Universal coverage of renal dialysis in Thailand: promise, progress, and prospects

Thailand's experience in introducing renal replacement therapy as part of its universal health coverage scheme shows the importance of evidence and stakeholders' active participation in all phases of policy development, say Sripen Tantivess and colleagues:

Estimating the willingness to pay for a quality-adjusted life year in Thailand: does the context of health gain matter?

BACKGROUND

This study aims to elicit the value of the willingness to pay (WTP) for a quality-adjusted life year (QALY) and to examine the factors associated with the WTP for a QALY (WTP/QALY) value under the Thai health care setting.

METHODS

A community-based survey was conducted among 1191 randomly selected respondents. Each respondent was interviewed face-to-face to elicit his/her health state preference in each of three pairs of health conditions: (1) unilateral and bilateral blindness, (2) paraplegia and quadriplegia, and (3) mild and moderate allergies. A visual analog scale (VAS) and time trade off (TTO) were used as the eliciting methods. Subsequently, the respondents were asked about their WTP for the treatment and prevention of each pair of health conditions by using a bidding-game technique.

RESULTS

With regards to treatment, the mean WTP for a QALY value (WTP/QALY(treatment)) estimated by the TTO method ranged from 59,000 to 285,000 baht (16.49 baht = US$1 purchasing power parity [PPP]). In contrast, the mean WTP for a QALY value in terms of prevention (WTP/QALY(prevention)) was significantly lower, ranging from 26,000 to 137,000 baht. Gender, household income, and hypothetical scenarios were also significant factors associated with the WTP/QALY values.

CONCLUSION

The WTP/QALY values elicited in this study were approximately 0.4 to 2 times Thailand's 2008 GDP per capita. These values were in line with previous studies conducted in several different settings. This study's findings clearly support the opinion that a single ceiling threshold should not be used for the resource allocation of all types of interventions.

The use of comparative effectiveness research to inform policy decisions on the inclusion of bevacizumab for the treatment of macular diseases in Thailand's pharmaceutical benefit package

There is increasing impetus to use pharmaceutical interventions, ie, ranibizumab or bevacizumab, for the treatment of particular macular diseases. This paper describes the evidence and decision-making of the National List of Essential Medicines Committee that recently announced the inclusion of bevacizumab for the treatment of macular diseases in its pharmaceutical benefit package. The findings of a systematic review and meta-analysis in this paper indicate that the intravitreal administration of bevacizumab is superior to nonpharmaceutical treatments for age-related macular degeneration (AMD) and diabetic macular edema (DME), but inconclusive for retinal vein occlusion, given the limited evidence. The study also failed to distinguish among the differences in terms of visual acuity improvement, reduction of central macular thickness, and response to treatment between AMD and DME patients treated with bevacizumab and those treated with ranibizumab. Although bevacizumab was not licensed for AMD and DME, the committee decided to include bevacizumab in the National List of Essential Medicines. It is expected that many patients who are in need of treatment but who are unable to afford the expensive alternative drug, ranibizumab, will be able to receive this effective treatment instead and be prevented from suffering irreversible loss of vision. At the same time, this policy will help generate evidence about the real-life effectiveness and safety profiles of the drug for future policy development in Thailand and other settings.

Social values and health policy: a new international research programme

PURPOSE

This editorial aims to outline the context of healthcare priority-setting, and summarise each of the other ten papers in this special edition. It introduces a new multidisciplinary research programme drawing on ethics, philosophy, health economics, political science and health technology assessment, out of which the papers in this edition have arisen.

DESIGN/METHODOLOGY/APPROACH

Key normative concepts are introduced and policy and research context provided to frame subsequent papers in the edition.

FINDINGS

Common challenges of health priority-setting are faced by many countries across the world, and a range of social value judgments is in play as resource allocation decisions are made. Although the challenges faced by different countries are in many ways similar, the way in which social values affect the processes and content of priority-setting decisions means that those challenges are resolved very differently in a variety of social, political, cultural and institutional settings, as subsequent papers in this edition demonstrate. How social values affect decision making in this way is the subject of a new multi-disciplinary research programme.

ORIGINALITY/VALUE

Technical analyses of health priority setting are commonplace, but approaching the issues from the perspective of social values and conducting comparative analyses across countries with very different cultural, social and institutional contexts provides the content for a new research agenda.

Multicriteria decision analysis for including health interventions in the universal health coverage benefit package in Thailand

OBJECTIVES

Considering rising health expenditure on the one hand and increasing public expectations on the other hand, there is a need for explicit health care rationing to secure public acceptance of coverage decisions of health interventions. The National Health Security Office, the institute managing the Universal Coverage Scheme in Thailand, recently called for more rational, transparent, and fair decisions on the public reimbursement of health interventions. This article describes the application of multicriteria decision analysis (MCDA) to guide the coverage decisions on including health interventions in the Universal Coverage Scheme health benefit package in the period 2009-2010.

METHODS

We described the MCDA priority-setting process through participatory observation and evaluated the rational, transparency, and fairness of the priority-setting process against the accountability for reasonableness framework.

RESULTS

The MCDA was applied in four steps: 1) 17 interventions were nominated for assessment; 2) nine interventions were selected for further quantitative assessment on the basis of the following criteria: size of population affected by disease, severity of disease, effectiveness of health intervention, variation in practice, economic impact on household expenditure, and equity and social implications; 3) these interventions were then assessed in terms of cost-effectiveness and budget impact; and 4) decision makers qualitatively appraised, deliberated, and reached consensus on which interventions should be adopted in the package.

CONCLUSION

This project was carried out in a real-world context and has considerably contributed to the rational, transparent, and fair priority-setting process through the application of MCDA. Although the present project has applied MCDA in the Thai context, MCDA is adaptable to other settings.

Lessons drawn from research utilization in the maternal iodine supplementation policy development in Thailand

In this paper, the authors share their experience on evidence utilization in the development of Thailand’s maternal iodine supplementation policy in 2009–2010. Observations and reflections on their experience of engaging with research for policymaking are illustrated. The case study indicates that rapid approaches in conducting research, namely a targeted literature review and cross-sectional survey of professionals’ opinions and current practices were efficient in achieving the timeliness of evidence provision. In addition pro-activity, trust and interaction between researchers and policymakers enhanced the research–policy integration. The Thai experience may be useful for other developing countries which pursue evidence-informed policymaking, despite differences in the health system context.

Priority-setting institutions in health: recommendations from a center for global development working group

The rationing problem is common to all health systems-the challenge of managing finite resources to address unlimited demand for services. In most low- and middle-income countries, rationing occurs as an ad hoc, haphazard series of nontransparent choices that reflect the competing interests of governments, donors, and other stakeholders. Yet in a growing number of countries, more explicit processes, with strengths and limitations, are under development that merit better support. Against this background, the purpose of the Center for Global Development Working Group, which is to examine how priorities are set currently, and to propose institutional arrangements that promote country ownership and improve health outcomes by more systematically managing this complex process of politics and economics, is discussed. Current global and national priority-setting practices in low- and middle-income countries, the potential for strengthened national institutions, and increased global support are reviewed. Recommendations for action are provided.

Systematic review of economic evaluations of preparedness strategies and interventions against influenza pandemics

BACKGROUND

Although public health guidelines have implications for resource allocation, these issues were not explicitly considered in previous WHO pandemic preparedness and response guidance. In order to ensure a thorough and informed revision of this guidance following the H1N1 2009 pandemic, a systematic review of published and unpublished economic evaluations of preparedness strategies and interventions against influenza pandemics was conducted.

METHODS

The search was performed in September 2011 using 10 electronic databases, 2 internet search engines, reference list screening, cited reference searching, and direct communication with relevant authors. Full and partial economic evaluations considering both costs and outcomes were included. Conversely, reviews, editorials, and studies on economic impact or complications were excluded. Studies were selected by 2 independent reviewers.

RESULTS

44 studies were included. Although most complied with the cost effectiveness guidelines, the quality of evidence was limited. However, the data sources used were of higher quality in economic evaluations conducted after the 2009 H1N1 pandemic. Vaccination and drug regimens were varied. Pharmaceutical plus non-pharmaceutical interventions are relatively cost effective in comparison to vaccines and/or antivirals alone. Pharmaceutical interventions vary from cost saving to high cost effectiveness ratios. According to ceiling thresholds (Gross National Income per capita), the reduction of non-essential contacts and the use of pharmaceutical prophylaxis plus the closure of schools are amongst the cost effective strategies for all countries. However, quarantine for household contacts is not cost effective even for low and middle income countries.

CONCLUSION

The available evidence is generally inconclusive regarding the cost effectiveness of preparedness strategies and interventions against influenza pandemics. Studies on their effectiveness and cost effectiveness should be readily implemented in forthcoming events that also involve the developing world. Guidelines for assessing the impact of disease and interventions should be drawn up to facilitate these studies.

Multi-criteria decision analysis for setting priorities on HIV/AIDS interventions in Thailand

Background

A wide range of preventive, treatment, and care programs for HIV/AIDS are currently available and some of them have been implemented in Thailand. Policy makers are now facing challenges on how the scarce resources for HIV/AIDS control can be spent more wisely. Although effectiveness and cost-effectiveness information is useful for guiding policy decisions, empirical evidence indicates the importance of other criteria, such as equity and the characteristics of the target population, also play important roles in priority setting. This study aims to experiment with the use of multi-criteria decision analysis (MCDA) to prioritise interventions in HIV/AIDS control in Thailand.

Methods

We used MCDA to rank 40 HIV/AIDS interventions on the basis of the priority setting criteria put forward by three groups of stakeholders including policy makers, people living with HIV/AIDs (PLWHA), and village health volunteers (VHVs). MCDA incorporated an explicit component of deliberation to let stakeholders reflect on the rank ordering, and adapt where necessary.

Results

Upon deliberation, policy makers expressed a preference for programs that target high risk groups such as men who have sex with men, injecting drug users, and female sex workers. The VHVs preferred interventions that target the youth or the general population, and gave lower priority to programs that target high risk groups. PLWHA gave all interventions the same priority. The rank order correlation between the priorities as expressed before and after deliberation was 37% among the policy makers and 46% among the VHVs.

Conclusion

This study documented the feasibility of MCDA to prioritize HIV/AIDS interventions in Thailand, and has shown the usefulness of a deliberative process as an integrated component of MCDA. MCDA holds potential to contribute to a more transparent and accountable priority setting process, and further application of this approach in the prioritisation of health interventions is warranted.

Impact of the introduction of government use licenses on the drug expenditure on seven medicines in Thailand

OBJECTIVES

To assess the budget impact of the government use licenses policy, a form of compulsory licensing used by the government, on seven patented drugs, namely, efavirenz, lopinavir/ritonavir combination, clopidogrel, letrozole, docetaxel, erlotinib, and imatinib, in Thailand between 2006 and 2008.

METHODS

By using government's perspective, budget impact was estimated within a 5-year period after the introduction of the policy. The number of patients who need treatment with each drug and the costs of treatments by both original and generic versions were obtained from Thai government agencies. Probabilistic sensitivity analysis was used to determine the impact of uncertainty surrounding parameters such as the numbers of patients and the health-care costs.

RESULTS

The study indicated that the use of generic drugs under the policy could save the government budget approximately $370 million over 5 years. It was also found that each drug had a different effect on budget saving depending on the number of patients treated, the difference in drug costs between original and generic drugs, and the lag time from the introduction of the policy to the availability of the generic drugs on the market.

CONCLUSION

The study showed that the introduction of the government use licenses policy in Thailand would provide significant benefits for the study timeframe; however, there are several issues that should be taken into account when the government use licenses policy is adopted.

Evidence to inform decision makers in Thailand: a cost-effectiveness analysis of screening and treatment strategies for postmenopausal osteoporosis

OBJECTIVES

To assess value for money of providing systematic screening for osteoporosis among postmenopausal women and medical treatments for those diagnosed with osteoporosis as evidence-based decision making for the revision of the National List of Essential Medicines.

METHODS

Decision analytic models were constructed, using a societal perspective, to assess the cost per quality-adjusted life-years (QALYs) gained from systematic screening using the Osteoporosis Self-Assessment Tool and dual-energy X-ray absorptiometry or dual-energy X-ray absorptiometry alone compared with no screening. Alendronate, risedronate, raloxifene, and nasal calcitonin were economically evaluated to determine a treatment of choice for the prevention of osteoporosis-related fractures. Most input parameters were obtained from literature reviews, and systematic reviews and meta-analyses, if available. The service costs and related household expenses were based on the Thai setting. Probabilistic and one-way sensitivity analyses were used to incorporate the impact of parameter uncertainty.

RESULTS

The Osteoporosis Self-Assessment Tool and sequential dual-energy X-ray absorptiometry provided better value for money for osteoporosis screening among young age groups (<60 years old). Although there was no significant difference in cost per QALY for older age groups, alendronate provided the lowest incremental cost-effectiveness ratio while nasal calcitonin presented the highest incremental cost-effectiveness ratio. It was shown that providing medication for a secondary prevention yielded a much higher cost per QALY gained compared with providing medication for a primary prevention.

CONCLUSIONS

Given the benchmark set at 100,000 Thai baht per QALY gained, providing systematic screening and treatment for osteoporosis was cost-ineffective in the Thai setting.

Economic evaluation of policy options for prevention and control of cervical cancer in Thailand

BACKGROUND

The Thai healthcare setting has seen patients with cervical cancer experience an increasing burden of morbidity and mortality, a stagnation in the performance of cervical screening programmes and the introduction of a vaccine for the prevention of human papillomavirus (HPV) infection.

OBJECTIVE

This study aims to identify the optimum mix of interventions that are cost effective, from societal and healthcare provider perspectives, for the prevention and control of cervical cancer.

METHODS

A computer-based Markov model of the natural history of cervical cancer was used to simulate an age-stratified cohort of women in Thailand. The strategy comparators, including both control and prevention programmes, were (i) conventional cytology screening (Pap smears); (ii) screening by visual inspection with acetic acid (VIA); and (iii) HPV-16, -18 vaccination. Input parameters (e.g. age-specific incidence of HPV infection, progression and regression of the infection, test performance of screening methods and efficacy of vaccine) were synthesized from a systematic review and meta-analysis. Costs (year 2007 values) and outcomes were evaluated separately, and compared for each combination. The screening strategies were started from the age of 30-40 years and repeated at 5- and 10-year intervals. In addition, HPV vaccines were introduced at age 15-60 years.

RESULTS

All of the screening strategies showed certain benefits due to a decreased number of women developing cervical cancer versus 'no intervention'. Moreover, the most cost-effective strategy from the societal perspective was the combination of VIA and sequential Pap smear (i.e., VIA every 5 years for women aged 30-45 years, followed by Pap smear every 5 years for women aged 50-60 years). This strategy was dominant, with a QALY gain of 0.01 and a total cost saving of Baht (Bt) 800, compared with doing nothing. From the societal perspective, universal HPV vaccination for girls aged 15 years without screening resulted in a QALY gain of 0.06 at an additional cost of Bt 8,800, based on the cost of Bt 15,000 for a full immunization schedule. The incremental cost-effectiveness ratio, comparing HPV vaccinations for girls aged 15 years with the current national policy of Pap smears for women aged 35-60 years every 5 years, was approximately Bt 18,1000 per QALY gained. This figure was relatively high for the Thai setting.

CONCLUSIONS

The results suggest that controlling cervical cancer by increasing the numbers of women accepting the VIA and Pap smear screening as routine and by improving the performance of the existing screening programmes is the most cost-effective policy option in Thailand.

Government use licenses in Thailand: an assessment of the health and economic impacts

BACKGROUND

Between 2006 and 2008, Thailand's Ministry of Public Health (MOPH) granted government use licenses for seven patented drugs in order to improve access to these essential treatments. The decision to grant the government use licenses was contentious both within and beyond the country. In particular, concerns were highlighted that the negative consequences might outweigh the expected benefits of the policy. This study conducted assessments of the health and economic implications of these government use licenses.

METHODS

The health and health-related economic impacts were quantified in terms of i) Quality Adjusted Life Years (QALYs) gained and ii) increased productivity in US dollars (USD) as a result of the increased access to drugs. The study adopted a five-year timeframe for the assessment, commencing from the time of the grant of the government use licenses. Empirical evidence gathered from national databases was used to assess the changes in volume of exports after US Generalized System of Preferences (GSP) withdrawal and level of foreign direct investment (FDI).

RESULTS

As a result of the granting of the government use licenses, an additional 84,158 patients were estimated to have received access to the seven drugs over five years. Health gains from the use of the seven drugs compared to their best alternative accounted for 12,493 QALYs gained, which translates into quantifiable incremental benefits to society of USD132.4 million. The government use license on efavirenze was found to have the greatest benefit. In respect of the country's economy, the study found that Thailand's overall exports increased overtime, although exports of the three US GSP withdrawal products to the US did decline. There was also found to be no relationship between the government use licenses and the level of foreign investment over the period 2002 to 2008.

CONCLUSIONS

The public health benefits of the government use licenses were generally positive. Specifically, the policy helped to increase access to patented drugs, while the impact of the US GSP withdrawal did not adversely affect the overall export status. Because the levels of benefit gained from the government use licenses varied widely between the seven drugs, depending on several factors, this study makes recommendations for the future implementation of the policy in order to maximise benefits.

Is a HIV vaccine a viable option and at what price? An economic evaluation of adding HIV vaccination into existing prevention programs in Thailand

Background

This study aims to determine the maximum price at which HIV vaccination is cost-effective in the Thai healthcare setting. It also aims to identify the relative importance of vaccine characteristics and risk behavior changes among vaccine recipients to determine how they affect this cost-effectiveness.

Methods

A semi-Markov model was developed to estimate the costs and health outcomes of HIV prevention programs combined with HIV vaccination in comparison to the existing HIV prevention programs without vaccination. The estimation was based on a lifetime horizon period (99 years) and used the government perspective. The analysis focused on both the general population and specific high-risk population groups. The maximum price of cost-effective vaccination was defined by using threshold analysis; one-way and probabilistic sensitivity analyses were performed. The study employed an expected value of perfect information (EVPI) analysis to determine the relative importance of parameters and to prioritize future studies.

Results

The most expensive HIV vaccination which is cost-effective when given to the general population was 12,000 Thai baht (US$1 = 34 Thai baht in 2009). This vaccination came with 70% vaccine efficacy and lifetime protection as long as risk behavior was unchanged post-vaccination. The vaccine would be considered cost-ineffective at any price if it demonstrated low efficacy (30%) and if post-vaccination risk behavior increased by 10% or more, especially among the high-risk population groups. The incremental cost-effectiveness ratios were the most sensitive to change in post-vaccination risk behavior, followed by vaccine efficacy and duration of protection. The EVPI indicated the need to quantify vaccine efficacy, changed post-vaccination risk behavior, and the costs of vaccination programs.

Conclusions

The approach used in this study differentiated it from other economic evaluations and can be applied for the economic evaluation of other health interventions not available in healthcare systems. This study is important not only for researchers conducting future HIV vaccine research but also for policy decision makers who, in the future, will consider vaccine adoption.

A cost-utility and budget impact analysis of allogeneic hematopoietic stem cell transplantation for severe thalassemic patients in Thailand

BACKGROUND

Hematopoietic stem cell transplantation (HSCT) is the only curative treatment available to severe thalassemic patients. The treatment, however, is very costly, particularly in the context of low and middle income countries, and no studies have been carried out to explore its economic justifiability. This study aimed to estimate the cost-utility of HSCT compared with blood transfusions combined with iron chelating therapy (BT-ICT) for severe thalassemia in Thailand, and to investigate the affordability of HSCT using a budget impact analysis.

METHODS

A Markov model was used to estimate the relevant costs and health outcomes over the patients' lifetimes taking a societal perspective as recommended by Thailand's health technology assessment guidelines. All future costs and outcomes were discounted at a rate of 3% per annum. Primary outcomes of interest were lifetime costs, quality adjusted life years (QALYs) gained, and the incremental cost-effectiveness ratio (ICER) in Thai baht (THB) per QALY gained.

RESULTS

Compared to BT-ICT, the incremental cost-effectiveness ratio increased with patient age from 80,700 to 183,000 THB per QALY gained for related HSCT and 209,000 to 953,000 THB per QALY gained for unrelated HSCT among patients aged 1 to 15 years (US$1= 34 THB). The governmental budget impact analysis showed that providing 200 related HSCT to patients aged 1 to 10 years, in accordance with the current infrastructure limitations, would initially require approximately 90 million additional THB per year.

CONCLUSIONS

At a societal willingness to pay of 100,000 THB per QALY gained, related HSCT was likely to be a cost-effective and affordable treatment for young children with severe thalassemia in Thailand.

Reviewing the evidence on effectiveness and cost-effectiveness of HIV prevention strategies in Thailand

Background

Following universal access to antiretroviral therapy in Thailand, evidence from National AIDS Spending Assessment indicates a decreasing proportion of expenditure on prevention interventions. To prompt policymakers to revitalize HIV prevention, this study identifies a comprehensive list of HIV/AIDs preventive interventions that are likely to be effective and cost-effective in Thailand.

Methods

A systematic review of the national and international literature on HIV prevention strategies from 1997 to 2008 was undertaken. The outcomes used to consider the effectiveness of HIV prevention interventions were changes in HIV risk behaviour and HIV incidence. Economic evaluations that presented their results in terms of cost per HIV infection averted or cost per quality-adjusted life year (QALY) gained were also included. All studies were assessed against quality criteria.

Results

The findings demonstrated that school based-sex education plus life-skill programs, voluntary and routine HIV counselling and testing, male condoms, street outreach programs, needle and syringe programs, programs for the prevention of mother-to-child HIV transmission, male circumcision, screening blood products and donated organs for HIV, and increased alcohol tax were all effective in reducing HIV infection among target populations in a cost-effective manner.

Conclusion

We found very limited local evidence regarding the effectiveness of HIV interventions amongst specific high risk populations. This underlines the urgent need to prioritise health research resources to assess the effectiveness and cost-effectiveness of HIV interventions aimed at reducing HIV infection among high risk groups in Thailand.

Criteria for priority setting of HIV/AIDS interventions in Thailand: a discrete choice experiment

Background

Although a sizeable budget is available for HIV/AIDS control in Thailand, there will never be enough resources to implement every programme for all target groups at full scale. As such, there is a need to prioritize HIV/AIDS programmes. However, as of yet, there is no evidence on the criteria that should guide the priority setting of HIV/AIDS programmes in Thailand, including their relative importance. Also, it is not clear whether different stakeholders share similar preferences.

Methods

Criteria for priority setting of HIV/AIDS interventions in Thailand were identified in group discussions with policy makers, people living with HIV/AIDS (PLWHA), and community members (i.e. village health volunteers (VHVs)). On the basis of these, discrete choice experiments were designed and administered among 28 policy makers, 74 PLWHA, and 50 VHVs.

Results

In order of importance, policy makers expressed a preference for interventions that are highly effective, that are preventive of nature (as compared to care and treatment), that are based on strong scientific evidence, that target high risk groups (as compared to teenagers, adults, or children), and that target both genders (rather than only men or women). PLWHA and VHVs had similar preferences but the former group expressed a strong preference for care and treatment for AIDS patients.

Conclusions

The study has identified criteria for priority setting of HIV/AIDS interventions in Thailand, and revealed that different stakeholders have different preferences vis-à-vis these criteria. This could be used for a broad ranking of interventions, and as such as a basis for more detailed priority setting, taking into account also qualitative criteria.

Scaling up cervical cancer screening in the midst of human papillomavirus vaccination advocacy in Thailand

Background

Screening tests for cervical cancer are effective in reducing the disease burden. In Thailand, a Pap smear program has been implemented throughout the country for 40 years. In 2008 the Ministry of Public Health (MoPH) unexpectedly decided to scale up the coverage of free cervical cancer screening services, to meet an ambitious target. This study analyzes the processes and factors that drove this policy innovation in the area of cervical cancer control in Thailand.

Methods

In-depth interviews with key policy actors and review of relevant documents were conducted in 2009. Data analysis was guided by a framework, developed on public policy models and existing literature on scaling-up health care interventions.

Results

Between 2006 and 2008 international organizations and the vaccine industry advocated the introduction of Human Papillomavirus (HPV) vaccine for the primary prevention of cervical cancer. Meanwhile, a local study suggested that the vaccine was considerably less cost-effective than cervical cancer screening in the Thai context. Then, from August to December 2008, the MoPH carried out a campaign to expand the coverage of its cervical cancer screening program, targeting one million women. The study reveals that several factors were influential in focusing the attention of policymakers on strengthening the screening services. These included the high burden of cervical cancer in Thailand, the launch of the HPV vaccine onto the global and domestic markets, the country’s political instability, and the dissemination of scientific evidence regarding the appropriateness of different options for cervical cancer prevention. Influenced by the country’s political crisis, the MoPH’s campaign was devised in a very short time. In the view of the responsible health officials, the campaign was not successful and indeed, did not achieve its ambitious target.

Conclusion

The Thai case study suggests that the political crisis was a crucial factor that drew the attention of policymakers to the cervical cancer problem and led the government to adopt a policy of expanding coverage of screening services. At the same time, the instability in the political system impeded the scaling up process, as it constrained the formulation and implementation of the policy in the later phase.

The economic costs of alcohol consumption in Thailand, 2006

BACKGROUND

There is evidence that the adverse consequences of alcohol impose a substantial economic burden on societies worldwide. Given the lack of generalizability of study results across different settings, many attempts have been made to estimate the economic costs of alcohol for various settings; however, these have mostly been confined to industrialized countries. To our knowledge, there are a very limited number of well-designed studies which estimate the economic costs of alcohol consumption in developing countries, including Thailand. Therefore, this study aims to estimate these economic costs, in Thailand, 2006.

METHODS

This is a prevalence-based, cost-of-illness study. The estimated costs in this study included both direct and indirect costs. Direct costs included health care costs, costs of law enforcement, and costs of property damage due to road-traffic accidents. Indirect costs included costs of productivity loss due to premature mortality, and costs of reduced productivity due to absenteeism and presenteeism (reduced on-the-job productivity).

RESULTS

The total economic cost of alcohol consumption in Thailand in 2006 was estimated at 156,105.4 million baht (9,627 million US$ PPP) or about 1.99% of the total Gross Domestic Product (GDP). Indirect costs outweigh direct costs, representing 96% of the total cost. The largest cost attributable to alcohol consumption is that of productivity loss due to premature mortality (104,128 million baht/6,422 million US$ PPP), followed by cost of productivity loss due to reduced productivity (45,464.6 million baht/2,804 million US$ PPP), health care cost (5,491.2 million baht/339 million US$ PPP), cost of property damage as a result of road traffic accidents (779.4 million baht/48 million US$ PPP), and cost of law enforcement (242.4 million baht/15 million US$ PPP), respectively. The results from the sensitivity analysis revealed that the cost ranges from 115,160.4 million baht to 214,053.0 million baht (7,102.1 - 13,201 million US$ PPP) depending on the methods and assumptions employed.

CONCLUSIONS

Alcohol imposes a substantial economic burden on Thai society, and according to these findings, the Thai government needs to pay significantly more attention to implementing more effective alcohol policies/interventions in order to reduce the negative consequences associated with alcohol.

The economic impact of alcohol consumption: a systematic review

BACKGROUND

Information on the economic impact of alcohol consumption can provide important evidence in supporting policies to reduce its associated harm. To date, several studies on the economic costs of alcohol consumption have been conducted worldwide. This study aims to review the economic impact of alcohol worldwide, summarizing the state of knowledge with regard to two elements: (1) cost components included in the estimation; (2) the methodologies employed in works conducted to date.

METHODS

Relevant publications concerning the societal cost of alcohol consumption published during the years 1990-2007 were identified through MEDLINE. The World Health Organization's global status report on alcohol, bibliographies and expert communications were also used to identify additional relevant studies.

RESULTS

Twenty studies met the inclusion criteria for full review while an additional two studies were considered for partial review. Most studies employed the human capital approach and estimated the gross cost of alcohol consumption. Both direct and indirect costs were taken into account in all studies while intangible costs were incorporated in only a few studies. The economic burden of alcohol in the 12 selected countries was estimated to equate to 0.45 - 5.44% of Gross Domestic Product (GDP).

CONCLUSION

Discrepancies in the estimation method and cost components included in the analyses limit a direct comparison across studies. The findings, however, consistently confirmed that the economic burden of alcohol on society is substantial. Given the importance of this issue and the limitation in generalizing the findings across different settings, further well-designed research studies are warranted in specific countries to support the formulation of alcohol-related policies.

The current capacity and future development of economic evaluation for policy decision-making: a survey among researchers and decision-makers in Thailand

OBJECTIVE

This study aims to explore the knowledge, experience, and attitudes toward economic evaluation (EE) among decision-makers and researchers in Thailand.

METHODS

Researchers were purposively selected from Thai academics and both public and private research organizations related to EE. Decision-makers at the provincial level were purposively selected from the members of the Management Committees of Provincial Health Offices, and those at hospital level were randomly selected from members of the public and private hospital formulary drug committees throughout Thailand. The self-administered postal questionnaires were distributed. Univariate and bivariate analyses were applied.

RESULTS

Of the total 2575 questionnaires distributed, 758 (29.4% response rate) were completed and sent back. The majority of researchers and decision-makers were not familiar with technical terms commonly used in health EE, e.g., incremental cost-effectiveness ratio, discounting, and sensitivity analysis. More decision-makers (70.6%) had never had EE training compared to researchers (50.0%). Both roles indicated that value for money was one of the important issues to consider for health technology adoption.

CONCLUSIONS

An extensive unmet demand for EE training among Thai researchers and decision-makers still exists. Findings from this study contribute to the short- and long-term plans for research capacity building.

Economic impact on health-care costs related to major diseases including HIV/AIDS due to alcohol drinking among Thai populations

OBJECTIVE

The objective of this study was to estimate health-care costs because of diseases caused by alcohol consumption based on health system's perspective.

METHODS

Total direct health-care costs of alcohol drinking were the summation of the costs of alcohol drinking in inpatient and outpatient departments due to chronic diseases and acute conditions using prevalence-based approach. The alcohol-attributable fractions, defined as the proportion of a disease or acute condition in a population attributable to alcohol drinking, were calculated to obtain the number of patients in each disease or acute condition attributable to alcohol drinking. Health-care costs of alcohol drinking were estimated by multiplying the number of patients in each disease category attributable to alcohol drinking with the unit cost of treatment.

RESULTS

Total health-care costs attributed to alcohol in this research were 5491 million baht (i.e., outpatient department [2488 million baht] and inpatient department [3003 million baht]). Cost derived from inpatient department accounted for 55% of the total health-care cost attributed to alcohol.

CONCLUSIONS

The result of this study suggested that alcohol drinking was significantly associated with a large number of health-care costs in Thailand. Estimation of health-care costs related to alcohol drinking would provide an important insight into future policy appraisal and evaluation.

Using economic evaluation in policy decision-making in Asian countries: mission impossible or mission probable?

OBJECTIVES AND METHODS

This article provides an extensive review of literature and an in-depth analysis aimed at introducing potential applications of economic evaluation and at addressing the barriers that could prohibit the use or diminish the usefulness of economic evaluation in Asian settings. It also proposes the probable solutions to overcome these barriers.

RESULTS

Potential uses of economic evaluation include the development of public reimbursement lists, price negotiation, the development of clinical practice guidelines, and communicating with prescribers. Two types of barriers to using economic evaluation, namely barriers relating to the production of economic evaluation data and decision context-related barriers, are identified. For the first sort of barrier, the development of the national guidelines, the development of economic evaluation database, planning and use of economic evaluation in a systematic manner, and prioritization of topics for assessment are recommended. Furthermore, educating potential users and the public, making the economic evaluation process transparent and participatory, and incorporating other health preferences into the decision-making framework have been promoted to conquer decision context-related barriers.

CONCLUSIONS

It seems practically impossible to adopt other countries' approaches using economic evaluation for priority setting because of several constraints specifically related to the context of each setting. Nevertheless, given a better understanding of its resistance, and proper policies and strategies to overcome the barriers applied, it is more than probable that a method with system/mechanisms specifically designed to fit particular settings will be used.