Integrated Treatment Programme for Alcohol Related Problems in Community Hospitals, Songkhla Province of Thailand : A Social Return on Investment

Abstract

Objective: To estimate the impacts and social value relative to the cost of the Integrated Management of Alcohol Intervention Program in the Health Care System (i-MAP), which provides screening and interventions based on drinking risk level, using a Social Return on Investment (SROI) analysis. Methods: A mixed-method study was conducted at four i-MAP piloted districts (Singhanakhon, Satingphra, Bangklam and Rattaphum) in Songkhla province of Thailand. Data was collected between January and April 2019. The qualitative portion (part 1) of the study involved identification and in-depth interviews with stakeholders who were direct beneficiaries of the i-MAP to identify relevant outcomes from the programme to construct a follow-up questionnaire. The quantitative portion (part 2) of the study was conducted among a sample of current drinkers aged 15 years or older and their families at community hospitals in the piloted district. An activity-based costing analysis was conducted at baseline and a follow-up survey was performed 6 months after completion of the programme. The selected outcomes, both tangible and intangible, were monetized using appropriate financial proxies, projected to 5 years and deducted by counterfactuals and discount rate. Social benefit to cost (SROI) ratiosamong treatment subgroups were calculated under basic and alternative scenarios (one year timeframe, different discount rates, proportions of achieved outcomes and counterfactual values) using one-way and probabilistic sensitivity analyses. Results: In qualitative portion of the study, identified direct beneficiaries of the i-MAP included drinkers, families, healthcare providers, local communities and third parties in the wider society such as legal authorities and labour markets. In-depth interviews with representative groups of each stakeholder could identify the tangible and intangible outcomes of the i-MAP, including outcomes to the drinkers ("improved self-esteem", "better decision-making ability", "better emotional control" "receive more support from family" and "increased interaction with community"), outcomes to the families ("less argument within family", "reduced stress" and "reduced burden”), an outcome to the local community ("empathic attitude towards the drinkers”), outcomes to the healthcare providers (avoided service utilization from alcohol-related diseases and injuries), and outcomes to the wider society (avoided alcohol-related crimes and accidents, and productivity gain). The quantitative portion of the study was conducted among 113 screened drinkers (29 low-risk, 43 high-risk, and 41 dependent drinkers) who consecutively received i-MAP at the hospitals. The average i-MAP cost (in 2017 Thai baht, where US$1.00 = 33.1 baht) per individual with low-risk drinking, high-risk drinking, dependent drinking without detoxification, and dependent drinking with detoxification were 547 baht 2,961 baht, 3,804 baht and 9,681 baht, respectively. The annual cost of implementation calculated from the expected number of drinkers was estimated to be 25.5 million baht per hospital, of which 41% and 26% pertained to staff labor cost and patient opportunity cost, respectively. Patient factors associated with higher individual i-MAP cost were more episodes of lifetime history alcohol treatment, and alcohol-related functional disturbance more than 20 days out of the previous 365 days. After six months, 42% and 46% of high-risk and dependent drinkers, respectively, reduced their drinking to low risk or abstinence levels. Approximately 20-30% of high-risk drinkers experienced improvement in selected psychosocial outcomes, with "increased interaction with community" as the least common achieved outcome by this group (17%). On the other hand, approximately 20-30% of high-risk drinkers experienced improvement in selected psychosocial outcomes, except for "increased interaction with community” and “improved self-esteem" which were achieved by only 3% and 8% of dependent drinkers, respectively. Among families of both drinking groups, "reduced stress" was the most common outcome experienced, while "reduced burden" was the least common one. The social value created by the programme at 5 years, after deduction by counterfactuals and discount rate, was estimated at 51 million baht, most of which was attributed to broader gains to society, such as productivity gains and averted crime costs, and drinkers. Under basic assumptions, the SROI ratio was estimated at 2:1, which indicates that the i-MAP was expected to generate social value at 2 baht for every baht invested. The SROI ratios under various alternatives ranged between 1.3 and 2.4 baht per every baht invested. Subgroup analyses suggested that the SROI ratio for high-risk drinkers was twice that for dependent drinkers (2.8 vs. 1.5). The probabilistic sensitivity analysis showed that more than 99% of the simulated treatments for both high-risk and dependent groups yielded benefits beyond the corresponding costs. Conclusion: By considering a societal perspective, the i-MAP demonstrated a social value of twice its investment cost. There is therefore potential for the programme to be implemented nationwide investment. Keywords: alcohol use disorder, primary care service, social return on