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Economic valuation of informal care in Asia: A case study of care for disabled stroke survivors in Thailand
Social Science & Medicine 69 (2009) 648–653
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Economic valuation of informal care in Asia: A case study of care for disabled stroke survivors in Thailand Arthorn Riewpaiboon a, *, Wachara Riewpaiboon b, Kanyarat Ponsoongnern a, Bernard Van den Berg c, d a
Division of Social and Administrative Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand Health Promotion Program for People with Disability, Sirindhorn National Medical Rehabilitation Center, Ministry of Public Health, Thailand c Department of Health Sciences, VU University Amsterdam, The Netherlands d Department of Economics and Business and CRES, Universitat Pompeu Fabra, Barcelona, Spain b
a r t i c l e i n f o
a b s t r a c t
Article history: Available online 1 July 2009
This study values informal care for disabled stroke survivors in Thailand. It applies the conventional recommended opportunity cost method to value informal care in monetary terms. Data were collected by means of face-to-face interviews conducted during 2006. The sample consisted of 101 disabled persons who had suffered a stroke at least six months prior to the interview, and who had a functional status score of less than 95 as measured by the Barthel Index. Average monthly time spent on informal care was 94.6 hours, and the major source of opportunity cost was forgone unpaid work (43.5%). The average monthly monetary value of informal care was 4642.6 baht, based on 2006 prices. This study shows that providing informal care involves a substantial opportunity cost, implying a hidden value to Thai society. Ó 2009 Elsevier Ltd. All rights reserved.
Keywords: Informal care Economic value Cost of illness Stroke Disabled persons Caregivers Thailand
Introduction Cerebrovascular disease, or stroke, is a major public health problem associated with mortality, and a major cause of disability in elderly people in many countries (Bomia, Helmkamp, & Lyons, 2007; Fisher, 2008; Kalra & Ratan, 2008). Based on Disability Adjusted Life Year (DALY) calculations in Thailand, in 1999 stroke was ranked the second and third greatest burden of disease in women and men, respectively (The Thai Working Group on Burden of Disease and Injuries, 2002). Disabled stroke survivors, who mainly depend on others for their activities of daily living, can impose a significant social and economic burden on society. After a stroke attack, some survivors have functional impairment and disability; rehabilitation is consequently important. However, conventional hospital rehabilitation services are expensive, as described in a review by Evers, Ament, and Blaauw (2000). Therefore, home-based and/or community-based rehabilitation have been developed as cost-saving or complementary alternatives (Anderson, Mhurchu, Brown, & Carter, 2002; Anderson et al., 2000). In Thailand, health care for stroke survivors is first based in a hospital’s acute inpatient department, where the duration of care
* Corresponding author. Faculty of Pharmacy, Mahidol University, 447 Sri Ayutthaya Road, Ratchathevi, Bangkok, Thailand. Tel.: þ66 81 8290578; fax: þ66 2 6448694. E-mail address: [email protected] (A. Riewpaiboon). 0277-9536/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2009.05.033
ends when the patient’s medical or surgical condition becomes stable. The functional problem of survivors who need further care for rehabilitation can be addressed by their becoming inpatients. Some disabled stroke survivors can continue their rehabilitation program by utilizing outpatient department services. Due to limitations in supply, such rehabilitation services are generally not offered at district hospitals. Therefore, it is likely that most stroke survivors will receive care at home from family caregivers. Occasionally they will be visited by health care professionals, complemented by outpatient follow-up visits. ‘‘Informal care’’ is the name given to the care provided by people from a care recipient’s social network: family, friends, acquaintances or neighbors (Brouwer, Rutten, & Koopmanschap, 2001). Alternatively, it is defined as a nonmarket composite commodity consisting of heterogeneous parts produced (paid or unpaid) by one or more members of the social environment of the care recipient as a result of the care demands of the care recipient (Van den Berg, Brouwer, & Koopmanschap, 2004). There might be informal caregivers getting payments according to the second definition but this does not imply that informal care is a free resource from an economic perspective. Providing informal care entails opportunity costs in various forms: e.g. giving up paid work time or leisure time; investing energy; and, in some cases, possibly even making fewer social contacts (Brouwer, van Exel, Koopmanschap, & Rutten, 1999). Not determining the economic value of informal care implicitly assumes that providing informal care does not involve opportunity
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costs to caregivers and society. Cost calculations and economic evaluations excluding informal care might suggest interventions to be cost-saving or cost-effective, whereas this result would simply be due to the exclusion of informal care from the analysis (Van den Berg et al., 2004; Van den Berg & Spauwen, 2006). Determining the economic value of informal care is also important in formulating health policy, because it reveals societies’ opportunity costs of caring for people with various diseases, and what could be saved by eradicating them (Byford, Torgerson, & Raftery, 2000). Values of informal care for stroke victims have been estimated mainly in Western countries, including Australia, Sweden, the United Kingdom, and the United States (Claesson, GosmanHedstrom, Johannesson, Fagerberg, & Blomstrand, 2000; Dewey et al., 2002; Hickenbottom et al., 2002; Patel, Knapp, Perez, Evans, & Kalra, 2004) [see Table 1 for an overview]. They were determined using opportunity cost or proxy good methods. The opportunity cost method values caregivers‘ paid work, unpaid work, and leisure time forgone in providing informal care by estimating forgone wages. The proxy good method values informal care time by the wage rate of close substitutes in the labor market, e.g. professional caregivers or house workers. In Asia, based on our knowledge, the economic value of informal care has never been estimated. This paper attempts to fill part of this gap in the literature by estimating the economic value of informal care for disabled stroke survivors in Thailand. We apply the conventionally recommended opportunity cost method to value informal care in monetary terms. Although alternative methods have been proposed and applied to value informal care – such as proxy good (Van den Berg et al., 2006); contingent valuation (Van den Berg, Bleichrodt, & Eeckhoudt, 2005); conjoint analysis (Van den Berg, Al, Brouwer, van Exel, & Koopmanschap, 2005); or the well-being valuation method (Van den Berg & Ferrer-i-Carbonell, 2007) – the opportunity cost method is the most advocated and the most often used (Van den Berg et al., 2006). We mainly follow the approach of Van den Berg et al. (2006) as a first step in determining the economic value of informal care for disabled stroke survivors in Thailand.
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selected as it is the only national center for medical rehabilitation located in central Thailand. It is a tertiary hospital with 48 patient beds. Buriram Hospital is a 590-bed regional hospital, one of 25 regional hospitals in Thailand. Buriram is in the northeast, which is the poorest area of Thailand. The hospitals were selected based on being representative of the central and northeastern regions, and because the administrators permitted us to access their data. The study received ethical approval from both study hospitals. We approached informal caregivers through disabled stroke survivors who were registered at the study hospitals during the period from January 1, 2001, to December 31, 2005. The retrospective study period was extended to five years to include enough respondents. Interviews were conducted at least six months after stroke attack, because disability is normally determined six months after a stroke (Kwon, Hartzema, Duncan, & Lai, 2004; Loewen & Anderson, 1990; Uyttenboogaart, Stewart, Vroomen, De Keyser, & Luijckx, 2005; Van Swieten, Koudstaal, Visser, Schouten, & Van Gijn, 1998). All informal caregivers of stroke survivors with the following characteristics were included in the study: Stroke survivors with diagnosis classified by the International Classification of Diseases, 10th Revision (ICD-10), code I60-I69 (cerebrovascular diseases) and G81 (hemiplegia) (World Health Organization, 1992). Stroke survivors having suffered a stroke at least six months prior. Stroke survivors having a functional status of not more than 95 out of 100, as measured by the Barthel Index. This indicates the degree of disability (Mahoney & Barthel, 1965; Prasat Neurological Institute, 2002). Stroke survivors who had been hospitalized for more than one week at the time of the interview were excluded. This is because, during hospitalization, the informal care activities are different from the usual. Data collection and management
Methods Study sample Our study sample consisted of the Sirindhorn National Medical Rehabilitation Center (SNMRC) and Buriram Hospital. SNMRC was
Data collection began with stroke survivor selection. Two interviewers (the third author and a hospital pharmacist studying for a master’s degree in Pharmacy Administration) were trained by the first and second authors. Face-to-face interviews were conducted at the study sites if the survivors had entered the study sites
Table 1 Overview of economic valuations of informal care for stroke victims. Study
Opportunity cost method Paid work
Unpaid work
Proxy good method Leisure
Not mentioned
Claesson et al., 2000
–
–
O
–
Hickenbottom et al., 2002
–
–
–
O
Dewey et al., 2002
–
–
O
–
Patel et al., 2004
–
–
–
O
Van den Berg et al., 2006
O
O
O
–
Shadow price
Shadow price
35% of gross wage rate (38 SEK/hour) National median wage for home health aid ($8.20/hour) 35% of average Australian weekly wage (A$5.86/hour)
–
UK minimum wage rate (£3.53/hour) Caregiver’s hourly wage and shadow price
*$1.00 ¼ £0.67 ¼ A$1.32 (Australian dollar) ¼ 6.70SEK (Swedish krona) ¼ ] 0.78 = 37.93 Thai baht (in 2006). HDL ¼ Household activities of daily living, e.g. preparing food, shopping, doing chores. ADL ¼ Activities of daily living, e.g. toilet activities, eating. IADL ¼ Instrumental activities of daily living, e.g. traveling outside the house.
– *Unqualified health care worker (A$11.20/hour) *Nursing employees at level 2 (A$13.45/hour) Social service home help worker (£10.61/hour) Professional home care: *HDL (]8.53/hour) *ADL, IADL (]32.67/hour)
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during the month of the interview period; otherwise, interviews were conducted at the survivors’ homes. If a disabled person had more than one caregiver, each of them was interviewed. In case not all caregivers could be accessed, an estimate of total caregiving time was collected from the primary caregiver. The interviews were conducted during August-October 2006. To control quality of the data, data management activities were performed. At the end of each interview, completeness of data collection was checked by the researcher. To avoid human error, double data entry was performed by different data enterers into Microsoft Excel files. Time measurement The first pieces of information necessary for the valuation of informal care using the opportunity cost method are the sources and amounts of time forgone in order to provide informal care. We asked caregivers how much time they spent in providing informal care, and what types of activities they gave up: paid work (including working on their own farms), unpaid work (household work), and/or leisure (Van den Berg et al., 2006). Monetary valuation The time spent on providing informal care was valued according to the opportunity cost method. This method uses informal caregivers’ wage rates to value paid work, unpaid work and leisure time forgone (Van den Berg et al., 2006). We applied the time-cost approach, which covers the time of all caregivers even if they are of retirement age (Pritchard & Sculpher, 2000; Weinstein et al., 1997). This method is most comparable to the study of Van den Berg et al. (2006). Real income was used for caregivers with a paid job. In the cases of household workers (e.g. housewives), unemployed persons, or pensioners, we used area minimum wages in the calculation – 184 baht/day and 144 baht/day for Bangkok and Buriram province, respectively (Ministry of Labor, 2006). Both real income and minimum wage were used to calculate the monetary value of paid work, unpaid work, and leisure time. We also performed one-way sensitivity analysis (Briggs, 2001). Calculations were repeated by using the 25th and 75th percentiles of caregivers’ real incomes. Other survey questions Here we describe other questions in the structured interviews for disabled persons and caregivers. The disabled person questionnaire included ability assessment for daily living (Barthel Index), disability level, demographics, self-reported co-morbidities, hospital use, social factors, and demographics of caregivers. The Barthel Index is used to evaluate the disability level of a stroke victim. It measures the activities of daily living using 10 items with weighted scores (Mahoney & Barthel, 1965; Uyttenboogaart et al., 2005). They include: feeding, transfers (e.g. from chair to bed), grooming, toilet use, bathing, mobility, stair climbing, dressing, and control of bowels and bladder. Demographics include age, gender, family size, type of family, and health insurance status. Caregivers were asked about their gender, age, occupation, income, relationship to the care receivers, and duration of providing informal care. Content validity of the questionnaire was assessed by two experts. Then the questionnaire was tested by interviewing five general people. Finally, it was tested on one disabled person and one informal caregiver, confirming the content validity of the questionnaire. Just a few details were changed in the framing of the questions.
Results Response and non-response A group of 608 stroke survivors was drawn from the hospital databases: 297 (49%) from the SNMRC, and 311 (51%) from Buriram Hospital. The status of these survivors was then checked. Of those persons, 507 (83%) were not eligible due to various causes: death (210 cases), recovery (156 cases), migration (108 cases), having a full-time formal helper (27 cases), hospitalization (3 cases) or no consent (3 cases). One hundred and one (17%) disabled persons were included in the analysis: 52 (51%) from SNMRC and 49 (49%) from Buriram Hospital. Characteristics of stroke survivors The 101 stroke survivors included in the study had 149 caregivers. The rate of caregiver per stroke survivor in Buriram (1.54 persons) was slightly higher than that of Bangkok (1.44 persons). There was only one stroke survivor (in Buriram) who did not have an informal caregiver. Characteristics of stroke survivors are shown in Table 2. Most of them were male (52.5%), and their mean age was 66 years. A majority in Bangkok were either mildly (36.5%) or moderately (38.5%) disabled; whereas in Buriram 30.6% were very severely disabled, and another 30.6% were mildly disabled. In terms of family, more than half were part of an extended family, which is defined as more than two generations living together: i.e., grandparents, parents and children/grandchildren. The average household of the disabled person consisted of 4.6 family members. Most of them (81%) still received medical services from hospitals. More than three-fourths also received rehabilitation care from caregivers. Nearly half of the disabled persons (48%) had Universal Health Coverage (UC). In total, 82 disabled persons were currently receiving care from the hospitals, but only 20 of them had received rehabilitation services during the previous month. Characteristics of informal caregivers The average age of caregivers (Table 3) was 46 years. Most of them were female (61.1%), and either sons/daughters (38.9%) or spouses (36.2%) of the disabled persons. More than half (62%) were employed persons, followed by pensioners (18%), unemployed (15%) and students (5%). Regarding the dynamics of informal caregiving, approximately half of the caregivers spent their time in a manner similar to the annual average time of the previous year. The average monthly income of caregivers in Bangkok was higher than the monthly per capita GDP – 11,400 baht (Office of The National Economic and Social Development Board, 2006) – while that in Buriram was lower. Time measurement Table 4 shows the various types of time forgone in order to provide informal care: paid work, unpaid work, and leisure time in Buriram and Bangkok. The totals show that caregivers provided an average of 94.6 hours of care per month. Most of that time spent (41.2 hours/month, or 43.5%) was at the cost of unpaid work forgone. Time of paid work and leisure time forgone were both approximately 28%. Comparing between the two locations, caregivers in Bangkok provided most of their care (45.0%) at the cost of unpaid work time (43.5 hours/month), whereas those in Buriram provided most of their care (42.3%) at the cost of paid work time (39.0 hours/month).
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Table 2 Characteristics of disabled persons. Characteristics
Buriram (N ¼ 74) N(%)
Bangkok (N ¼ 75) Mean(95%CI)
N(%)
Total (N ¼ 149) Mean(95%CI)
N(%)
Mean(95%CI)
63.6(60.9–66.4) 59.6(52.8–66.4)
53(52.5) 101 101
65.8(63.7–68.0) 53.4(47.7–59.0)
Gender; female (%) Age (years) Barthel Index score
23(47.0) 49 49
68.2(65.1–71.3) 46.7(37.9–55.5)
30(57.7) 52 52
Disability level Very severely disabled Severely disabled Moderately disabled Mildly disabled Stroke period (years) Number of diseases
15(30.6) 10(20.4) 9(18.4) 15(30.6) 49 37
n/a n/a n/a n/a 3.3(3.0–3.7) 1.7(1.3–2.0)
6(11.5) 7(13.5) 20(38.5) 19(36.5) 52 47
n/a n/a n/a n/a 2.9(2.5–3.3) 1.9(1.6–2.2)
21(20.8) 17(16.8) 29(28.7) 34(33.7) 101 84
n/a n/a n/a n/a 3.1(2.8–3.4) 1.8(1.6–2.0)
11(29.7) 28(75.6) 5(13.5) 8(21.6) 1(2.7) 2(5.4) 2(5.4) 1(2.7) 2(5.4) 2(5.4) 49
n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 4.2(3.7–4.7)
19(40.4) 35(74.5) 20(42.6) 7(15.0) 1(2.1) 2(4.3) 0 1(2.1) 4(8.5) 1(2.1) 52
n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 4.9(4.2–5.6)
30(35.7) 63(75.0) 25(29.8) 15(17.9) 2(2.4) 4(4.8) 2(2.4) 2(2.4) 6(7.1) 3(3.6) 101
n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 4.6(4.1–5.0)
48b
1.5(1.4–1.7)
52
1.4(1.3–1.6)
100
1.5(1.4–1.6)
Family type Single family Extended family
17(34.7) 32(65.3)
n/a n/a
26(50.0) 26(50.0)
n/a n/a
43(42.6) 58(57.4)
n/a n/a
Insurance Government Universal Coverage Social Security Scheme Out of pocket
7(14.3) 39(79.6) 0 3(6.1)
n/a n/a n/a n/a
27(51.9) 10(19.2) 3(5.8) 12(23.1)
n/a n/a n/a n/a
34(33.7) 49(48.5) 3(3.0) 15(14.9)
n/a n/a n/a n/a
Currently receiving hospital care No Yes
14(28.6) 35(71.7)
n/a n/a
5(9.6) 47(90.4)
n/a n/a
19(18.8) 82(81.2)
n/a n/a
20(46.5) 5(11.6) 34(79.1) 1(2.3)
n/a n/a n/a n/a
20(31.2) 5(7.8) 49(76.6) 7(10.9)
n/a n/a n/a n/a
Co-morbiditya Diabetes Hypertension Hyperlipidemia Heart disease Asthma Gout Renal failure Psychosis Epilepsy Other Number of family members in the household (persons) Number of caregivers (persons)
Rehabilitation among those who received services in the past monthc Hospital physical therapist 0 n/a Home physical therapist 0 n/a Caregiver at home 15(71.4) n/a Self 6(28.6) n/a
Reported % based on the total number of services received. n/a ¼ Not applicable. a Self report, able to answer more than one item. b One disabled person in Buriram did not have a caregiver. c Based on the patients currently receiving hospital care, receiving rehabilitation services during the last month, and able to answer more than one item.
Monetary value Monetary values of informal care were calculated according to the opportunity cost method. Table 4 presents the results. The table shows that the mean monthly monetary value of informal care was 4642.6 baht (95% CI; 2606.3–6678.8). Point estimate of the value in Bangkok was higher than in Buriram (5670.5 baht vs. 3528.0 baht). Comparing values among types of time: the values of forgone paid work time, unpaid work time, and leisure time were 1560.1 baht, 1952.4 baht, and 1130.1 baht, respectively. Patterns of the activities were similar between Bangkok and Buriram. The major source of forgone activities was unpaid work time, which accounted for 38.9% and 47.5% in Bangkok and Buriram, respectively. To analyze robustness of the results, sensitivity analysis was employed. The effect of income on monetary valuation was tested. Individual real incomes used in the calculation of opportunity cost values ranged widely. Therefore, real incomes at the 25th and 75th percentiles (2408.3 baht/month and 15,000.0 baht/month, respectively) were used in the sensitivity analysis. It was found that
the monetary value was decreased by 73.0% and increased by 104.2% when the 25th and 75th percentiles of income were used in the calculation, respectively.
Discussion and conclusion Our sample has characteristics similar to previous studies (Dewey et al., 2002; Jullamate, de Azeredo, Paul, & Subgranon, 2006; Van den Berg et al., 2006). Informal caregivers were mainly daughters or spouses of disabled persons (in the latter case, usually wives of disabled men). Regarding the gender of the caregivers, one possible explanation is related to the typical Thai family culture. Men commonly work outside the home to earn money for their family members. Meanwhile, women are primarily responsible for household tasks, including providing care to all family members, including sick or disabled persons. The average monthly time forgone for providing informal care was 94.6 hours. Total time forgone in Buriram was similar to that in Bangkok.
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Table 3 Characteristics of informal caregivers. Characteristics
Buriram (N ¼ 74)
Bangkok (N ¼ 75)
Total (N ¼ 149)
N(%)
Mean(95%CI)
N(%)
Mean(95%CI)
N(%)
Mean(95%CI)
Gender; female (%) Age (years)
48(64.9) 74
n/a 46.2(42.4–50.1)
55(73.3) 75
n/a 46.5(42.8–50.2)
103(61.1) 149
n/a 446.4(43.7–49.1)
Occupation Employed Unemployed Student Retired Income (baht/month)
49(66.2) 12(16.2) 4(5.4) 9(12.2) 48
n/a n/a n/a n/a 6610.0 (490.4–12,729.5)
43(57.4) 10(13.3) 4(5.3) 18(24.0) 40
n/a n/a n/a n/a 221,708.8 (15,106.1–28,311.6)
92(61.7) 22(14.8) 8(5.4) 27(18.1) 88
n/a n/a n/a n/a 13,473.1 (8776.0–18,170.2)
Relationship to disabled person Father/mother 1(1.3) Husband/wife 23(31.1) Son/daughter 27(36.5) Relative 21(28.4) Friend/neighbor 2(2.7)
n/a n/a n/a n/a n/a
1(1.3) 31(41.3) 31(41.3) 11(14.8) 1(1.3)
n/a n/a n/a n/a n/a
2(1.3) 54(36.3) 58(38.9) 32(21.5) 3(2.0)
n/a n/a n/a n/a n/a
Dwelling Same house Another house Period of care (years) Similar Increase Decrease
n/a n/a 3.2(2.9–3.5) n/a n/a n/a
65(86.7) 10(13.3) 75 40(54.1)a 10(13.5) 24(32.4)
n/a n/a 2.8(2.4–3.2) n/a n/a n/a
133(89.3) 16(10.7) 149 68(46.0) 31(20.9) 49(33.1)
n/a n/a 3.0(2.7–3.2) n/a n/a n/a
a
68(91.9) 6(8.1) 74 28(37.8) 21(28.4) 25(33.8)
Missing one case; n/a ¼ Not applicable.
The literature shows that the main source of informal caregivers‘ opportunity cost is leisure time (Table 1). Our study differs in this respect from the literature, as the major source of opportunity cost of providing informal care seems to be unpaid work. An explanation might be that most of the caregivers in the study were females who were mainly responsible for housework in their families. Most previous studies have valued informal care by calculating opportunity cost using minimum, average, and median wage rates (Claesson et al., 2000; Dewey et al., 2002; Hickenbottom et al., 2002; Patel et al., 2004). Table 1 gives details. Only one study employed the real income of informal caregivers in calculating opportunity cost (Van den Berg et al., 2006). It has been argued that using real income is unethical (Pritchard & Sculpher, 2000) because including high-income caregivers results in a high value of informal care, thus resulting in unfair rankings of health care priorities. Despite this criticism, we utilized real income in the calculation of estimated real economic loss. A major advantage of using real income is that this allows the valuation of informal care using the opportunity cost method in the context of developing countries, where national averages or other statistics might be unavailable.
By using our economic values of informal care, one could translate the results into a nationwide average in order to calculate the economic value of informal care provided in Thailand as a whole. Statistics from the Bureau of Empowerment for Persons with Disabilities show that there were 446,614 registered disabled people in Thailand in 2005. If these disabled persons received informal care similar to those in this study, the country would stand to lose an amount equal to 2073.4 million baht/month, at an annual opportunity cost of 24.9 billion baht. It is interesting to compare the value of provided informal care to other major costs. Youngkong, Riewpaiboon, Towanabut, and Riewpaiboon (2002) estimated the economic costs of cerebral infarction at Prasat Neurological Institute in 1999. They found that the average cost was 14960 baht/ month (adjusted to 2005 prices). The study included direct medical costs and indirect cost, but did not include informal care cost. If we add the value of informal care (4642 baht/month) to the cost of stroke, the total cost would be approximately 19602 baht/month. Informal care hence accounts for 24%, or nearly one-fourth, of the total cost. This illustrates that ignoring the monetary value of informal care would result in a huge underestimation of the cost of
Table 4 Time forgone and monetary value of informal care. Buriram (N ¼ 48) Mean(95%CI); % Time (hours/month) Paid work Unpaid work Leisure Total Value (baht/month) Paid work Unpaid work Leisure Total
39.0(19.6–58.3); 42.3% 38.6(22.8–54.5); 41.9% 14.6(1.1–28.2); 15.8% 92.2(68.2–116.3); 100% 1606.0(63.3–3275.3); 45.5% 1675.6(445.8–3797.0); 47.5% 247.4 (3.3–491.4);7.0% 3528.0(25.0–7032.9);100%
Bangkok (N ¼ 52) Median 10.75 13.79 0.00 80.50 115.08 212.17 0.00 981.98
Mean(95%CI); % 15.3(3.7–26.9); 15.8% 43.5 (16.0–70.9); 45.0% 37.9 (22.7–53.2); 39.2% 96.7 (66.7–126.7); 100% 1517.7(249.7–3285.0); 26.8% 2207.9(701.5–3714.4); 38.9% 1944.9(953.6–2936.2); 34.3% 5670.5(3429.4–7911.6); 100%
Total (N ¼ 100) Median 0.00 2.09 14.25 68.17 0 126.50 651.75 2820.94
Mean(95%CI); % 26.7 41.2 26.8 94.6
(15.2 – 37.8); 28.2% (25.2 – 57.1); 43.5% (16.4 – 37.1); 28.3% (75.5 – 113.6); 100%
1560.1(362.1–2758.1); 33.6% 1952.4(689.7–3215.1); 42.1% 1130.1(583.3–1676.8); 24.3% 4642.6(2606.3–6678.8); 100%
Median 0.00 7.29 2.50 71.58 0 190.42 57.50 1627.08
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strokes. Policymakers could use this new information in the decision-making process when allocating funds for health care. Three limitations of our study should be noted. First, the sample size was relatively small, limited to 101 disabled persons. Second, in order to generalize the results to the national level, sample selectivity should be considered. Although all eligible survivors from both study sites were included in the study, populations were selected from only two health facilities in Thailand based on convenience. Stroke survivors can receive acute care and outpatient rehabilitation services from 95 provincial and regional hospitals in Thailand. Third, time-use data were collected using the recall method, whereas a diary is considered to be the gold standard of data collection. However, Van den Berg and Spauwen (2006) conducted a comparison of both methods, and recommended that ‘‘Whether or not the benefits of increasing precision of using the diary instead of the recall method outweigh the additional costs is debatable and depends on the research objectives and the outcome of future research regarding the validity of the recall method.’’ In sum, this study shows that informal care plays a substantial role in the total care provided to stroke victims in Thailand, and involves opportunity costs to the caregivers. This might have a major impact on both families and society, including the national economy. Informal care involves a substantial hidden value to society according to the opportunity cost method. References Anderson, C., Mhurchu, C. N., Brown, P. M., & Carter, K. (2002). Stroke rehabilitation services to accelerate hospital discharge and provide home-based care: an overview and cost analysis. Pharmacoeconomics, 20(8), 537–552. Anderson, C., Mhurchu, C. N., Rubenach, S., Clark, M., Spencer, C., & Winsor, A. (2000). Home or hospital for stroke rehabilitation? Results of a randomized controlled trial: II: cost minimization analysis at 6 months. Stroke, 31(5), 1032–1037. Bomia, J., Helmkamp, N., & Lyons, S. (2007). Stroke rehabilitation evolves: new strategies, improved outcomes. Rehabilitation Management, 20(10), 14–17, 10, 12. Briggs, A. (2001). Uncertainty in economic evaluation and presenting the results. In M. Drummond, & A. McGuire (Eds.), Economic evaluation in health care: Merging theory with practice. Oxford: Oxford University Press. Brouwer, W. B., Rutten, F. F., & Koopmanschap, M. A. (2001). Costing in economic evaluations. In M. Drummond, & A. McGuire (Eds.), Economic evaluation in health care: merging theory with practice. New York: Oxford University Press. Brouwer, W. B., van Exel, N. J., Koopmanschap, M. A., & Rutten, F. F. (1999). The valuation of informal care in economic appraisal: a consideration of individual choice and societal costs of time. International Journal of Technology Assessment in Health Care, 15(1), 147–160. Byford, S., Torgerson, D. J., & Raftery, J. (2000). Economic note: cost of illness studies. British Medical Journal, 320(7245), 1335. Claesson, L., Gosman-Hedstrom, G., Johannesson, M., Fagerberg, B., & Blomstrand, C. (2000). Resource utilization and cost of stroke unit care integrated in a care continuum: a one-year controlled, prospective, randomized study in elderly patients. Stroke, 31, 2569–2577. Dewey, H. M., Thrift, A. G., Mihalopoulos, C., Carter, R., Macdonell, R. A. L., McNeil, J. J., et al. (2002). Informal care for stroke survivors: results from the North East Melbourne Stroke Incidence Study (NEMESIS). Stroke, 33(4), 1028–1033. Evers, S. M., Ament, A. J., & Blaauw, G. (2000). Economic evaluation in stroke research: a systematic review. Stroke, 31(5), 1046–1053.
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Economic valuation of informal care in Asia: A case study of care for disabled stroke survivors in Thailand Arthorn Riewpaiboon a, *, Wachara Riewpaiboon b, Kanyarat Ponsoongnern a, Bernard Van den Berg c, d a
Division of Social and Administrative Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand Health Promotion Program for People with Disability, Sirindhorn National Medical Rehabilitation Center, Ministry of Public Health, Thailand c Department of Health Sciences, VU University Amsterdam, The Netherlands d Department of Economics and Business and CRES, Universitat Pompeu Fabra, Barcelona, Spain b
a r t i c l e i n f o
a b s t r a c t
Article history: Available online 1 July 2009
This study values informal care for disabled stroke survivors in Thailand. It applies the conventional recommended opportunity cost method to value informal care in monetary terms. Data were collected by means of face-to-face interviews conducted during 2006. The sample consisted of 101 disabled persons who had suffered a stroke at least six months prior to the interview, and who had a functional status score of less than 95 as measured by the Barthel Index. Average monthly time spent on informal care was 94.6 hours, and the major source of opportunity cost was forgone unpaid work (43.5%). The average monthly monetary value of informal care was 4642.6 baht, based on 2006 prices. This study shows that providing informal care involves a substantial opportunity cost, implying a hidden value to Thai society. Ó 2009 Elsevier Ltd. All rights reserved.
Keywords: Informal care Economic value Cost of illness Stroke Disabled persons Caregivers Thailand
Introduction Cerebrovascular disease, or stroke, is a major public health problem associated with mortality, and a major cause of disability in elderly people in many countries (Bomia, Helmkamp, & Lyons, 2007; Fisher, 2008; Kalra & Ratan, 2008). Based on Disability Adjusted Life Year (DALY) calculations in Thailand, in 1999 stroke was ranked the second and third greatest burden of disease in women and men, respectively (The Thai Working Group on Burden of Disease and Injuries, 2002). Disabled stroke survivors, who mainly depend on others for their activities of daily living, can impose a significant social and economic burden on society. After a stroke attack, some survivors have functional impairment and disability; rehabilitation is consequently important. However, conventional hospital rehabilitation services are expensive, as described in a review by Evers, Ament, and Blaauw (2000). Therefore, home-based and/or community-based rehabilitation have been developed as cost-saving or complementary alternatives (Anderson, Mhurchu, Brown, & Carter, 2002; Anderson et al., 2000). In Thailand, health care for stroke survivors is first based in a hospital’s acute inpatient department, where the duration of care
* Corresponding author. Faculty of Pharmacy, Mahidol University, 447 Sri Ayutthaya Road, Ratchathevi, Bangkok, Thailand. Tel.: þ66 81 8290578; fax: þ66 2 6448694. E-mail address: [email protected] (A. Riewpaiboon). 0277-9536/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2009.05.033
ends when the patient’s medical or surgical condition becomes stable. The functional problem of survivors who need further care for rehabilitation can be addressed by their becoming inpatients. Some disabled stroke survivors can continue their rehabilitation program by utilizing outpatient department services. Due to limitations in supply, such rehabilitation services are generally not offered at district hospitals. Therefore, it is likely that most stroke survivors will receive care at home from family caregivers. Occasionally they will be visited by health care professionals, complemented by outpatient follow-up visits. ‘‘Informal care’’ is the name given to the care provided by people from a care recipient’s social network: family, friends, acquaintances or neighbors (Brouwer, Rutten, & Koopmanschap, 2001). Alternatively, it is defined as a nonmarket composite commodity consisting of heterogeneous parts produced (paid or unpaid) by one or more members of the social environment of the care recipient as a result of the care demands of the care recipient (Van den Berg, Brouwer, & Koopmanschap, 2004). There might be informal caregivers getting payments according to the second definition but this does not imply that informal care is a free resource from an economic perspective. Providing informal care entails opportunity costs in various forms: e.g. giving up paid work time or leisure time; investing energy; and, in some cases, possibly even making fewer social contacts (Brouwer, van Exel, Koopmanschap, & Rutten, 1999). Not determining the economic value of informal care implicitly assumes that providing informal care does not involve opportunity
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costs to caregivers and society. Cost calculations and economic evaluations excluding informal care might suggest interventions to be cost-saving or cost-effective, whereas this result would simply be due to the exclusion of informal care from the analysis (Van den Berg et al., 2004; Van den Berg & Spauwen, 2006). Determining the economic value of informal care is also important in formulating health policy, because it reveals societies’ opportunity costs of caring for people with various diseases, and what could be saved by eradicating them (Byford, Torgerson, & Raftery, 2000). Values of informal care for stroke victims have been estimated mainly in Western countries, including Australia, Sweden, the United Kingdom, and the United States (Claesson, GosmanHedstrom, Johannesson, Fagerberg, & Blomstrand, 2000; Dewey et al., 2002; Hickenbottom et al., 2002; Patel, Knapp, Perez, Evans, & Kalra, 2004) [see Table 1 for an overview]. They were determined using opportunity cost or proxy good methods. The opportunity cost method values caregivers‘ paid work, unpaid work, and leisure time forgone in providing informal care by estimating forgone wages. The proxy good method values informal care time by the wage rate of close substitutes in the labor market, e.g. professional caregivers or house workers. In Asia, based on our knowledge, the economic value of informal care has never been estimated. This paper attempts to fill part of this gap in the literature by estimating the economic value of informal care for disabled stroke survivors in Thailand. We apply the conventionally recommended opportunity cost method to value informal care in monetary terms. Although alternative methods have been proposed and applied to value informal care – such as proxy good (Van den Berg et al., 2006); contingent valuation (Van den Berg, Bleichrodt, & Eeckhoudt, 2005); conjoint analysis (Van den Berg, Al, Brouwer, van Exel, & Koopmanschap, 2005); or the well-being valuation method (Van den Berg & Ferrer-i-Carbonell, 2007) – the opportunity cost method is the most advocated and the most often used (Van den Berg et al., 2006). We mainly follow the approach of Van den Berg et al. (2006) as a first step in determining the economic value of informal care for disabled stroke survivors in Thailand.
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selected as it is the only national center for medical rehabilitation located in central Thailand. It is a tertiary hospital with 48 patient beds. Buriram Hospital is a 590-bed regional hospital, one of 25 regional hospitals in Thailand. Buriram is in the northeast, which is the poorest area of Thailand. The hospitals were selected based on being representative of the central and northeastern regions, and because the administrators permitted us to access their data. The study received ethical approval from both study hospitals. We approached informal caregivers through disabled stroke survivors who were registered at the study hospitals during the period from January 1, 2001, to December 31, 2005. The retrospective study period was extended to five years to include enough respondents. Interviews were conducted at least six months after stroke attack, because disability is normally determined six months after a stroke (Kwon, Hartzema, Duncan, & Lai, 2004; Loewen & Anderson, 1990; Uyttenboogaart, Stewart, Vroomen, De Keyser, & Luijckx, 2005; Van Swieten, Koudstaal, Visser, Schouten, & Van Gijn, 1998). All informal caregivers of stroke survivors with the following characteristics were included in the study: Stroke survivors with diagnosis classified by the International Classification of Diseases, 10th Revision (ICD-10), code I60-I69 (cerebrovascular diseases) and G81 (hemiplegia) (World Health Organization, 1992). Stroke survivors having suffered a stroke at least six months prior. Stroke survivors having a functional status of not more than 95 out of 100, as measured by the Barthel Index. This indicates the degree of disability (Mahoney & Barthel, 1965; Prasat Neurological Institute, 2002). Stroke survivors who had been hospitalized for more than one week at the time of the interview were excluded. This is because, during hospitalization, the informal care activities are different from the usual. Data collection and management
Methods Study sample Our study sample consisted of the Sirindhorn National Medical Rehabilitation Center (SNMRC) and Buriram Hospital. SNMRC was
Data collection began with stroke survivor selection. Two interviewers (the third author and a hospital pharmacist studying for a master’s degree in Pharmacy Administration) were trained by the first and second authors. Face-to-face interviews were conducted at the study sites if the survivors had entered the study sites
Table 1 Overview of economic valuations of informal care for stroke victims. Study
Opportunity cost method Paid work
Unpaid work
Proxy good method Leisure
Not mentioned
Claesson et al., 2000
–
–
O
–
Hickenbottom et al., 2002
–
–
–
O
Dewey et al., 2002
–
–
O
–
Patel et al., 2004
–
–
–
O
Van den Berg et al., 2006
O
O
O
–
Shadow price
Shadow price
35% of gross wage rate (38 SEK/hour) National median wage for home health aid ($8.20/hour) 35% of average Australian weekly wage (A$5.86/hour)
–
UK minimum wage rate (£3.53/hour) Caregiver’s hourly wage and shadow price
*$1.00 ¼ £0.67 ¼ A$1.32 (Australian dollar) ¼ 6.70SEK (Swedish krona) ¼ ] 0.78 = 37.93 Thai baht (in 2006). HDL ¼ Household activities of daily living, e.g. preparing food, shopping, doing chores. ADL ¼ Activities of daily living, e.g. toilet activities, eating. IADL ¼ Instrumental activities of daily living, e.g. traveling outside the house.
– *Unqualified health care worker (A$11.20/hour) *Nursing employees at level 2 (A$13.45/hour) Social service home help worker (£10.61/hour) Professional home care: *HDL (]8.53/hour) *ADL, IADL (]32.67/hour)
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during the month of the interview period; otherwise, interviews were conducted at the survivors’ homes. If a disabled person had more than one caregiver, each of them was interviewed. In case not all caregivers could be accessed, an estimate of total caregiving time was collected from the primary caregiver. The interviews were conducted during August-October 2006. To control quality of the data, data management activities were performed. At the end of each interview, completeness of data collection was checked by the researcher. To avoid human error, double data entry was performed by different data enterers into Microsoft Excel files. Time measurement The first pieces of information necessary for the valuation of informal care using the opportunity cost method are the sources and amounts of time forgone in order to provide informal care. We asked caregivers how much time they spent in providing informal care, and what types of activities they gave up: paid work (including working on their own farms), unpaid work (household work), and/or leisure (Van den Berg et al., 2006). Monetary valuation The time spent on providing informal care was valued according to the opportunity cost method. This method uses informal caregivers’ wage rates to value paid work, unpaid work and leisure time forgone (Van den Berg et al., 2006). We applied the time-cost approach, which covers the time of all caregivers even if they are of retirement age (Pritchard & Sculpher, 2000; Weinstein et al., 1997). This method is most comparable to the study of Van den Berg et al. (2006). Real income was used for caregivers with a paid job. In the cases of household workers (e.g. housewives), unemployed persons, or pensioners, we used area minimum wages in the calculation – 184 baht/day and 144 baht/day for Bangkok and Buriram province, respectively (Ministry of Labor, 2006). Both real income and minimum wage were used to calculate the monetary value of paid work, unpaid work, and leisure time. We also performed one-way sensitivity analysis (Briggs, 2001). Calculations were repeated by using the 25th and 75th percentiles of caregivers’ real incomes. Other survey questions Here we describe other questions in the structured interviews for disabled persons and caregivers. The disabled person questionnaire included ability assessment for daily living (Barthel Index), disability level, demographics, self-reported co-morbidities, hospital use, social factors, and demographics of caregivers. The Barthel Index is used to evaluate the disability level of a stroke victim. It measures the activities of daily living using 10 items with weighted scores (Mahoney & Barthel, 1965; Uyttenboogaart et al., 2005). They include: feeding, transfers (e.g. from chair to bed), grooming, toilet use, bathing, mobility, stair climbing, dressing, and control of bowels and bladder. Demographics include age, gender, family size, type of family, and health insurance status. Caregivers were asked about their gender, age, occupation, income, relationship to the care receivers, and duration of providing informal care. Content validity of the questionnaire was assessed by two experts. Then the questionnaire was tested by interviewing five general people. Finally, it was tested on one disabled person and one informal caregiver, confirming the content validity of the questionnaire. Just a few details were changed in the framing of the questions.
Results Response and non-response A group of 608 stroke survivors was drawn from the hospital databases: 297 (49%) from the SNMRC, and 311 (51%) from Buriram Hospital. The status of these survivors was then checked. Of those persons, 507 (83%) were not eligible due to various causes: death (210 cases), recovery (156 cases), migration (108 cases), having a full-time formal helper (27 cases), hospitalization (3 cases) or no consent (3 cases). One hundred and one (17%) disabled persons were included in the analysis: 52 (51%) from SNMRC and 49 (49%) from Buriram Hospital. Characteristics of stroke survivors The 101 stroke survivors included in the study had 149 caregivers. The rate of caregiver per stroke survivor in Buriram (1.54 persons) was slightly higher than that of Bangkok (1.44 persons). There was only one stroke survivor (in Buriram) who did not have an informal caregiver. Characteristics of stroke survivors are shown in Table 2. Most of them were male (52.5%), and their mean age was 66 years. A majority in Bangkok were either mildly (36.5%) or moderately (38.5%) disabled; whereas in Buriram 30.6% were very severely disabled, and another 30.6% were mildly disabled. In terms of family, more than half were part of an extended family, which is defined as more than two generations living together: i.e., grandparents, parents and children/grandchildren. The average household of the disabled person consisted of 4.6 family members. Most of them (81%) still received medical services from hospitals. More than three-fourths also received rehabilitation care from caregivers. Nearly half of the disabled persons (48%) had Universal Health Coverage (UC). In total, 82 disabled persons were currently receiving care from the hospitals, but only 20 of them had received rehabilitation services during the previous month. Characteristics of informal caregivers The average age of caregivers (Table 3) was 46 years. Most of them were female (61.1%), and either sons/daughters (38.9%) or spouses (36.2%) of the disabled persons. More than half (62%) were employed persons, followed by pensioners (18%), unemployed (15%) and students (5%). Regarding the dynamics of informal caregiving, approximately half of the caregivers spent their time in a manner similar to the annual average time of the previous year. The average monthly income of caregivers in Bangkok was higher than the monthly per capita GDP – 11,400 baht (Office of The National Economic and Social Development Board, 2006) – while that in Buriram was lower. Time measurement Table 4 shows the various types of time forgone in order to provide informal care: paid work, unpaid work, and leisure time in Buriram and Bangkok. The totals show that caregivers provided an average of 94.6 hours of care per month. Most of that time spent (41.2 hours/month, or 43.5%) was at the cost of unpaid work forgone. Time of paid work and leisure time forgone were both approximately 28%. Comparing between the two locations, caregivers in Bangkok provided most of their care (45.0%) at the cost of unpaid work time (43.5 hours/month), whereas those in Buriram provided most of their care (42.3%) at the cost of paid work time (39.0 hours/month).
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Table 2 Characteristics of disabled persons. Characteristics
Buriram (N ¼ 74) N(%)
Bangkok (N ¼ 75) Mean(95%CI)
N(%)
Total (N ¼ 149) Mean(95%CI)
N(%)
Mean(95%CI)
63.6(60.9–66.4) 59.6(52.8–66.4)
53(52.5) 101 101
65.8(63.7–68.0) 53.4(47.7–59.0)
Gender; female (%) Age (years) Barthel Index score
23(47.0) 49 49
68.2(65.1–71.3) 46.7(37.9–55.5)
30(57.7) 52 52
Disability level Very severely disabled Severely disabled Moderately disabled Mildly disabled Stroke period (years) Number of diseases
15(30.6) 10(20.4) 9(18.4) 15(30.6) 49 37
n/a n/a n/a n/a 3.3(3.0–3.7) 1.7(1.3–2.0)
6(11.5) 7(13.5) 20(38.5) 19(36.5) 52 47
n/a n/a n/a n/a 2.9(2.5–3.3) 1.9(1.6–2.2)
21(20.8) 17(16.8) 29(28.7) 34(33.7) 101 84
n/a n/a n/a n/a 3.1(2.8–3.4) 1.8(1.6–2.0)
11(29.7) 28(75.6) 5(13.5) 8(21.6) 1(2.7) 2(5.4) 2(5.4) 1(2.7) 2(5.4) 2(5.4) 49
n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 4.2(3.7–4.7)
19(40.4) 35(74.5) 20(42.6) 7(15.0) 1(2.1) 2(4.3) 0 1(2.1) 4(8.5) 1(2.1) 52
n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 4.9(4.2–5.6)
30(35.7) 63(75.0) 25(29.8) 15(17.9) 2(2.4) 4(4.8) 2(2.4) 2(2.4) 6(7.1) 3(3.6) 101
n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 4.6(4.1–5.0)
48b
1.5(1.4–1.7)
52
1.4(1.3–1.6)
100
1.5(1.4–1.6)
Family type Single family Extended family
17(34.7) 32(65.3)
n/a n/a
26(50.0) 26(50.0)
n/a n/a
43(42.6) 58(57.4)
n/a n/a
Insurance Government Universal Coverage Social Security Scheme Out of pocket
7(14.3) 39(79.6) 0 3(6.1)
n/a n/a n/a n/a
27(51.9) 10(19.2) 3(5.8) 12(23.1)
n/a n/a n/a n/a
34(33.7) 49(48.5) 3(3.0) 15(14.9)
n/a n/a n/a n/a
Currently receiving hospital care No Yes
14(28.6) 35(71.7)
n/a n/a
5(9.6) 47(90.4)
n/a n/a
19(18.8) 82(81.2)
n/a n/a
20(46.5) 5(11.6) 34(79.1) 1(2.3)
n/a n/a n/a n/a
20(31.2) 5(7.8) 49(76.6) 7(10.9)
n/a n/a n/a n/a
Co-morbiditya Diabetes Hypertension Hyperlipidemia Heart disease Asthma Gout Renal failure Psychosis Epilepsy Other Number of family members in the household (persons) Number of caregivers (persons)
Rehabilitation among those who received services in the past monthc Hospital physical therapist 0 n/a Home physical therapist 0 n/a Caregiver at home 15(71.4) n/a Self 6(28.6) n/a
Reported % based on the total number of services received. n/a ¼ Not applicable. a Self report, able to answer more than one item. b One disabled person in Buriram did not have a caregiver. c Based on the patients currently receiving hospital care, receiving rehabilitation services during the last month, and able to answer more than one item.
Monetary value Monetary values of informal care were calculated according to the opportunity cost method. Table 4 presents the results. The table shows that the mean monthly monetary value of informal care was 4642.6 baht (95% CI; 2606.3–6678.8). Point estimate of the value in Bangkok was higher than in Buriram (5670.5 baht vs. 3528.0 baht). Comparing values among types of time: the values of forgone paid work time, unpaid work time, and leisure time were 1560.1 baht, 1952.4 baht, and 1130.1 baht, respectively. Patterns of the activities were similar between Bangkok and Buriram. The major source of forgone activities was unpaid work time, which accounted for 38.9% and 47.5% in Bangkok and Buriram, respectively. To analyze robustness of the results, sensitivity analysis was employed. The effect of income on monetary valuation was tested. Individual real incomes used in the calculation of opportunity cost values ranged widely. Therefore, real incomes at the 25th and 75th percentiles (2408.3 baht/month and 15,000.0 baht/month, respectively) were used in the sensitivity analysis. It was found that
the monetary value was decreased by 73.0% and increased by 104.2% when the 25th and 75th percentiles of income were used in the calculation, respectively.
Discussion and conclusion Our sample has characteristics similar to previous studies (Dewey et al., 2002; Jullamate, de Azeredo, Paul, & Subgranon, 2006; Van den Berg et al., 2006). Informal caregivers were mainly daughters or spouses of disabled persons (in the latter case, usually wives of disabled men). Regarding the gender of the caregivers, one possible explanation is related to the typical Thai family culture. Men commonly work outside the home to earn money for their family members. Meanwhile, women are primarily responsible for household tasks, including providing care to all family members, including sick or disabled persons. The average monthly time forgone for providing informal care was 94.6 hours. Total time forgone in Buriram was similar to that in Bangkok.
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Table 3 Characteristics of informal caregivers. Characteristics
Buriram (N ¼ 74)
Bangkok (N ¼ 75)
Total (N ¼ 149)
N(%)
Mean(95%CI)
N(%)
Mean(95%CI)
N(%)
Mean(95%CI)
Gender; female (%) Age (years)
48(64.9) 74
n/a 46.2(42.4–50.1)
55(73.3) 75
n/a 46.5(42.8–50.2)
103(61.1) 149
n/a 446.4(43.7–49.1)
Occupation Employed Unemployed Student Retired Income (baht/month)
49(66.2) 12(16.2) 4(5.4) 9(12.2) 48
n/a n/a n/a n/a 6610.0 (490.4–12,729.5)
43(57.4) 10(13.3) 4(5.3) 18(24.0) 40
n/a n/a n/a n/a 221,708.8 (15,106.1–28,311.6)
92(61.7) 22(14.8) 8(5.4) 27(18.1) 88
n/a n/a n/a n/a 13,473.1 (8776.0–18,170.2)
Relationship to disabled person Father/mother 1(1.3) Husband/wife 23(31.1) Son/daughter 27(36.5) Relative 21(28.4) Friend/neighbor 2(2.7)
n/a n/a n/a n/a n/a
1(1.3) 31(41.3) 31(41.3) 11(14.8) 1(1.3)
n/a n/a n/a n/a n/a
2(1.3) 54(36.3) 58(38.9) 32(21.5) 3(2.0)
n/a n/a n/a n/a n/a
Dwelling Same house Another house Period of care (years) Similar Increase Decrease
n/a n/a 3.2(2.9–3.5) n/a n/a n/a
65(86.7) 10(13.3) 75 40(54.1)a 10(13.5) 24(32.4)
n/a n/a 2.8(2.4–3.2) n/a n/a n/a
133(89.3) 16(10.7) 149 68(46.0) 31(20.9) 49(33.1)
n/a n/a 3.0(2.7–3.2) n/a n/a n/a
a
68(91.9) 6(8.1) 74 28(37.8) 21(28.4) 25(33.8)
Missing one case; n/a ¼ Not applicable.
The literature shows that the main source of informal caregivers‘ opportunity cost is leisure time (Table 1). Our study differs in this respect from the literature, as the major source of opportunity cost of providing informal care seems to be unpaid work. An explanation might be that most of the caregivers in the study were females who were mainly responsible for housework in their families. Most previous studies have valued informal care by calculating opportunity cost using minimum, average, and median wage rates (Claesson et al., 2000; Dewey et al., 2002; Hickenbottom et al., 2002; Patel et al., 2004). Table 1 gives details. Only one study employed the real income of informal caregivers in calculating opportunity cost (Van den Berg et al., 2006). It has been argued that using real income is unethical (Pritchard & Sculpher, 2000) because including high-income caregivers results in a high value of informal care, thus resulting in unfair rankings of health care priorities. Despite this criticism, we utilized real income in the calculation of estimated real economic loss. A major advantage of using real income is that this allows the valuation of informal care using the opportunity cost method in the context of developing countries, where national averages or other statistics might be unavailable.
By using our economic values of informal care, one could translate the results into a nationwide average in order to calculate the economic value of informal care provided in Thailand as a whole. Statistics from the Bureau of Empowerment for Persons with Disabilities show that there were 446,614 registered disabled people in Thailand in 2005. If these disabled persons received informal care similar to those in this study, the country would stand to lose an amount equal to 2073.4 million baht/month, at an annual opportunity cost of 24.9 billion baht. It is interesting to compare the value of provided informal care to other major costs. Youngkong, Riewpaiboon, Towanabut, and Riewpaiboon (2002) estimated the economic costs of cerebral infarction at Prasat Neurological Institute in 1999. They found that the average cost was 14960 baht/ month (adjusted to 2005 prices). The study included direct medical costs and indirect cost, but did not include informal care cost. If we add the value of informal care (4642 baht/month) to the cost of stroke, the total cost would be approximately 19602 baht/month. Informal care hence accounts for 24%, or nearly one-fourth, of the total cost. This illustrates that ignoring the monetary value of informal care would result in a huge underestimation of the cost of
Table 4 Time forgone and monetary value of informal care. Buriram (N ¼ 48) Mean(95%CI); % Time (hours/month) Paid work Unpaid work Leisure Total Value (baht/month) Paid work Unpaid work Leisure Total
39.0(19.6–58.3); 42.3% 38.6(22.8–54.5); 41.9% 14.6(1.1–28.2); 15.8% 92.2(68.2–116.3); 100% 1606.0(63.3–3275.3); 45.5% 1675.6(445.8–3797.0); 47.5% 247.4 (3.3–491.4);7.0% 3528.0(25.0–7032.9);100%
Bangkok (N ¼ 52) Median 10.75 13.79 0.00 80.50 115.08 212.17 0.00 981.98
Mean(95%CI); % 15.3(3.7–26.9); 15.8% 43.5 (16.0–70.9); 45.0% 37.9 (22.7–53.2); 39.2% 96.7 (66.7–126.7); 100% 1517.7(249.7–3285.0); 26.8% 2207.9(701.5–3714.4); 38.9% 1944.9(953.6–2936.2); 34.3% 5670.5(3429.4–7911.6); 100%
Total (N ¼ 100) Median 0.00 2.09 14.25 68.17 0 126.50 651.75 2820.94
Mean(95%CI); % 26.7 41.2 26.8 94.6
(15.2 – 37.8); 28.2% (25.2 – 57.1); 43.5% (16.4 – 37.1); 28.3% (75.5 – 113.6); 100%
1560.1(362.1–2758.1); 33.6% 1952.4(689.7–3215.1); 42.1% 1130.1(583.3–1676.8); 24.3% 4642.6(2606.3–6678.8); 100%
Median 0.00 7.29 2.50 71.58 0 190.42 57.50 1627.08
A. Riewpaiboon et al. / Social Science & Medicine 69 (2009) 648–653
strokes. Policymakers could use this new information in the decision-making process when allocating funds for health care. Three limitations of our study should be noted. First, the sample size was relatively small, limited to 101 disabled persons. Second, in order to generalize the results to the national level, sample selectivity should be considered. Although all eligible survivors from both study sites were included in the study, populations were selected from only two health facilities in Thailand based on convenience. Stroke survivors can receive acute care and outpatient rehabilitation services from 95 provincial and regional hospitals in Thailand. Third, time-use data were collected using the recall method, whereas a diary is considered to be the gold standard of data collection. However, Van den Berg and Spauwen (2006) conducted a comparison of both methods, and recommended that ‘‘Whether or not the benefits of increasing precision of using the diary instead of the recall method outweigh the additional costs is debatable and depends on the research objectives and the outcome of future research regarding the validity of the recall method.’’ In sum, this study shows that informal care plays a substantial role in the total care provided to stroke victims in Thailand, and involves opportunity costs to the caregivers. This might have a major impact on both families and society, including the national economy. Informal care involves a substantial hidden value to society according to the opportunity cost method. References Anderson, C., Mhurchu, C. N., Brown, P. M., & Carter, K. (2002). Stroke rehabilitation services to accelerate hospital discharge and provide home-based care: an overview and cost analysis. Pharmacoeconomics, 20(8), 537–552. Anderson, C., Mhurchu, C. N., Rubenach, S., Clark, M., Spencer, C., & Winsor, A. (2000). Home or hospital for stroke rehabilitation? Results of a randomized controlled trial: II: cost minimization analysis at 6 months. Stroke, 31(5), 1032–1037. Bomia, J., Helmkamp, N., & Lyons, S. (2007). Stroke rehabilitation evolves: new strategies, improved outcomes. Rehabilitation Management, 20(10), 14–17, 10, 12. Briggs, A. (2001). Uncertainty in economic evaluation and presenting the results. In M. Drummond, & A. McGuire (Eds.), Economic evaluation in health care: Merging theory with practice. Oxford: Oxford University Press. Brouwer, W. B., Rutten, F. F., & Koopmanschap, M. A. (2001). Costing in economic evaluations. In M. Drummond, & A. McGuire (Eds.), Economic evaluation in health care: merging theory with practice. New York: Oxford University Press. Brouwer, W. B., van Exel, N. J., Koopmanschap, M. A., & Rutten, F. F. (1999). The valuation of informal care in economic appraisal: a consideration of individual choice and societal costs of time. International Journal of Technology Assessment in Health Care, 15(1), 147–160. Byford, S., Torgerson, D. J., & Raftery, J. (2000). Economic note: cost of illness studies. British Medical Journal, 320(7245), 1335. Claesson, L., Gosman-Hedstrom, G., Johannesson, M., Fagerberg, B., & Blomstrand, C. (2000). Resource utilization and cost of stroke unit care integrated in a care continuum: a one-year controlled, prospective, randomized study in elderly patients. Stroke, 31, 2569–2577. Dewey, H. M., Thrift, A. G., Mihalopoulos, C., Carter, R., Macdonell, R. A. L., McNeil, J. J., et al. (2002). Informal care for stroke survivors: results from the North East Melbourne Stroke Incidence Study (NEMESIS). Stroke, 33(4), 1028–1033. Evers, S. M., Ament, A. J., & Blaauw, G. (2000). Economic evaluation in stroke research: a systematic review. Stroke, 31(5), 1046–1053.
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