Thailand effective coverage of diabetes and hypertension: challenges and solutions

BackgroundIncreased Disability Adjusted Life Year (DALY) of diabetes and hypertension draws policy attention to improve effective coverage. This study assesses effective coverage of the two conditions in Thailand between 2016 and 2019.MethodWe estimated total diabetes and hypertension cases using age and sex specific prevalence rates for respective populations. Individual data from public insurance databases (2016-2019) were retrieved to estimate three indicators: detected need (diagnosed/total estimated cases), crude coverage (received health services/total estimated cases) and effective coverage (controlled/total estimated cases). Controlled diabetes was defined as Haemoglobin A1C (HbA1C) below 7% and controlled hypertension as blood pressure below 140/90 mmHg. In-depth interview of 85 multi-stakeholder key informants was conducted to identify challenges to better effective coverage.FindingsIn 2016-2019, among Universal Coverage Scheme members residing outside Bangkok, estimated cases were around 3.1-3.2 million for diabetes and 8.7-9.2 million for hypertension. For diabetes services, all three indicators have shown slow increase over the four years (67.4%, 69.9%, 71.9%, and 74.7% for detected need; 38.7%, 43.1%, 45.1%, 49.8% for crude coverage; and 8.1%, 10.5%, 11.8%, 11.7% for effective coverage). For hypertension services, the performance was poorer for detection (48.9%, 50.3%, 51.8%, 53.3%) and crude coverage (22.3%, 24.7%, 26.5%, 29.2%) but was better for effective coverage (11.3%, 13.2%, 15.1%, 15.7%) than diabetes service. For both diseases, the estimates were higher for the females and older age groups than their counterparts. Complex interplays between supply and demand side barriers were a key challenge. Database challenges remain which hamper regular assessment of effective coverage.RecommendationsGiven the increased diabetes and hypertension prevalence, strategic recommendations cover long term actions for primary prevention of known risk factors as unhealthy diet and sedentary behaviour. Short term actions aim to improve effective coverage through the application of Chronic Care Model, increase attention to non-pharmacological intervention and patient empowerment.

The Effective Coverage of Maternal and Child Primary Health Care Services and its Relationship with Health Expenditures: An Analysis at Sub-National Level in Iran

Backgrounds: Measuring the effective coverage of essential health services is necessary for monitoring progress towards Universal Health Coverage (UHC). So, this study aimed to assess the geographic variations in key maternal and child indicators (as essential health services) provided at the primary health care (PHC) level in terms of their crude and effective coverage, and also to investigate the relationship between the effective coverage and health expenditures in the national and sub-national level of Iran. Methods: This study was a secondary analysis, which analyzed the spatial distribution of six key maternal and child health indicators using the latest available data of Demographic Health Survey-DHS (2010) across 31 provinces of Iran. Moreover, two composite indicators, the crude, and the effective coverage were calculated. The median cut-off was used to compare provinces situations. Furthermore, the relationship between coverage indicators and total health expenditure per capita was evaluated. Results: At the national level, the crude and the effective composite coverage were 89.56 and 77.22%, respectively. Also, the medians of composite crude and effective service coverage in the provinces were 90.25 and 77.62%, respectively. There was no significant difference between urban and rural areas. Conclusions: in this study, we found that there is a significant gap between crude and effective service coverage of the selected indicators. Overall, coverage indicators of maternal services were higher compared to those of children. In addition, geographic variations in key Indicators of maternal and child health services coverage among provinces were almost high. Although the services are free of charge in the rural areas, they did not have higher coverage than those of urban areas. PHC services in Iran are far away from reaching the desired coverage and achieving UHC.

Impact of imprecise household location on effective coverage estimates generated through linking household and health provider data by geographic proximity: a simulation study

Background Geographic proximity is often used to link household and health provider data to estimate effective coverage of health interventions. Existing household surveys often provide displaced data on the central point within household clusters rather than household location. This may introduce error into analyses based on the distance between households and providers. Methods We assessed the effect of imprecise household location on quality-adjusted effective coverage of child curative services estimated by linking sick children to providers based on geographic proximity. We used data on care-seeking for child illness and health provider quality in Southern Province, Zambia. The dataset included the location of respondent households, a census of providers, and data on the exact outlets utilized by sick children included in the study. We displaced the central point of each household cluster point five times. We calculated quality-adjusted coverage by assigning each sick child to a provider’s care based on three measures of geographic proximity (Euclidean distance, travel time, and geographic radius) from the household location, cluster point, and displaced cluster locations. We compared the estimates of quality-adjusted coverage to each other and estimates using each sick child’s true source of care. We performed sensitivity analyses with simulated preferential care-seeking from higher-quality providers and randomly generated provider quality scores. Results Fewer children were linked to their true source of care using cluster locations than household locations. Effective coverage estimates produced using undisplaced or displaced cluster points did not vary significantly from estimates produced using household location data or each sick child’s true source of care. However, the sensitivity analyses simulating greater variability in provider quality showed bias in effective coverage estimates produced with the geographic radius and travel time method using imprecise location data in some scenarios. Conclusions Use of undisplaced or displaced cluster location reduced the proportion of children that linked to their true source of care. In settings with minimal variability in quality within provider categories, the impact on effective coverage estimates is limited. However, use of imprecise household location and choice of geographic linking method can bias estimates in areas with high variability in provider quality or preferential care-seeking.

Methodological considerations for linking household and healthcare provider data for estimating effective coverage: a systematic review

ObjectiveTo assess existing knowledge related to methodological considerations for linking population-based surveys and health facility data to generate effective coverage estimates. Effective coverage estimates the proportion of individuals in need of an intervention who receive it with sufficient quality to achieve health benefit.DesignSystematic review of available literature.Data sourcesMedline, Carolina Population Health Center and Demographic and Health Survey publications and handsearch of related or referenced works of all articles included in full text review. The search included publications from 1 January 2000 to 29 March 2021.Eligibility criteriaPublications explicitly evaluating (1) the suitability of data, (2) the implications of the design of existing data sources and (3) the impact of choice of method for combining datasets to obtain linked coverage estimates.ResultsOf 3805 papers reviewed, 70 publications addressed relevant issues. Limited data suggest household surveys can be used to identify sources of care, but their validity in estimating intervention need was variable. Methods for collecting provider data and constructing quality indices were diverse and presented limitations. There was little empirical data supporting an association between structural, process and outcome quality. Few studies addressed the influence of the design of common data sources on linking analyses, including imprecise household geographical information system data, provider sampling design and estimate stability. The most consistent evidence suggested under certain conditions, combining data based on geographical proximity or administrative catchment (ecological linking) produced similar estimates to linking based on the specific provider utilised (exact match linking).ConclusionsLinking household and healthcare provider data can leverage existing data sources to generate more informative estimates of intervention coverage and care. However, existing evidence on methods for linking data for effective coverage estimation are variable and numerous methodological questions remain. There is need for additional research to develop evidence-based, standardised best practices for these analyses.

Digital tools of territorial communities in improving the quality of services to the population

The article considers the main aspects of the introduction of digital tools of local communities and their role in improving the quality of services to the population.The purpose of the study is an analysis of the ways and scope of use of digital tools by the United Territorial Communities (UTC) in it's activities, in particular to: involve residents in decision-making processes in these communities and improve the quality of services to the population - as a result of UTC cooperation through digital communications. The study focuses on interaction with residents of relevant UTCs, and on the cooperation of local communities in improving the quality of services to the population. Peculiarities and main aspects of digital interaction with the residents of the territorial community and effective coverage of the government's activities with digital tools are identified. It is proposed as a mechanism of cooperation of UTC by means of digital communications to improve the quality of services to the population of territorial communities implementation of the digital communication strategy.

Patterns and determinants of effective coverage of routine maternal and newborn health visits in Nepal: Analysis of the 2016 Demographic and Health Survey

Background Antenatal care (ANC) visits, institutional delivery, and postnatal care (PNC) visits are vital for improved health of mothers and newborns. Access of these routine maternal and newborn health (MNH) visits have increased in the last few decades in Nepal; however, little is known on the effective uptake (including timely, skilled, frequent, and adequate care) of essential MNH interventions during those visits. This study examined the patterns of effective coverage (EC) of routine MNH visits and their determinants in Nepal. Methods A secondary analysis was conducted taking data from the Nepal Demographic and Health Survey (NDHS) 2016. The study included 1,978 women aged 15–49 years who had a live birth in the two years preceding the survey. Three outcome variables were EC of i) at least 4ANC visits, ii) institutional delivery, and iii) first PNC visit for newborns and mothers within 48 hours of childbirth. The independent variables included several structural, intermediary and health system factors. Binomial logistic regression analysis was conducted, and the magnitude of EC was reported as odds ratio (OR) with 95% confidence intervals (CIs). The statistical significance level was set at p<0.05 (two-tailed).Results The effective coverage of 4ANC visits, institutional delivery, and PNC visit was 52%, 33% and 23%, respectively. Women with advantaged ethnicity were more likely and women living in province six, who speak the Maithili language, who had high birth order (≥4) were less likely to have good EC of MNH visits compared to their reference categories. Women who had access to a bank account, completed at least 4ANC visits or had caesarian-section delivery were more likely to have good EC of MNH visits. Women who perceived problem if not seen by female providers had poor EC of MNH visits compared to their reference counterpart. Conclusions Women with ethnic and social disadvantages and remote areas had poor EC of MNH visits. Continuous monitoring of EC of MNH visits is vital, especially among women with markers of disadvantages. Policies and programs should focus on increasing the uptake of essential MNH interventions, especially among women with social disadvantages and those living in remote areas.

The Cost-Effectiveness of Existing and Hypothetical Iron Fortification Programs in Haiti

Objectives Our objectives were to estimate apparent intake of iron in Haiti, to assess the adequacy of iron intake among women of reproductive age (WRA), and to model the cost-effectiveness of fortifying alternative food vehicles for reducing inadequate intake. Methods We analyzed the most recent Haiti household food consumption data (2012 ECVMAS) to estimate adequacy of apparent iron intake from dietary sources (using the adult male equivalent method; assuming 10% absorption) and modeled the impacts of fortifying currently mandated (wheat flour, applying local data on current compliance) and hypothetical (bouillon and rice) food vehicles on reductions in the prevalence of inadequate iron intake (effective coverage). We built activity-based cost models to estimate large scale food fortification (LSFF) program establishment and management costs, based on key informant interviews and on published cost estimates from other settings adapted to fit the Haitian case. Results The prevalence of inadequate dietary intake of iron among WRA was 79% (100% among pregnant women). Iron-fortified wheat flour was the most cost-effective vehicle: $4.32 and $4.75 per WRA-year effectively covered at current (75% of flour fortified to the standard of 30 mg/kg) and target (90% fortified to the standard) fortification levels. Fortified wheat flour effectively covered 11–13% of non-pregnant WRA, but almost no pregnant women. Although bouillon was consumed by &gt; 98% of households, low estimated iron absorption from fortified bouillon (2%) led to low effective coverage. Iron-fortified rice (90% fortified at 120 mg/kg) was predicted to effectively cover the largest number of WRA (reducing inadequate intake to ∼30%), but at a cost of $7.80 per WRA-year effectively covered. Conclusions Of the food vehicles modeled, wheat flour was the most cost-effective for reducing inadequate iron intake. Modeling iron fortification of individual and combinations of food vehicles showed that well-designed LSFF programs can contribute to improving iron status among non-pregnant women, but eliminating inadequate iron intake among all WRA will require complementary iron interventions. Funding Sources This work was supported by grants to UC Davis from the Global Alliance for Improved Nutrition (GAIN) and to Partners of the Americas from the United States Agency for International Development (USAID).