidence interval (95% CI) were estimated based on normal approximation to binomial distribution. Chi-square test for trend was used.

Results

Of the 17,686 RNs, 47.8% (95% CI: 47.0–48.5) reported having MSDs during the previous 12 months. The prevalence of MSDs significantly increased with age, body mass index, and working duration (all P < 0.001). Compared to the non-MSD group, RNs with MSDs had a higher proportion who perceived MSDs as a long-term, chronic medical condition (78.1% vs 20.7%; p < 0.001), being currently on medication (49.4% vs 14.7%; p < 0.001), using pain relief medication almost every day (9.0% vs 1.9%; p < 0.001), experiencing sickness absence (15.7% vs 1.1%; p < 0.001), seeking medical specialist consultations (odds ratio, OR 2.2; 95% CI: 2.0–2.3; p < 0.001), and seeking alternative medications (OR 2.5; 95% CI: 2.3–2.7; p < 0.001).

Conclusions

Musculoskeletal disorders affected almost half of the RNs in Thailand annually. They placed a major healthcare burden and were a major cause of working days lost due to sick leaves, diminished productivity and quality of patient care. More attention should be paid to the prevention and effective management of MSDs in RNs in Thailand. Further study on ergonomics related to MSDs and its prevention are needed.

Extreme exploitation in Southeast Asia waters: Challenges in progressing towards universal health coverage for migrant workers

Rapeepong Suphanchaimat and colleagues present the plight of migrant workers in the fishing industry in Southeast Asia and discuss challenges in providing for their health and safety.

Implementing health insurance for migrants, Thailand

PROBLEM

Undocumented migrant workers are generally ineligible for state social security schemes, and either forego needed health services or pay out of pocket.

APPROACH

In 2001, the Thai Ministry of Public Health introduced a policy on migrant health. Migrant health insurance is a voluntary scheme, funded by an annual premium paid by workers. It enables access to health care at public facilities and reduces catastrophic health expenditures for undocumented migrants and their dependants. A range of migrant-friendly services, including trained community health volunteers, was introduced in the community and workplace. In 2014, the government introduced a multisectoral policy on migrants, coordinated across the interior, labour, public health and immigration ministries.

LOCAL SETTING

In 2011, around 0.3 million workers, less than 9% of the estimated migrant labour force of 3.5 million, were covered by Thailand's social security scheme.

RELEVANT CHANGES

A review of the latest data showed that from April to July 2016, 1 146 979 people (33.7% of the total estimated migrant labourers of 3 400 787) applied, were screened and were enrolled in the migrant health insurance scheme. Health volunteers, recruited from migrant communities and workplaces are appreciated by local communities and are effective in promoting health and increasing uptake of health services by migrants.

LESSONS LEARNT

The capacity of the health ministry to innovate and manage migrant health insurance was a crucial factor enabling expanded health insurance coverage for undocumented migrants. Continued policy support will be needed to increase recruitment to the insurance scheme and to scale-up migrant-friendly services.