The Thai Health Promotion Foundation: Two Decades of Joint Contributions to Addressing Noncommunicable Diseases and Creating Healthy Populations

Globally, the current investment in preventive care is inadequate and ineffective for addressing noncommunicable diseases and their causes. The Thai Health Promotion Foundation, with its sustainable funding from 2% levies on tobacco and alcohol, together with partners, has been used to address noncommunicable diseases effectively.

Governance, policy, and health systems responses to the COVID-19 pandemic in Thailand: a qualitative study

Background

Since 2020, Thailand has experienced four waves of COVID-19. By 31 January 2022, there were 2.4 million cumulative cases and 22,176 deaths nationwide. This study assessed the governance and policy responses adapted to different sizes of the pandemic outbreaks and other challenges.

Methods

A qualitative study was applied, including literature reviews and in-depth interviews with 17 multi-sectoral actors purposively identified from those who were responsible for pandemic control and vaccine rollout. We applied deductive approaches using health systems building blocks, and inductive approaches using analysis of in-depth interview content, where key content formed sub-themes, and different sub-themes formed the themes of the study.

Findings

Three themes emerged from this study. First, the large scale of COVID-19 infections, especially the Delta strain in 2021, challenged the functioning of the health system's capacity to respond to cases and maintain essential health services. The Bangkok local government insufficiently performed due to its limited capacity, ineffective multi-sectoral collaboration, and high levels of vulnerability in the population. However, adequate financing, universal health coverage, and health workforce professionalism and commitment were key enabling factors that supported the health system. Second, the population's vulnerability exacerbated infection spread, and protracted political conflicts and political interference resulted in the politicization of pandemic control measures and vaccine roll-out; all were key barriers to effective pandemic control. Third, various innovations and adaptive capacities minimized the supply-side gaps, while social capital and civil society engagement boosted community resilience.

Conclusion

This study identifies key governance gaps including in public communication, managing infodemics, and inadequate coordination with Bangkok local government, and between public and private sectors on pandemic control and health service provisions. The Bangkok government had limited capacity in light of high levels of population vulnerability. These gaps were widened by political conflicts and interference. Key strengths are universal health coverage with full funding support, and health workforce commitment, innovations, and capacity to adapt interventions to the unfolding emergency. Existing social capital and civil society action increases community resilience and minimizes negative impacts on the population.

Health Insurance Schemes and Their Influences on Healthcare Variation in Asian Countries: A Realist Review and Theory's Testing in Thailand

BACKGROUND

Various features in health insurance schemes may lead to variation in health care. Unwarranted variations raise concerns about suboptimal quality of care, differing treatments for similar needs, or unnecessary financial burdens on patients and health systems. This realist review aims to explore insurance features that may contribute to health care variation in Asian countries; and to understand influencing mechanisms and contexts.

METHODS

We undertook a realist review. First, we developed an initial theory. Second, we conducted a systematic review of peer-reviewed literature in Scopus, MEDLINE, EMBASE, and Web of Science to produce a middle range theory for Asian countries. The Mixed Methods Appraisal Tool (MMAT) was used to appraise the methodological quality of included studies. Finally, we tested the theory in Thailand by interviewing nine experts, and further refined the theory.

RESULTS

Our systematic search identified 14 empirical studies. We produced a middle range theory in a context-mechanism-outcome configuration (CMOc) which presented seven insurance features: benefit package, cost-sharing policies, beneficiaries, contracted providers, provider payment methods, budget size, and administration and management, that influenced variation through 20 interlinked demand- and supply-side mechanisms. The refined theory for Thailand added eight mechanisms and discarded six mechanisms irrelevant to the local context.

CONCLUSION

Our middle range and refined theories provide information about health insurance features associated with health care variation. We encourage policymakers and researchers to test the CMOc in their specific contexts. Appropriately validated, it can help design interventions in health insurance schemes to prevent or mitigate the detrimental effects of unwarranted health care variation.

All-cause excess mortality among end-stage renal disease (ESRD) patients during the COVID-19 pandemic in Thailand: a cross-sectional study from a national-level claims database

OBJECTIVES

COVID-19 infection increased nephrology-related risks and mortality rate among end-stage renal disease (ESRD) patients. The pandemic also disrupted essential healthcare services. We aim to explore all-cause excess mortality among ESRD patients who were members of the Universal Coverage Scheme (UCS), the largest public health insurance scheme in Thailand covering citizens who are not employed in the formal sector, including children and older persons.

DESIGN

A cross-sectional study.

SETTING

We retrieved the dataset from the UCS claims database-electronic health records used for processing healthcare expense claims from medical facilities of all UCS members. This database links mortality outcome to civil registration. We employed the WHO's excess mortality methodology using pre-pandemic data to estimate expected deaths during the pandemic period (March 2020 to August 2022).

PARTICIPANTS

This study included ESRD patients from across Thailand, covered by the UCS.

PRIMARY OUTCOME MEASURE

Excess deaths are the difference between predicted and reported deaths.

RESULTS

Over a 30-month period of the pandemic, the total number of all-cause excess deaths among ESRD patients was 4966 (male 1284; female 3682). The excess death per 100 000 ESRD patients was 3601 (male 2012; female 4969). The relative excess death was 5.7% of expected deaths (95% CI 1.7%, 10.0%). The excess deaths were highly concentrated among patients aged 65 and older.

CONCLUSION

ESRD patients are significantly more vulnerable to pandemic-related mortality than the general population. Health systems' capacity to contain the pandemic at varying virulence and maintain essential health services for ESRD patients might be related to the size of excess deaths at different periods. The observed excess deaths highlight the importance of established strategies to reduce all-cause mortality such as rapid vaccine rollout for ESRD patients and sustaining dialysis and other essential services for older patients and other high-risk groups.

Procedural fairness in benefit package design: inclusion of pre-exposure prophylaxis of HIV in Universal Coverage Scheme in Thailand

Since 2002, Thailand's Universal Coverage Scheme (UCS) has adopted a comprehensive benefits package with few exclusions. A positive-list approach has gradually been applied, with pre-exposure prophylaxis (PrEP) of HIV recently being included. Disagreements resulting from competing values and diverging interests necessitate an emphasis on procedural fairness when making any decisions. This qualitative study analyses agenda setting, policy formulation and early implementation of PrEP from a procedural fairness lens. Literature reviews and in-depth interviews with 13 key stakeholders involved in PrEP policy processes were conducted. Civil society organizations (CSOs) and academia piloted PrEP service models and co-produced evidence on programmatic feasibility and outcomes. Through a broad stakeholder representation process, the Department of Disease Control proposed PrEP for inclusion in UCS benefits package in 2017. PrEP was shown to be cost-effective and affordable through rigorous health technology assessment, peer review, use of up-to-date evidence and safe-guards against conflicts of interest. In 2021, Thailand's National Health Security Board decided to include PrEP as a prevention and promotion package, free of charge, for the populations at risk. Favourable conditions for procedural fairness were created by Thailand's legislative provisions that enable responsive governance, notably inclusiveness, transparency, safeguarding public interest and accountable budget allocations; longstanding institutional capacity to generate local evidence; and implementation capacity for realisation of procedural fairness criteria. Multiple stakeholders including CSOs, academia and the government deliberated in the policy process through working groups and sub-committees. However, a key lesson from Thailand's deliberative process concerns a possible 'over interpretation' of conflicts of interest, intended to promote impartial decision-making, which inadvertently limited the voices of key populations represented in the decision processes. Finally, this case study underscores the value of examining the full policy cycle when assessing procedural fairness, since some stages of the process may be more amenable to certain procedural criteria than others.

Children orphaned from COVID-19 in Thailand: maximize use of civil registration database for policies

Orphans, especially those who experience maternal loss at a young age, face significant long-term negative impacts on their lives and psychological well-being, extending beyond the age of 18. As of July 2023, the global death toll of COVID-19 has reached 6.9 million, leaving behind an unknown number of orphans who require immediate attention and support from policymakers. In Thailand, from April 2020 to July 2022, the total number of COVID-19-related deaths reached 42,194, resulting in 4,139 parental orphans. Among them, 452 (10.9%) were children under the age of five, who are particularly vulnerable and necessitate special policy attention and ongoing support. While the provision of 12 years of free education for all and Universal Health Coverage helps alleviate the education and health expenses borne by households supporting these orphans, the monthly government support of 2,000 Baht until the age of 18 is insufficient to cover their living costs and other education-related expenditures. We advocate for adequate financial and social support for COVID-19 orphans, emphasizing the importance of placing them with relatives rather than institutional homes. In the context of post-pandemic recovery, this perspective calls upon governments and global communities to estimate the number of orphans and implement policies to safeguard and support them in the aftermath of COVID-19.

Patterns and correlates of physical activity and sedentary behavior among Bangkok residents: A cross-sectional study

BACKGROUND

Physical inactivity and sedentary behavior are significant risk factors for various non-communicable diseases. Bangkok, Thailand's capital, is one of the fastest-growing metropolitans in Southeast Asia. Few studies have investigated the epidemiology of physical activity and sedentary behavior among Bangkok residents. This study aims to investigate the prevalence of combined physical activity and sedentary behavior patterns among Bangkok residents and examine relationships between participants' characteristics and the combined movement patterns.

METHODS

We analyzed data from the nationally representative 2021 Health Behavior Survey conducted by the Thailand National Statistical Office. The Global Physical Activity Questionnaire was used to assess physical activity and sedentary behavior. 'Sufficiently active' was defined as meeting the World Health Organization's guidelines for aerobic physical activity (≥150 minutes of moderate-to-vigorous physical activity per week). 'Low sedentary time' was defined as sitting for ≤7 hours per day. Participants were categorized into one of four movement patterns: highly active/low sedentary, highly active/highly sedentary, low active/low sedentary, and low active/highly sedentary. Multinomial logistic regression was used to identify the factors associated with each group of four movement patterns.

RESULTS

Among the 3,137 individuals included in the study, the majority were categorized as highly active/highly sedentary (64.8%), followed by highly active/low sedentary (17.9%) and low active/highly sedentary (14.3%). Only a few (3.0%) of participants were categorized as being low active/low sedentary. Compared to males, female participants had a significantly higher likelihood of belonging to the highly active/low sedentary (AOR = 1.69, 95%CI: 1.25, 2.28) or highly active/highly sedentary (AOR = 1.51, 95%CI: 1.19, 1.93) group, rather than the low active/high sedentary group. Compared to unemployed/retired participants, those in labor-intensive occupations had a significantly higher likelihood of being in the highly active/low sedentary group (AOR = 1.89, 95%CI: 1.22, 2.94). Compared to participants with no chronic physical conditions, participants who reported multimorbidity had a significantly lower likelihood of being in the highly active/low sedentary group (AOR = 0.60, 95%CI: 0.37, 0.98).

CONCLUSION

This study provides valuable insights into the patterns of physical activity and sedentary behavior among residents of Bangkok using up-to-date data. The majority belonged to the highly active/highly sedentary group, followed by the highly active/low sedentary group. Correlates such as sex, occupation, and chronic conditions were associated with these patterns. Targeted interventions in recreational activities, workplaces, and urban areas, including screen time control measures, movement breaks and improved built environments, are crucial in reducing sedentary behavior and promoting physical activity.

Effective Infodemic Management: A Substantive Article of the Pandemic Accord

Social media has proven to be valuable for disseminating public health information during pandemics. However, the circulation of misinformation through social media during public health emergencies, such as the SARS (severe acute respiratory syndrome), Ebola, and COVID-19 pandemics, has seriously hampered effective responses, leading to negative consequences. Intentionally misleading and deceptive fake news aims to harm organizations and individuals. To effectively respond to misinformation, governments should strengthen the management of an "infodemic," which involves monitoring the impact of infodemics through social listening, detecting signals of infodemic spread, mitigating the harmful effects of infodemics, and strengthening the resilience of individuals and communities. The global spread of misinformation requires multisectoral collaboration, such as researchers identifying leading sources of misinformation and superspreaders, media agencies identifying and debunking misinformation, technology platforms reducing the distribution of false or misleading posts and guiding users to health information from credible sources, and governments disseminating clear public health information in partnership with trusted messengers. Additionally, fact-checking has room for improvement through the use of automated checks. Collaboration between governments and fact-checking agencies should also be strengthened via effective and timely debunking mechanisms. Though the Intergovernmental Negotiating Body (INB) has yet to define the term "infodemic," Article 18 of the INB Bureau's text, developed for the Pandemic Accord, encompasses a range of actions aimed at enhancing infodemic management. The INB Bureau continues to facilitate evidence-informed discussion for an implementable article on infodemic management.

The impact of a complex school nutrition intervention on double burden of malnutrition among Thai primary school children: a 2-year quasi-experiment

OBJECTIVE

This study assessed the impacts of the Dekthai Kamsai programme on overweight/obesity, underweight and stunting among male and female primary school students.

STUDY DESIGN

A quasi-experiment was conducted in 16 intervention and 19 control schools across Thailand in 2018 and 2019. In total, 896 treated and 1779 control students from grades 1 to 3 were recruited. In intervention schools, a set of multifaceted intervention components were added into school routine practices. Anthropometric outcomes were measured at baseline and at the beginning and end of every school term.

METHODS

Propensity score matching with linear and Poisson difference-in-difference analyses were used to adjust for the non-randomisation and to analyse the intervention's effects over time.

RESULTS

Compared with controls, the increases in mean BMI-for-age Z-score (BAZ) and the incidence rate of overweight/obesity were lower in the intervention schools at the 3rd, 4th and 8th measurements and the 3rd measurement, respectively. The decrease in mean height-for-age Z-score (HAZ) was lower at the 4th measurement. The decrease in the incidence rate of wasting was lower at the 5th, 7th and 8th measurements. The favourable impacts on BAZ and HAZ were found in both sexes, while the favourable impact on overweight/obesity and unfavourable impact on wasting were found in girls.

CONCLUSIONS

This intervention might be effective in reducing BAZ, overweight/obesity, poor height gain, but not wasting. These findings highlight the benefits of a multifaceted school nutrition intervention and a need to incorporate tailor-made interventions for wasting to comprehensively address the double burden of malnutrition.

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

BACKGROUND

Indonesia implemented one of the world's largest single-payer national health insurance schemes (the Jaminan Kesehatan Nasional or JKN) in 2014. This study aims to assess the incidence of catastrophic health spending (CHS) and its determinants and trends between 2018 and 2019 by which time JKN enrolment coverage exceeded 80%.

METHODS

This study analysed data collected from a two-round cross-sectional household survey conducted in ten provinces of Indonesia in February-April 2018 and August-October 2019. The incidence of CHS was defined as the proportion of households with out-of-pocket (OOP) health spending exceeding 10% of household consumption expenditure. Chi-squared tests were used to compare the incidences of CHS across subgroups for each household characteristic. Logistic regression models were used to investigate factors associated with incurring CHS and the trend over time. Sensitivity analyses assessing the incidence of CHS based on a higher threshold of 25% of total household expenditure were conducted.

RESULTS

The overall incidence of CHS at the 10% threshold fell from 7.9% to 2018 to 4.4% in 2019. The logistic regression models showed that households with JKN membership experienced significantly lower incidence of CHS compared to households without insurance coverage in both years. The poorest households were more likely to incur CHS compared to households in other wealth quintiles. Other predictors of incurring CHS included living in rural areas and visiting private health facilities.

CONCLUSIONS

This study demonstrated that the overall incidence of CHS decreased in Indonesia between 2018 and 2019. OOP payments for health care and the risk of CHS still loom high among JKN members and among the lowest income households. More needs to be done to further contain OOP payments and further research is needed to investigate whether CHS pushes households below the poverty line.

Illustrating the impact of commercial determinants of health on the global COVID-19 pandemic: Thematic analysis of 16 country case studies

Previous research on commercial determinants of health has primarily focused on their impact on non-communicable diseases. However, they also impact on infectious diseases and on the broader preconditions for health. We describe, through case studies in 16 countries, how commercial determinants of health were visible during the COVID-19 pandemic, and how they may have influenced national responses and health outcomes. We use a comparative qualitative case study design in selected low- middle- and high-income countries that performed differently in COVID-19 health outcomes, and for which we had country experts to lead local analysis. We created a data collection framework and developed detailed case studies, including extensive grey and peer-reviewed literature. Themes were identified and explored using iterative rapid literature reviews. We found evidence of the influence of commercial determinants of health in the spread of COVID-19. This occurred through working conditions that exacerbated spread, including precarious, low-paid employment, use of migrant workers, procurement practices that limited the availability of protective goods and services such as personal protective equipment, and commercial actors lobbying against public health measures. Commercial determinants also influenced health outcomes by influencing vaccine availability and the health system response to COVID-19. Our findings contribute to determining the appropriate role of governments in governing for health, wellbeing, and equity, and regulating and addressing negative commercial determinants of health.

Definition, Practice, Regulations, and Effects of Balance Billing: A Scoping Review

Background

Additional billing is commonly and legally practiced in some countries for patients covered by health insurance. However, knowledge and understanding of the additional billings are limited. This study reviews evidence on additional billing practices including definition, scope of practice, regulations and their effects on insured patients.

Methods

A systematic search of the full-text papers that provided the details of balance billing for health services, written in English, and published between 2000 and 2021 was carried out in Scopus, MEDLINE, EMBASE and Web of Science. Articles were screened independently by at least 2 reviewers for eligibility. Thematic analysis was applied.

Results

In total, 94 studies were selected for the final analysis. Most of the included articles (83%) reported findings from the United States (US). Numerous terms of additional billings were used across countries such as balance billing, surprise billing, extra billing, supplements and out-of-pocket (OOP) spending. The range of services incurred these additional bills also varied across countries, insurance plans, and healthcare facilities; the frequently reported were emergency services, surgeries, and specialist consultation. There were a few positive though more studies reported negative effects of the substantial additional bills which undermined universal health coverage (UHC) goals by causing financial hardship and reducing access to care. A range of government measures had been applied to mitigate these adverse effects, but some difficulties still exist.

Conclusion

Additional billings varied in terms of terminology, definitions, practices, profiles, regulations, and outcomes. There were a set of policy tools aimed to control substantial billing to insured patients despite some limitations and challenges. Governments should apply multiple policy measures to improve financial risk protection to the insured population.

Corporate Political Activity: Taxonomies and Model of Corporate Influence on Public Policy

BACKGROUND

Non-communicable diseases (NCDs) kill 41 million people a year. The products and services of unhealthy commodity industries (UCIs) such as tobacco, alcohol, ultra-processed foods and beverages and gambling are responsible for much of this health burden. While effective public health policies are available to address this, UCIs have consistently sought to stop governments and global organisations adopting such policies through what is known as corporate political activity (CPA). We aimed to contribute to the study of CPA and development of effective counter-measures by formulating a model and evidence-informed taxonomies of UCI political activity.

METHODS

We used five complementary methods: critical interpretive synthesis of the conceptual CPA literature; brief interviews; expert co-author knowledge; stakeholder workshops; testing against the literature.

RESULTS

We found 11 original conceptualisations of CPA; four had been used by other researchers and reported in 24 additional review papers. Combining an interpretive synthesis of all these papers and feedback from users, we developed two taxonomies - one on framing strategies and one on action strategies. The former identified three frames (policy actors, problem, and solutions) and the latter six strategies (access and influence policy-making, use the law, manufacture support for industry, shape evidence to manufacture doubt, displace, and usurp public health, manage reputations to industry's advantage). We also offer an analysis of the strengths and weaknesses of UCI strategies and a model that situates industry CPA in the wider social, political, and economic context.

CONCLUSION

Our work confirms the similarity of CPA across UCIs and demonstrates its extensive and multi-faceted nature, the disproportionate power of corporations in policy spaces and the unacceptable conflicts of interest that characterise their engagement with policy-making. We suggest that industry CPA is recognised as a corruption of democracy, not an element of participatory democracy. Our taxonomies and model provide a starting point for developing effective solutions.

The road to achieving epidemic-ready primary health care

Millions of avoidable deaths arising from the COVID-19 pandemic emphasise the need for epidemic-ready primary health care aligned with public health to identify and stop outbreaks, maintain essential services during disruptions, strengthen population resilience, and ensure health worker and patient safety. The improvement in health security from epidemic-ready primary health care is a strong argument for increased political support and can expand primary health-care capacities to improve detection, vaccination, treatment, and coordination with public health-needs that became more apparent during the pandemic. Progress towards epidemic-ready primary health care is likely to be stepwise and incremental, advancing when opportunity arises based on explicit agreement on a core set of services, improved use of external and national funds, and payment based in large part on empanelment and capitation to improve outcomes and accountability, supplemented with funding for core staffing and infrastructure and well designed incentives for health improvement. Health-care worker and broader civil society advocacy, political consensus, and bolstering government legitimacy could promote strong primary health care. Epidemic-ready primary health-care infrastructure that is able to help prevent and withstand the next pandemic will require substantial financial and structural reforms and sustained political and financial commitment. Governments, advocates, and bilateral and multilateral agencies should seize this window of opportunity before it closes.

The benefits and burden of health financing in Indonesia: analyses of nationally representative cross-sectional data

BACKGROUND

Indonesia has committed to deliver universal health coverage by 2024. Reforming the country's health-financing system is key to achieving this commitment. We aimed to evaluate how the benefits and burden of health financing are distributed across income groups and the extent to which Indonesia has achieved equity in the funding and delivery of health care after financing reforms.

METHODS

We conducted benefit incidence analyses (BIA) and financing incidence analyses (FIA) using cross-sectional nationally representative data from several datasets. Two waves (Feb 1 to April 30, 2018, and Aug 1 to Oct 31, 2019) of the Equity and Health Care Financing in Indonesia (ENHANCE) study household survey involving 7500 households from ten of the 34 provinces in Indonesia were used to obtain health and socioeconomic status data for the BIA. Two waves (2018 and 2019) of the National Socioeconomic Survey (SUSENAS), the most recent wave (2014) of the Indonesian Family Life Survey, and the 2017 and 2018 National Health Accounts were used to obtain data for the FIA. In the BIA, we calculated a concentration index to assess the distribution of health-care benefits (-1·0 [pro-poor] to 1·0 [pro-rich]), considering potential differences in health-care need. In the FIA, we evaluated the equity of health-financing contributions by socioeconomic quintiles by calculating the Kakwani index to assess the relative progressivity of each financing source. Both the BIA and FIA compared results from early 2018 (baseline) with results from late 2019.

FINDINGS

There were 31 864 participants in the ENHANCE survey in 2018 compared with 31 215 in 2019. Women constituted 50·5% and men constituted 49·5% of the total participants for each year. SUSENAS had 1 131 825 participants in 2018 compared with 1 204 466 in 2019. Women constituted 49·9% of the participants for each year, whereas men constituted 51·1%. The distribution of health-care benefits in the public sector was marginally pro-poor; people with low income received a greater proportion of benefits from health services than people with high income between 2018 (concentration index -0·008, 95% CI -0·075 to 0·059) and 2019 (-0·060, -0·139 to 0·019). The benefit incidence in the private health sector was significantly pro-rich in 2018 (0·134, 0·065 to 0·203, p=0·0010) and 2019 (0·190, -0·192 to 0·572, p=0·0070). Health-financing incidence changed from being moderately progressive in 2018 (Kakwani index 0·034, 95% CI 0·030 to 0·038) to mildly regressive in 2019 (-0·030, -0·034 to -0·025).

INTERPRETATION

Although Indonesia has made substantial progress in expanding health-care coverage, a lot remains to be done to improve equity in financing and spending. Improving comprehensiveness of benefits will reduce out-of-pocket spending and allocating more funding to primary care would improve access to health-care services for people with low income.

FUNDING

UK Health Systems Research Initiative, UK Department of International Development, UK Economic and Social Research Council, UK Medical Research Council, and Wellcome Trust.

Defining and conceptualising the commercial determinants of health

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

Learning from pandemic responses: Informing a resilient and equitable health system recovery in Thailand

This article is part of the Research Topic 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict'. The third quarter of 2022 saw COVID-19 cases and deaths in Thailand reduced significantly, and high levels of COVID-19 vaccine coverage. COVID-19 was declared an "endemic" disease, and economic activities resumed. This paper reviews pre-pandemic health systems capacity and identifies pandemic response strengths, weaknesses and lessons that guided resilient and equitable health system recovery. Robust health systems and adaptive strategies drive an effective pandemic response. To support health system recovery Thailand should (1) minimize vulnerability and extend universal health coverage to include migrant workers and dependents; (2) sustain provincial primary healthcare (PHC) capacity and strengthen PHC in greater Bangkok; (3) leverage information technology for telemedicine and teleconsultation; (4) enhance and extend case and event-based surveillance of notifiable diseases, and for public health threats, including pathogens with pandemic potential in wildlife and domesticated animals. This requires policy and financial commitment across successive governments, adequate numbers of committed and competent health workforce at all levels supported by over a million village health volunteers, strong social capital and community resilience. A strengthened global health architecture and international collaboration also have critical roles in establishing local capacities to develop and manufacture pandemic response products through transfer of technology and know-how. Countries should engage in the ongoing Inter-government Negotiating Body to ensure a legally binding instrument to safeguard the world from catastrophic impacts of future pandemics.

Role of social capital in response to and recovery from the first wave of COVID-19 in Thailand: a qualitative study

OBJECTIVE

This study assesses the role of social capital among people and communities in response to the first wave of the pandemic in 2020.

DESIGN

Qualitative study using focus group discussions.

SETTING

Capital city (Bangkok) and the four regions (north, northeast, south and central) of Thailand.

PARTICIPANTS

161 participants of 19 focus groups with diverse backgrounds in terms of gender, profession, education and geography (urban/rural; regions). They are selected for different levels of impact from the pandemic.

FINDINGS

The solidarity among the Thai people was a key contributing factor to societal resilience during the pandemic. Findings illustrate how three levels of social capital structure-family, community and local networks-mobilised resources from internal and external social networks to support people affected by the pandemic. The results also highlight different types of resources mobilised from the three levels of social capital, factors that affect resilience, collective action to combat the negative impacts of the pandemic, and the roles of social media and gender.

CONCLUSION

Social capital plays significant roles in the resilience of individuals, households and communities to respond to and recover from the impacts of the pandemic. In many instances, social capital is a faster and more efficient response than other kinds of formal support. Social capital can be enhanced by interactions and exchanges in the communities. While face-to-face social contacts are challenged by the need for social distancing and travel restrictions, social media steps in as alternative socialisation to enhance social capital.

Point prevalence survey of antibiotic use among hospitalized patients across 41 hospitals in Thailand

Objectives

To describe the antibiotic use among hospitalized patients in Thailand.

Methods

A standardized cross-sectional point prevalence survey (PPS) modified from the WHO PPS protocol was conducted in 41 selected hospitals in Thailand. All inpatients who received an antibiotic at 9 a.m. on the survey date were enrolled. The total number of inpatients on that day was the denominator.

Results

Between March and May 2021, a total of 8958 inpatients were enumerated; 4745 inpatients received antibiotics on the day of the survey and there were 6619 prescriptions of antibiotics. The prevalence of antibiotic use was 53.0% (95% CI 51.1%-54.0%), ranging from 14.3% to 73.4%. The antibiotic use was highest among adults aged >65 years (57.1%; 95% CI 55.3%-58.9%). From 6619 antibiotics prescribed, 68.6% were used to treat infection, 26.7% for prophylaxis and 4.7% for other or unknown indications. Overall, the top three commonly used antibiotics were third-generation cephalosporins (1993; 30.1%), followed by first-generation cephalosporins (737; 11.1%) and carbapenems (703; 10.6%). The most frequently used antibiotics for community-acquired infections were third-generation cephalosporins (36.8%), followed by β-lactam/β-lactamase inhibitors (11.8%) and carbapenems (11.3%) whereas for the patients with hospital-acquired infections, the most common antibiotics used were carbapenems (32.7%), followed by β-lactam/β-lactamase inhibitors (15.7%), third-generation cephalosporins (11.7%) and colistin (11.7%). The first-generation cephalosporins were the most commonly used antibiotics (37.7%) for surgical prophylaxis. Seventy percent of the patients received surgical prophylaxis for more than 1 day post surgery.

Conclusions

The prevalence of antibiotic use among hospitalized patients in Thailand is high and one-quarter of these antibiotics were used for prophylaxis. The majority of surgical prophylaxis was inappropriately used for a long duration post operation. Therefore, it is recommended that local guidelines should be developed and implemented.

Contracting the private health sector in Thailand's Universal Health Coverage

Private sector plays an import role in health service provision, therefore the engagement of private health facilities is important for ensuring access to health services. In Thailand, two of the three public health insurance schemes, Universal Coverage Scheme and Social Health Insurance, contract with private health facilities to fill gaps of public providers for the provision of health services under Universal Health Coverage. The National Health Security Office (NHSO) and Social Security Office (SSO), which manage the schemes respectively, have designed their own contractual agreements for private facilities. We aim to understand the current situation of contracting private health facilities within UHC of the two purchasing agencies. This qualitative descriptive case study was conducted through document review and in-depth interviews with key informants to understand how they contract private primary care facilities, service types, duration of contract, standard and quality requirement and renewal and termination of contracts. Private providers make a small contribution to the service provision in Thailand as a whole but they are important actors in Bangkok. The current approaches used by two purchasers are not adequate in engaging private sector to fill the gap of public provision in urban cities. One important reason is that large private hospitals do not find public contracts financially attractive. NHSO classifies contracts into 3 categories: main contracting units, primary care units, and referral units; while SSO only contracts main contracting units. Both allows subcontracting by the main contractors. Contractual agreements are effective in ensuring mandatory infrastructure and quality standards. Both purchasers have established technical capacities to enforce quality monitoring and financial compliance although there remains room for improvement especially on identifying fraud and taking legal actions. Contracting private healthcare facilities can fill the gap of public healthcare facilities, especially in urban settings. Purchasers need to balance the right level of incentives and accountability measures to ensure access to quality of care. In contracting private-for-profit providers, strong regulatory enforcement and auditing capacities are necessary. Further studies may explore various aspects contracting outcomes including access, equity, quality and efficiency impacts.

Antimicrobial consumption in food-producing animals in Thailand between 2017 and 2019: The analysis of national importation and production data

Antimicrobial resistance (AMR) threatens health security and the economy worldwide. AMR bacteria can spread across humans, animals, food webs and the environment. Excessive use of antimicrobials in food-producing animals has been recognised as one of the main drivers of the emergence of resistant bacteria. This study aims to quantify and identify patterns of antimicrobial consumption in food-producing animals in Thailand in a three-year period (2017-2019). Milligrams of active ingredient from total volume of imported and locally manufactured products minus exports were obtained from Thai FDA. Annual population production of food-producing animals in 2017, 2018 and 2019 was compiled and validated through cooperation between the Department of Livestock Development (DLD), Department of Fisheries (DOF). The total amount of antimicrobial consumption for food-producing animals decreased 49.0% over the three-year period from 658.7 mg/PCUThailand in 2017 to 336.3 mg/PCUThailand in 2019. In 2017, the most common antimicrobials used was macrolides which was replaced by aminopenicillins and pleuromutilins in 2019, while tetracyclines was consistently common over the three-year period. Consumption of the WHO Critically Important Antimicrobials (CIA) group declined significantly over this period, from 259.0 in 2017 to 193.2 mg/PCUThailand in 2019 (a 25.4% reduction). Findings from this study were in line with national policies which curtails prudent use of antimicrobials in food-producing animals. The government should maintain the decreasing trend of consumption, in particular of the CIA category. Improving information systems which captures consumption by specific species contributes to precision of interventions to minimise prudent use in each species.

The impact of vaccine information and other factors on COVID-19 vaccine acceptance in the Thai population

Increased misinformation circulating among the population during the COVID-10 pandemic can trigger rejection to take up vaccines. This study assesses the influence of vaccine information and other factors on vaccine acceptance in the Thai population. Between March and August 2021, six rounds of cross-sectional surveys through village health volunteer networks and online channels were conducted; as well as qualitative interviews with frontline health workers, patients with chronic diseases, and religious believers and leaders. Descriptive and multiple logistic regression with 95% level of confidence were used for survey findings while deductive thematic analysis was used for in-depth interview findings. Among the total 193,744 respondents, the initial COVID-19 vaccine acceptance rate decreased from 60.3% in March 2021 to 44.0% in April 2021, then increased to 88.8% in August 2021. Participants who were able to differentiate true and false statements were 1.2 to 2.4 times more likely to accept vaccine than those who were not. Those who perceived a high risk of infection (Adjusted odds ratio; AOR = 2.6-4.7), perceived vaccine safety (AOR = 1.4-2.4), judged the importance of vaccination (AOR = 2.3-5.1), and had trust in vaccine manufacture (AOR = 1.9-3.2) were also more likely to accept the vaccine. Moreover, higher education (AOR = 1.6-4.1) and living in outbreak areas (AOR = 1.4-3.0) were significantly related to vaccine uptake, except in people with chronic diseases who tended not to accept the vaccine (AOR = 0.7-0.9). This study recommends effective infodemic management and comprehensive public communication, prioritising vulnerable groups such as those with a low level of education and people with chronic conditions. Communication through reliable channels can support higher vaccine acceptance and rapid vaccine rollout. Finally, regular monitoring of misinformation is important such as fact checking support, timely legal actions and specific debunking communication.

COP27: The Prospects and Challenges for the Middle East and North Africa (MENA)

In line with the global trend, the Middle East and North Africa (MENA) region has been growing vulnerable to the direct and indirect health effects of climate change including death tolls due to climatological disasters and diseases sensitive to climate change since the industrial revolution. Regarding the limited capacity of MENA countries to adapt and respond to these effects, and also after relative failures of the previous negotiation in Glasgow, in the upcoming COP27 in Egypt, the heads of the region's parties are determined to take advantage of the opportunity to host MENA to mitigate and prevent the worst effects of climate change. This would be achieved through mobilizing international partners to support climate resilience, a major economic transformation, and put health policy and management in a strategic position to contribute to thinking and action on these pressing matters, at least to avoid or minimize the future adverse consequences.

Effective coverage of diabetes and hypertension: an analysis of Thailand's national insurance database 2016-2019

OBJECTIVES

This study assesses effective coverage of diabetes and hypertension in Thailand during 2016-2019.

DESIGN

Mixed method, analysis of National health insurance database 2016-2019 and in-depth interviews.

SETTING

Beneficiaries of Universal Coverage Scheme residing outside Bangkok.

PARTICIPANTS

Quantitative analysis was performed by acquiring individual patient data of diabetes and hypertension cases in the Universal Coverage Scheme residing outside bangkok in 2016-2019. Qualitative analysis was conducted by in-depth interview of 85 multi-stakeholder key informants to identify challenges.

OUTCOMES

Estimate three indicators: detected need (diagnosed/total estimated cases), crude coverage (received health services/total estimated cases) and effective coverage (controlled/total estimated cases) were compared. Controlled diabetes was defined as haemoglobin A1C (HbA1C) below 7% and controlled hypertension as blood pressure below 140/90 mm Hg.

RESULTS

Estimated cases were 3.1-3.2 million for diabetes and 8.7-9.2 million for hypertension. For diabetes, all indicators have shown slow improvement between 2016 and 2019 (67.4%, 69.9%, 71.9% and 74.7% for detected need; 38.7%, 43.1%, 45.1% and 49.8% for crude coverage and 8.1%, 10.5%, 11.8% and 11.7% for effective coverage). For hypertension, the performance was poorer for detection (48.9%, 50.3%, 51.8% and 53.3%) and crude coverage (22.3%, 24.7%, 26.5% and 29.2%) but was better for effective coverage (11.3%, 13.2%, 15.1% and 15.7%) than diabetes. Results were better for the women and older age groups in both diseases. Complex interplays between supply and demand side were a key challenge. Database challenges also hamper regular assessment of effective coverage. Sensitivity analysis when using at least three annual visits shows slight improvement of effective coverage.

CONCLUSION

Effective coverage was low for both diseases, though improving in 2016-2019, especially among men and ัyounger populations. The increasing rate of effective coverage was significantly smaller than crude coverage. Health information systems limitation is a major barrier to comprehensive measurement. To maximise effective coverage, long-term actions should address primary prevention of non-communicable disease risk factors, while short-term actions focus on improving Chronic Care Model.

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

BACKGROUND

Many countries implementing pro-poor reforms to expand subsidized health care, especially for the poor, recognize that high-quality healthcare, and not just access alone, is necessary to meet the Sustainable Development Goals. As the poor are more likely to use low quality health services, measures to improve access to health care need to emphasise quality as the cornerstone to achieving equity goals. Current methods to evaluate health systems financing equity fail to take into account measures of quality. This paper aims to provide a worked example of how to adapt a popular quantitative approach, Benefit Incidence Analysis (BIA), to incorporate a quality weighting into the computation of public subsidies for health care.

METHODS

We used a dataset consisting of a sample of households surveyed in 10 provinces of Indonesia in early-2018. In parallel, a survey of public health facilities was conducted in the same geographical areas, and information about health facility infrastructure and basic equipment was collected. In each facility, an index of service readiness was computed as a measure of quality. Individuals who reported visiting a primary health care facility in the month before the interview were matched to their chosen facility. Standard BIA and an extended BIA that adjusts for service quality were conducted.

RESULTS

Quality scores were relatively high across all facilities, with an average of 82%. Scores for basic equipment were highest, with an average score of 99% compared to essential medicines with an average score of 60%. Our findings from the quality-weighted BIA show that the distribution of subsidies for public primary health care facilities became less 'pro-poor' while private clinics became more 'pro-rich' after accounting for quality of care. Overall the distribution of subsidies became significantly pro-rich (CI = 0.037).

CONCLUSIONS

Routine collection of quality indicators that can be linked to individuals is needed to enable a comprehensive understanding of individuals' pathways of care. From a policy perspective, accounting for quality of care in health financing assessment is crucial in a context where quality of care is a nationwide issue. In such a context, any health financing performance assessment is likely to be biased if quality is not accounted for.

COVID-19 public health and social measures: a comprehensive picture of six Asian countries

The COVID-19 pandemic will not be the last of its kind. As the world charts a way towards an equitable and resilient recovery, Public Health and Social Measures (PHSMs) that were implemented since the beginning of the pandemic need to be made a permanent feature of health systems that can be activated and readily deployed to tackle sudden surges in infections going forward. Although PHSMs aim to blunt the spread of the virus, and in turn protect lives and preserve health system capacity, there are also unintended consequences attributed to them. Importantly, the interactions between PHSMs and their accompanying key indicators that influence the strength and duration of PHSMs are elements that require in-depth exploration. This research employs case studies from six Asian countries, namely Indonesia, Singapore, South Korea, Thailand, the Philippines and Vietnam, to paint a comprehensive picture of PHSMs that protect the lives and livelihoods of populations. Nine typologies of PHSMs that emerged are as follows: (1) physical distancing, (2) border controls, (3) personal protective equipment requirements, (4) transmission monitoring, (5) surge health infrastructure capacity, (6) surge medical supplies, (7) surge human resources, (8) vaccine availability and roll-out and (9) social and economic support measures. The key indicators that influence the strength and duration of PHSMs are as follows: (1) size of community transmission, (2) number of severe cases and mortality, (3) health system capacity, (4) vaccine coverage, (5) fiscal space and (6) technology. Interactions between PHSMs can be synergistic or inhibiting, depending on various contextual factors. Fundamentally, PHSMs do not operate in silos, and a suite of PHSMs that are complementary is required to ensure that lives and livelihoods are safeguarded with an equity lens. For that to be achieved, strong governance structures and community engagement are also required at all levels of the health system.

Rehabilitation services and related health databases, Japan

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

Health Policy and Systems Research Capacities in Ethiopia and Ghana: Findings From a Self-Assessment

Government investment in strengthening health policy and systems research capacities is needed to enhance the generation of evidence for effective policy making. Researchers’ engagement in the policy-making process helps shape policy-relevant research and support policy-relevant decisions.

Introduction:

Health systems are complex. Policies targeted at health system development may be informed by health policy and systems research (HPSR). This study assesses HPSR capacity to generate evidence and inform policy in Ethiopia and Ghana.

Methods:

We used a mixed-methods approach including a self-administered survey at selected HPSR institutes and in-depth interviews of policy makers.

Results:

Both countries have limited capacity to generate HPSR evidence, especially in terms of mobilizing adequate funding and retaining a critical number of competent researchers who understand complex policy processes, have the skills to influence policy, and know policy makers’ demands for evidence. Common challenges are limited government research funding, rigidity in executing the research budget, and reliance on donor funding that might not respond to national health priorities. There are no large research programs in either country. The annual number of HPSR projects per research institute in Ethiopia (10 projects) was higher than in Ghana (2.5 projects), Ethiopia has a significantly smaller annual budget for health research. Policy makers in the 2 countries increasingly recognize the importance of evidence-informed policy making, but various challenges remain in building effective interactions with HPSR institutes.

Conclusion:

We propose 3 synergistic recommendations to strengthen HPSR capacity in Ethiopia and Ghana. First, strengthen researchers’ capacity and enhance their opportunities to know policy actors; engage with the policy community; and identify and work with policy entrepreneurs, who have attributes, skills, and strategies to achieve a successful policy. Second, deliver policy-relevant research findings in a timely way and embed research into key health programs to guide effective implementation. Third, mobilize local and international funding to strengthen HPSR capacities as well as address challenges with recruiting and retaining a critical number of talented researchers. These recommendations may be applied to other low- and middle-income countries to strengthen HPSR capacities.

COVID-19 Aftermath: Direction Towards Universal Health Coverage in Low-Income Countries Comment on "Health Coverage and Financial Protection in Uganda: A Political Economy Perspective"

Progressive realization of universal health coverage (UHC) requires health systems capacity to provide quality service and financial risk protection which supports access to services without financial hardship. Government health spending in low-income countries (LICs) has been low and heavily relied on external donor resources and out-of-pocket payment. This has resulted in high prevalence of catastrophic health spending or foregone care by those who cannot afford. Under fiscal constraints posed by pandemic, reforms in LICs should focus on efficiency through health resource waste reduction. Targeting the poor even with low level of health spending can make a significant health gain. Investment in primary healthcare and health workforce is the foundation for realizing UHC which cannot be postponed. Innovative tax on health hazardous products, conditional debt relief can increase fiscal space for health; while international collaboration to accelerate coronavirus disease 2019 (COVID-19) vaccine coverage can bring LICs out of acute phase of pandemic.

Living through the psychological consequences of COVID-19 pandemic: a systematic review of effective mitigating interventions

OBJECTIVE

This review assesses interventions and their effectiveness in mitigating psychological consequences from pandemic.

METHOD

Published English literatures were searched from four databases (Medline, PubMed, Embase and PsycINFO) from January 2020 and September 2021. A total of 27 papers with 29 studies (one paper reported three studies) met inclusion criteria. Cochrane risk-of-bias tool is applied to assess the quality of all randomised controlled trials (RCT).

RESULTS

All studies were recently conducted in 2020. Publications were from high-income (13, 44.8%), upper middle-income (12, 41.4%) and lower middle-income countries (3, 10.3%) and global (1, 3.5%). Half of the studies conducted for general population (51.7%). One-third of studies (8, 27.6%) provided interventions to patients with COVID-19 and 20.7% to healthcare workers. Of the 29 studies, 14 (48.3%) were RCT. All RCTs were assessed for risk of biases; five studies (15, 35.7%) had low risk as measured against all six dimensions reflecting high-quality study.Of these 29 studies, 26 diagnostic or screening measures were applied; 8 (30.9%) for anxiety, 7 (26.9%) for depression, 5 (19.2%) for stress, 5 (19.2%) for insomnia and 1 (3.8%) for suicide. Measures used to assess the baseline and outcomes of interventions were standardised and widely applied by other studies with high level of reliability and validity. Of 11 RCT studies, 10 (90.9%) showed that anxiety interventions significantly lowered anxiety in intervention groups. Five of the six RCT studies (83.3%) had significantly reduced the level of depression. Most interventions for anxiety and stress were mindfulness and meditation based.

CONCLUSIONS

Results from RCT studies (11%, 78.6%) were effective in mitigating psychological consequences from COVID-19 pandemic when applied to healthcare workers, patients with COVID-19 and general population. These effective interventions can be applied and scaled up in other country settings through adaptation of modes of delivery suitable to country resources, pandemic and health system context.

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

BACKGROUND

Health, social and economic crises triggered by the Coronavirus disease pandemic (COVID-19) can derail progress and achievement of the Sustainable Development Goals. This commentary analyses the complex nexus of multi-dimensional impacts of the pandemic on people, prosperity, planet, partnership and peace. From our analysis, we generate a causal loop diagram explaining these complex pathways and proposed policy recommendations.

MAIN TEXT

Health systems, health and wellbeing of people are directly affected by the pandemic, while impacts on prosperity, education, food security and environment are indirect consequences from pandemic containment, notably social measures, business and school closures and international travel restrictions. The magnitude of impacts is determined by the level of prior vulnerability and inequity in the society, and the effectiveness and timeliness of comprehensive pandemic responses.

CONCLUSIONS

To exit the acute phase of the pandemic, equitable access to COVID-19 vaccines by all countries and continued high coverage of face masks and hand hygiene are critical entry points. During recovery, governments should strengthen preparedness based on the One Health approach, rebuild resilient health systems and an equitable society, ensure universal health coverage and social protection mechanisms for all. Governments should review progress and challenges from the pandemic and sustain a commitment to implementing the Sustainable Development Goals.

Thailand Achievement of SDG Indicator 4.2.1 on Early Child Development: An Analysis of the 2019 Multiple Indicator Cluster Survey

The early years of a child’s life are the foundation for their future capability development. Poor health, hunger, poverty, low parental education, lack of parental interaction, high screen time, and poor housing environment hamper their development. There is little evidence of a link between early child development (ECD) and sociodemographic factors in Thailand. In response to monitoring the achievement of SDG target 4.2.1 (the proportion of young children who are developmentally on track in health, learning and psychosocial well-being) as required by all UN Member States, this study analyses the prevalence of appropriate levels of ECD and its correlates of Thai children aged 3 to 4 years. A cross-sectional study of the 6th Multiple Indicator Cluster Survey (MICS) data in 2019 conducted by the National Statistical Office was employed. Face-to-face interviews with mothers and/or legal guardians were conducted. A total of 5787 children aged 3 to 4 were enrolled in this study. The majority of participants, approximately 92.3%, had achieved an appropriate level of ECD index, defined as children who were developmentally on track in at least three out of these four domains: cognitive, physical, social, and learning. Multivariate logistic regression showed that girls had a higher appropriate development index than boys (Adjusted Odds Ratio [AOR] = 1.56, 95% Confidence Interval [95% CI] 1.28–1.90; children living in the 5th wealth quintile had a higher appropriate index than those in a less well-off family the first wealth quintile (AOR = 2.92, 95% CI: 1.86–4.58. Univariate logistic regression showed children living with parents achieving post-secondary education had a significantly greater appropriate index than children living with parents completing secondary education or below (Crude OR = 1.95, 95% CI 1.47–2.58); children who had appropriate parental interactions of more than four out of six interactions, had a significantly higher chance of having an appropriate index than less than four interactions (Crude OR = 1.52, 95% CI 1.14–2.04). Multi-sectoral policies to support child development in low socio-economic households should be strengthened. In addition, family and community should promote parental interactions through reading and playing with young children. Future studies which directly measure ECD in conjunction with regular monitoring through MICS are recommended.

Universal access to comprehensive COVID-19 services for everyone in Thailand

Despite Thailand having had universal health coverage (UHC) with comprehensive benefit packages since 2002, services are neither listed nor budget earmarked for COVID-19 responses. Policy decisions were made immediately after the first outbreak in 2020 to fully fund a comprehensive benefit package for COVID-19. The Cabinet approved significant additional budget to respond to the unfolding pandemic. The comprehensive benefit package includes laboratory tests, contact tracing, active case findings, 14-day quarantine measures (including tests, food and lodging), field hospitals, ambulance services for referral, clinical services both at hospitals and in home and community isolation, vaccines and vaccination cost, all without copayment by users. No-fault compensation for adverse events or deaths following vaccination is also provided. Services were purchased from qualified public and private providers using the same rate, terms and conditions. The benefit package applies to everyone living in Thailand including Thai citizens and migrant workers. A standardised and comprehensive COVID-19 benefit package for Thai and non-Thai population without copayment facilitates universal and equitable access to care irrespective of capacity to pay and social status and nationality, all while aiming to supporting pandemic containment. Making essential services available, notably laboratory tests, through the engagement of qualified both public and private sectors boost supply side capacity. These policies and implementations in this paper are useful lessons for other low-income and middle-income countries on how UHC reinforces pandemic containment.

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

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

Equity of health financing in Indonesia: A 5-year financing incidence analysis (2015-2019)

BACKGROUND

In 2014, Indonesia launched a single payer national health insurance scheme with the aim of covering the entire population by 2024. The objective of this paper is to assess the equity with which contributions to the health financing system were distributed in Indonesia over 2015 - 2019.

METHODS

This study is a secondary analysis of nationally representative data from the National Socioeconomic Survey of Indonesia (2015 - 2019). The relative progressivity of each health financing source and overall health financing was determined using a summary score, the Kakwani index.

FINDINGS

Around a third of health financing was sourced from out-of-pocket (OOP) payments each year, with direct taxes, indirect taxes and social health insurance (SHI) each taking up 15 - 20%. Direct taxes and OOP payments were progressive sources of health financing, and indirect tax payments regressive, for all of 2015 - 2019. SHI contributions were regressive except in 2017 and 2018. The overall health financing system was progressive from 2015 to 2018, but this declined year by year and became mildly regressive in 2019.

INTERPRETATION

The declining progressivity of the overall health financing system between 2015 - 2019 suggests that Indonesia still has a way to go in developing a fair and equitable health financing system that ensures the poor are financially protected.

FUNDING

This study is supported through the Health Systems Research Initiative in the UK, and is jointly funded by the Department of International Development, the Economic and Social Research Council, the Medical Research Council and the Wellcome Trust.

Self-Reported Parental Interactions through Play with Young Children in Thailand: An Analysis of the 2019 Multiple Indicator Cluster Survey (MICS)

Parental interactions through play contributes significantly to child development of cognitive and executive functioning skills. In Thailand, there is little evidence of factors contributing to parental–child interactions. In response to SDG target 4.2.3 monitoring (the percentage of children under 5 years experiencing positive and stimulating home learning environments), this study aimed to assess the prevalence and profile of parental interactions with their children under the age of five. We analysed data from the 6th Multiple Indicator Cluster Survey (MICS) conducted by the National Statistical Office in 2019. Face-to-face interviews with mothers and/or legal guardians were conducted. A total of 8856 children under the age of five were enrolled in this survey. Most participants, 90.3%, had engaged in at least four out of six activities with their children. Multivariate logistic regression analysis showed that children raised by parents with secondary or post-secondary educations had a significantly greater chance to have parental interactions than children raised by parents who completed primary education (adjusted odds ratio (AOR) = 1.66, and AOR = 2.34 for secondary and post-secondary education). Children who possessed three or more children’s books and had experience of toy play had a significantly higher chance of having parental interactions (AOR = 3.08 for book possessing, and AOR = 1.50 for the experience of toy play). Children who spent 1–3 h daily screen time had a significantly lower chance of having parental interactions than those who spent less than one hour of screen time (AOR = 0.67). In conclusion, with the emerging influence of digital technology, we recommend family and community promote parental interactions through play with young children.

Exclusive Breastfeeding Experiences of Thai Mothers in Metropolitan Bangkok

Introduction

In 2019, only 14% of mothers in Thailand performed six-month exclusive breastfeeding. This study sought to understand the pathways that mothers in Bangkok Metropolitan took to achieve successful six-month exclusive breastfeeding.

Methods

A total of 50 mothers living in Bangkok with children aged 6–12 months, who achieved and not achieved 6-month exclusive breastfeeding, were recruited for in-depth interviews during February to July 2020. Inductive thematic analysis of participants’ viewpoints was applied for data analysis and interpretation.

Results

Four themes that contributed to six-month exclusive breastfeeding were i)  maternal breastfeeding self-efficacy;  ii)  support provided by family members;  iii)  engagement with and support from healthcare professionals; and iv)  employers’ support and workplace environments. Mothers with strong breastfeeding intentions and “perceived capability” to succeed at breastfeeding tended to prioritize breastfeeding and overcome and cope well with unforeseen breastfeeding challenges. Supportive family members, who were convinced of the benefits of breastfeeding, engaged in maternal decision-making, and provided optimal support, contributed to successful exclusive breastfeeding. Health professionals were key in supporting mothers throughout pregnancy until the postpartum period. Lactating-mother-friendly working conditions, flexible working hours and enabling workplace environments, including the provision of breastfeeding breaks and a dedicate space for breast milk expression, were enabling factors for successful exclusive breastfeeding among working mothers.

Conclusion

We recommend that all mothers and their family members are fully informed and convinced of the benefit from breastfeeding and trained with practical skill during their visit to antenatal care clinics. These interventions aim to develop mothers’ self-efficacy for breastfeeding and to prepare them to manage common breastfeeding challenges. Health professionals should provide regular follow-up and counseling sessions on breastfeeding practices to mothers and families throughout the lactating period, especially working mothers for breastfeeding continuation after resume to work. Enhanced societal collective actions such as breastfeeding-friendly policy in workplace, including breastfeeding break-time and corner, can create enabling environments for successful exclusive breastfeeding.