Leaving No One Behind: Participatory Technology Appraisal as a Platform for Agenda Setting to Address Disparities in Access to Health Services in Thailand.

OBJECTIVES: This article discusses how participatory technology appraisal as part of the Universal Coverage Scheme (UCS) in Thailand contributes to improving access to essential health services among vulnerable populations. METHODS: Document review was conducted on health technology appraisal approaches introduced by the UCS. The review involves health benefit proposals advanced by stakeholders and also meeting minutes of relevant working groups and committees published between 2010 and 2015. RESULTS: From the establishment of the UCS participatory technology appraisal mechanism in 2010 until 2015, a total of 133 health interventions have been nominated. Some nominations highlight problems in access to care among vulnerable populations. As policy advocates continue to be involved in the latter stages of coverage decisions, they have opportunities to persuade policy makers and other stakeholders to agree to the rationales of their proposals. Some interventions were rejected because they did not meet value for money, affordability, and feasibility criteria; however, topic nominations from stakeholders as well as relevant deliberation throughout the technology appraisal processes have a potential to improve accessibility of health care among the disadvantaged. CONCLUSIONS: Through participation in the UCS policy-making processes, key stakeholders are able to direct the attention of decision makers to significant gaps in access to services among vulnerable citizens, a health system problem rarely brought to discussion by policy elites and experts. The Thai experience reaffirms participatory technology appraisal as a supportive measure to providing universal health coverage.

Health Technology Assessment in Thailand: Institutionalization and Contribution to Healthcare Decision Making: Review of Literature.

OBJECTIVES: To explore health technology assessment (HTA) in Thailand focusing on its institutionalization, key elements for HTA introduction, and HTA contribution to policy. METHODS: A review of literature covered a wide range of topics, including the institutionalization of HTA, elements of HTA introduction, and the role of HTA in policy decision making in Thai context. Additional information from the authors' involvement in the policy decision-making process in Thailand was also considered. RESULTS: HTA institutionalization comprises processes of introducing HTA, including evidence generation and use in policymaking, building capacity of HTA practitioners, organizations, system infrastructure, and collaborations. In Thailand, HTA has been formally integrated into coverage decisions, including in the development of the National List of Essential Medicines and the Universal Health Coverage Scheme benefits package. Contributing factors included political will and leadership, capacity building on HTA-related disciplines, adequate resources, technical expertise, and data. Conversely, challenges faced included the absence of a governing body and strategic plan for HTA systems development, a lack of formal mechanisms for mobilizing financial support, an inadequate number of HTA researchers in nonprofit institutes, and the rise in advanced biotechnologies. CONCLUSIONS: HTA plays an important role in evidence-based healthcare decision making. However, key elements of HTA institutionalization need to be strengthened, especially governance structure and policy for HTA systems development, building and retaining capacity of HTA practitioners to meet demand, addressing the challenges of complex and highly innovative health interventions. Lessons learned from the Thai experience may be used as guidance for HTA institutionalization in other developing countries.

Utilisation of evidence from Thailand's National Health Examination Survey in policy development: finding the weakest link.

BACKGROUND: Health surveillance and survey data are helpful in evidence-informed policy decisions. This study is part of an evaluation of the National Health Examination Survey (NHES) programme in Thailand. This paper focuses on the obstacles in the translation of survey information into policies at a national level. METHODS: In-depth interviews with relevant individuals and representatives of institutes were carried out for the data collection. A total of 26 focal informants included executives and staff of NHES funders, government health agencies, civil society organisations, health experts, NHES programme managers and researchers in the survey network. RESULTS: Utilisation of NHES data in policy-making is limited for many reasons. Despite the potential users' positive views on the technical integrity of experts and practitioners involved in the NHES, the strength of employing health examinations in the data collection is not well recognised. Meanwhile, alternative health surveillance platforms that offer similar information on a shorter timescale are preferable in policy monitoring and evaluation. In sum, the lack of governance of Thailand's health surveillance system is identified as a key element hindering the translation of health surveys, including the NHES, into policies. CONCLUSION: Despite an adequate capacity to conduct population health surveys, the lack of governance structure and function has resulted in a fragmented health monitoring system. Large and small survey projects are conducted and funded by different institutes without common policy direction and alignment mechanisms for prioritising survey topics, collective planning and capacity-building programmes for survey practitioners and users. Lessons drawn from Thailand's NHES can be helpful for policy-makers in other low- and middle-income countries, as effective governance for evidence generation and utilisation is necessary in all contexts, regardless of income level and available resources.

HISTORICAL DEVELOPMENT OF THE HTAsiaLINK NETWORK AND ITS KEY DETERMINANTS OF SUCCESS.

OBJECTIVES: The aim of this study was to describe the historical development of the HTAsiaLink network, draw lessons for other similar initiatives globally, and to analyze key determinants of its success and challenges for its future development. METHODS: This study is based on the collective and direct experiences of the founding members of the HTAsiaLink Network. Data were collected from presentations they made at various international forums and additional information was reviewed. Data analysis was done using the framework developed by San Martin-Rodriguez et al.Results and Conclusions:HTAsiaLink is a network of health technology assessment (HTA) agencies in Asia established in 2011 with the aim of strengthening individual and institutional HTA capacity, reducing duplication and optimizing resources, transfer and sharing of HTA-related lessons among members, and beyond. During its 6 years, the network has expanded, initiating several capacity building activities and joint-research projects, raising awareness of the importance of HTA within the region and beyond, and gaining global recognition while establishing relationships with other global networks. The study identifies the determinants of success of the collaboration. The systemic factors include the favorable outlook toward HTA as an approach for healthcare priority setting in countries with UHC mandates. On organizational factors, the number of newly established HTA agencies in the region with similar needs for capacity building and peer-to-peer support was catalytic for the network development. The interactional aspects include ownership, trust, and team spirit among network members. The network, however, faces challenges notably, financial sustainability and management of the expanded network.

Development of a Health Screening Package Under the Universal Health Coverage: The Role of Health Technology Assessment.

This study reports the systematic development of a population-based health screening package for all Thai people under the universal health coverage (UHC). To determine major disease areas and health problems for which health screening could mitigate health burden, a consultation process was conducted in a systematic, participatory, and evidence-based manner that involved 41 stakeholders in a half-day workshop. Twelve diseases/health problems were identified during the discussion. Subsequently, health technology assessments, including systematic review and meta-analysis of health benefits as well as economic evaluations and budget impact analyses of corresponding population-based screening interventions, were completed. The results led to advice against elements of current clinical practice, such as annual chest X-rays and particular blood tests (e.g. kidney function test), and indicated that the introduction of certain new population-based health screening programs, such as for chronic hepatitis B, would provide substantial health and economic benefits to the Thais. The final results were presented to a wide group of stakeholders, including decision-makers at the Ministry of Public Health and the public health insurance schemes, to verify and validate the findings and policy recommendations. The package has been endorsed by the Thai UHC Benefit Package Committee for implementation in fiscal year 2016.

What criteria do decision makers in Thailand use to set priorities for vaccine introduction?

BACKGROUND: There is a need to identify rational criteria and set priorities for vaccines. In Thailand, many licensed vaccines are being considering for introduction into the Expanded Program on Immunization; thus, the government has to make decisions about which vaccines should be adopted. This study aimed to set priorities for new vaccines and to facilitate decision analysis. METHODS: We used a best-worst scaling study for rank-ordering of vaccines. The candidate vaccines were determined by a set of criteria, including burden of disease, target age group, budget impact, side effect, effectiveness, severity of disease, and cost of vaccine. The criteria were identified from a literature review and by in-depth, open-ended interviews with experts. The priority-setting model was conducted among three groups of stakeholders, including policy makers, healthcare professionals and healthcare administrators. The vaccine data were mapped and then calculated for the probability of selection. RESULTS: From the candidate vaccines, the probability of hepatitis B vaccine being selected by all respondents (96.67 %) was ranked first. This was followed, respectively, by pneumococcal conjugate vaccine-13 (95.09 %) and Haemophilus influenzae type b vaccine (90.87 %). The three groups of stakeholders (policy makers, healthcare professionals and healthcare administrators) showed the same ranking trends. Most severe disease, high fever rate and high disease burden showed the highest coefficients for criterion levels being selected by all respondents. This result can be implied that a vaccine which can prevent most severe disease with high disease burden and has low safety has a greater chance of being selected by respondents in this study. CONCLUSIONS: The priority setting of vaccines through a multiple-criteria approach could contribute to transparency and accountability in the decision-making process. This is a step forward in the development of an evidence-based approach that meets the need of developing country. The methodology is generalizable but its application to another country would require the criteria as relevant to that country.

Maternal and child health voucher scheme in Myanmar: a review of early stage implementation.

BACKGROUND: The Maternal and Child Health Voucher Scheme (MCHVS) was introduced in Myanmar to address the high rate of maternal and infant mortalities. It aimed to increase access to maternal and child health (MCH) services by skilled birth attendants (SBAs) and improve the health of pregnant women and their babies. A study to pilot a voucher scheme was implemented in May 2013 in Yedarshey Township. This paper provides a report on a mid-term review of the programme after 7 months of implementation to determine the outcomes of the programme and its impediments. METHODS: Quantitative and qualitative approaches were used. Secondary quantitative data were analysed in order to measure the coverage and utilisation of the programme. Semi-structured interviews were conducted in groups and individually with 79 key informants to explore qualitative information on voucher communication, beneficiary's identification, voucher distribution, and challenges for beneficiaries and providers under the MCHVS. RESULTS: The results showed that 63 % of eligible pregnant women who registered to the programme received voucher booklets, while the utilisation of most of the MCH services increased over time; in particular, delivery by SBAs increased significantly (P < 0.01) after implementing MCHVS. Overall, the programme was implemented well in terms of promoting and communicating the programme to people in Yedarshey Township. Although a number of targeted poor pregnant women were included in the programme, some beneficiaries were overlooked for a variety of reasons. Nevertheless, both providers and beneficiaries who experienced the MCHVS service utilisation were satisfied with the programme. The evaluation indicated several programme challenges, i.e. external and internal programme communication, voluntary voucher distributor recruitment, incentive and support for voucher distributors, beneficiary screening criteria, and approaches to increase access of services for pregnant women living in remote areas. CONCLUSIONS: Generally, the MCHVS pilot programme is a promising initiative to increase access to and utilisation of the MCH services for pregnant women and their babies in Myanmar. However, increasing coverage of the programme and overcoming the barriers should be considered as high-priority issues that need to be addressed.

The influence of cost-per-DALY information in health prioritisation and desirable features for a registry: a survey of health policy experts in Vietnam, India and Bangladesh.

BACKGROUND: Economic evaluation has been implemented to inform policy in many areas, including coverage decisions, technology pricing, and the development of clinical practice guidelines. However, there are barriers to evidence-based policy in low- and middle-income countries (LMICs) that include limited stakeholder awareness, resources and data availability, as well as the lack of capacity to conduct country-specific economic evaluations. This study aims to survey health policy experts' opinions on barriers to use of cost-effectiveness data in these settings and to obtain their advice on how to make a new cost-per-DALY database being developed by Tufts Medical Center more relevant to LMICs. It also identifies the factors influencing transferability. METHODS: In-depth interviews were conducted with 32 participants, including policymakers, technical advisors, and researchers in Health Ministries, universities and non-governmental organisations in Bangladesh, India (New Delhi, Tamil Nadu and Karnataka) and Vietnam. RESULTS: The survey revealed that, in all settings, the use of cost-effectiveness information in policy development is lacking, owing to limited knowledge among policymakers and inadequate human resources with health economics expertise in the government sector. Furthermore, researchers in universities do not have close connections with health authorities. In India and Vietnam, the demand for evidence to inform coverage decisions tends to increase as the countries are moving towards universal health coverage. The informants in all countries argue that cost-effectiveness data are useful for decision-makers; however, most of them do not perform data searches by themselves but rely on the information provided by the technical advisor counterparts. Most interviewees were familiar with using evidence from other countries and were also aware of the influences of contextual elements as a limitation of transferability. Finally, strategies to promote the newly developed database include training on basic economic evaluation for policymakers and researchers, and effective communication programs, with support from reputable global agencies. CONCLUSIONS: Although cost-effectiveness information is recognised as essential in resource allocation, there are several impediments in the generation and use of such evidence to inform priority setting in LMICs. As such, the Cost-per-DALY database should be well-designed and introduced with appropriate promotion strategies so that it will be helpful in real-world policymaking.

How to meet the demand for good quality renal dialysis as part of universal health coverage in resource-limited settings?

BACKGROUND: It is very challenging for resource-limited settings to introduce universal health coverage (UHC), particularly regarding the inclusion of high-cost renal dialysis as part of the UHC benefit package. This paper addresses three issues: (1) whether a setting commits to include renal dialysis in its UHC benefit package and if so, why and how; (2) how to ensure quality of renal dialysis services; and (3) how to improve the quality of life of patients using psychosocial and community interventions. DISCUSSION: This article reviews experiences of renal dialysis programs in seven settings based on presentations and discussions during the International Forum on Peritoneal Dialysis as a Priority Health Policy in Asia. A literature review was conducted to verify and validate the data as well as to fill information gaps presented in the forum. Five out of the seven settings implemented renal dialysis as part of their benefits package, while the other two have pilots or programs in their nascent stage. Renal replacement therapy has become part of the universal access package because these governments recognize the rising number of chronic kidney disease (CKD) cases, the catastrophically high costs of treatment, and that this is the only life-saving treatment available to patients. The recommendations are as follows: Governments should have a holistic approach to CKD interventions, including primary prevention as well as psychosocial interventions. Governments should consider subsidizing CKD treatment costs depending on their resources. Multi-stakeholder cooperation should be facilitated to enact these policies and conduct research and development for all aspects of interventions. International collaboration should be initiated to share experiences, good practices, and joint activities (e.g. capacity building and multinational procurement of medical supplies). CONCLUSION: This study provides practical recommendations to country governments as well as the international community on how to meet the demand for good quality renal dialysis as part of UHC in resource-limited settings.

EFFECTIVENESS OF DIAPERS AMONG PEOPLE WITH CHRONIC INCONTINENCE IN THAILAND.

OBJECTIVES: The aim of this study was to assess effect of adult diapers on health-related quality of life (HRQOL) and the independent level of performing activities of daily living (ADLs) in people with urinary or fecal incontinence. Psychological consequences of patients' caregivers were also measured. METHODS: This quasi-experimental study was conducted at two rehabilitation centers in Thailand. People aged 15 years or greater with chronic urinary or fecal incontinence were eligible. Study participants received adult diapers for 10 weeks after recruitment. Thai EuroQol Five Dimensions (EQ-5D) and the Barthel Index were measured at baseline and weeks 2, 6, and 10 to evaluate HRQOL and the independent level of performing ADLs, respectively. The Braden Scale was used to assess the risk of having pressure ulcers. Mean differences in the Thai EQ-5D, the Barthel Index, and the Braden Scale, before and after receiving adult diapers, were estimated using a multilevel linear regression model. RESULTS: There were ninety patients and forty-eight caregivers who took part in this study. HRQOL and independent level of performing ADLs had improved significantly by week 10 after receiving adult diapers with mean differences of 0.102 (95% confidence interval [CI], 0.046-0.158) and 4.40 (95% CI, 1.74-7.07), respectively. The risk of having pressure ulcers had significantly decreased by 67 percent (95% CI, 16 percent-78 percent) by week 10 after receiving adult diapers. CONCLUSIONS: The results indicate a significant improvement of HRQOL and the independent level of performing ADLs among incontinent patients after receiving adult diapers. These results were used to inform the development of the health benefits package under the Universal Health Coverage Scheme in Thailand.

Social and ethical analysis in health technology assessment.

This paper presents a review of the domestic and international literature on the assessment of the social and ethical implications of health technologies. It gives an overview of the key concepts, principles, and approaches that should be taken into account when conducting a social and ethical analysis within health technology assessment (HTA). Although there is growing consensus among healthcare experts that the social and ethical ramifications of a given technology should be examined before its adoption, the demand for this kind of analysis among policy-makers around the world, including in Thailand, has so far been lacking. Currently decision-makers mainly base technology adoption decisions using evidence on clinical effectiveness, value for money, and budget impact, while social and ethical aspects have been neglected. Despite the recognized importance of considering equity, justice, and social issues when making decisions regarding health resource allocation, the absence of internationally-accepted principles and methodologies, among other factors, hinders research in these areas. Given that developing internationally agreed standards takes time, it has been recommended that priority be given to defining processes that are justifiable, transparent, and contestable. A discussion of the current situation in Thailand concerning social and ethical analysis of health technologies is also presented.

Advanced health biotechnologies in Thailand: redefining policy directions.

BACKGROUND: Thailand faces a significant burden in terms of treating and managing degenerative and chronic diseases. Moreover, incidences of rare diseases are rising. Many of these-such as diabetes, cancer, and inherited inborn metabolic diseases-have no definite treatments or cure. Meanwhile, advanced health biotechnology has been found, in principle, to be an effective solution for these health problems. METHODS: Qualitative approaches were employed to analyse the current situation and examine existing public policies related to advanced health biotechnologies in Thailand. The results of this analysis were then used to formulate policy recommendations. RESULTS: Our research revealed that the system in Thailand in relation to advanced health biotechnologies is fragmented, with multiple unaddressed gaps, underfunding of research and development (R&D), and a lack of incentives for the private sector. In addition, there are no clear definitions of advanced health biotechnologies, and coverage pathways are absent. Meanwhile, false advertising and misinformation are prevalent, with no responsible bodies to actively and effectively provide appropriate information and education (I&E). The establishment of a specialised institution to fill the gaps in this area is warranted. CONCLUSION: The development and implementation of a comprehensive national strategic plan related to advanced health biotechnologies, greater investment in R&D and I&E for all stakeholders, collaboration among agencies, harmonisation of reimbursement across public health schemes, and provision of targeted I&E are specifically recommended.

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

OBJECTIVES: Considering rising health expenditure on the one hand and increasing public expectations on the other hand, there is a need for explicit health care rationing to secure public acceptance of coverage decisions of health interventions. The National Health Security Office, the institute managing the Universal Coverage Scheme in Thailand, recently called for more rational, transparent, and fair decisions on the public reimbursement of health interventions. This article describes the application of multicriteria decision analysis (MCDA) to guide the coverage decisions on including health interventions in the Universal Coverage Scheme health benefit package in the period 2009-2010. METHODS: We described the MCDA priority-setting process through participatory observation and evaluated the rational, transparency, and fairness of the priority-setting process against the accountability for reasonableness framework. RESULTS: The MCDA was applied in four steps: 1) 17 interventions were nominated for assessment; 2) nine interventions were selected for further quantitative assessment on the basis of the following criteria: size of population affected by disease, severity of disease, effectiveness of health intervention, variation in practice, economic impact on household expenditure, and equity and social implications; 3) these interventions were then assessed in terms of cost-effectiveness and budget impact; and 4) decision makers qualitatively appraised, deliberated, and reached consensus on which interventions should be adopted in the package. CONCLUSION: This project was carried out in a real-world context and has considerably contributed to the rational, transparent, and fair priority-setting process through the application of MCDA. Although the present project has applied MCDA in the Thai context, MCDA is adaptable to other settings.

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

OBJECTIVES: To assess the budget impact of the government use licenses policy, a form of compulsory licensing used by the government, on seven patented drugs, namely, efavirenz, lopinavir/ritonavir combination, clopidogrel, letrozole, docetaxel, erlotinib, and imatinib, in Thailand between 2006 and 2008. METHODS: By using government's perspective, budget impact was estimated within a 5-year period after the introduction of the policy. The number of patients who need treatment with each drug and the costs of treatments by both original and generic versions were obtained from Thai government agencies. Probabilistic sensitivity analysis was used to determine the impact of uncertainty surrounding parameters such as the numbers of patients and the health-care costs. RESULTS: The study indicated that the use of generic drugs under the policy could save the government budget approximately $370 million over 5 years. It was also found that each drug had a different effect on budget saving depending on the number of patients treated, the difference in drug costs between original and generic drugs, and the lag time from the introduction of the policy to the availability of the generic drugs on the market. CONCLUSION: The study showed that the introduction of the government use licenses policy in Thailand would provide significant benefits for the study timeframe; however, there are several issues that should be taken into account when the government use licenses policy is adopted.

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

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

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

BACKGROUND: A wide range of preventive, treatment, and care programs for HIV/AIDS are currently available and some of them have been implemented in Thailand. Policy makers are now facing challenges on how the scarce resources for HIV/AIDS control can be spent more wisely. Although effectiveness and cost-effectiveness information is useful for guiding policy decisions, empirical evidence indicates the importance of other criteria, such as equity and the characteristics of the target population, also play important roles in priority setting. This study aims to experiment with the use of multi-criteria decision analysis (MCDA) to prioritise interventions in HIV/AIDS control in Thailand. METHODS: We used MCDA to rank 40 HIV/AIDS interventions on the basis of the priority setting criteria put forward by three groups of stakeholders including policy makers, people living with HIV/AIDs (PLWHA), and village health volunteers (VHVs). MCDA incorporated an explicit component of deliberation to let stakeholders reflect on the rank ordering, and adapt where necessary. RESULTS: Upon deliberation, policy makers expressed a preference for programs that target high risk groups such as men who have sex with men, injecting drug users, and female sex workers. The VHVs preferred interventions that target the youth or the general population, and gave lower priority to programs that target high risk groups. PLWHA gave all interventions the same priority. The rank order correlation between the priorities as expressed before and after deliberation was 37% among the policy makers and 46% among the VHVs. CONCLUSION: This study documented the feasibility of MCDA to prioritize HIV/AIDS interventions in Thailand, and has shown the usefulness of a deliberative process as an integrated component of MCDA. MCDA holds potential to contribute to a more transparent and accountable priority setting process, and further application of this approach in the prioritisation of health interventions is warranted.

Efficiency or equity: value judgments in coverage decisions in Thailand.

PURPOSE: The purpose of this paper is to analyse the roles of social values in the reform of coverage decisions for Thailand's Universal Health Coverage (UC) plan in 2009 and 2010. DESIGN/METHODOLOGY/APPROACH: Qualitative techniques, including document review and personal communication, were employed for data collection and triangulation. All relevant data and information regarding the reform and three case study interventions were interpreted and analysed according to the thematic elements in the conceptual framework. FINDINGS: Social values determined changes in the UC plan in two steps: the development of coverage decision guidelines and the introduction of such guidelines in benefit package formulation. The former was guided by process values, while the latter was shaped by different content ideals of stakeholders and policymakers. Analysis of the three interventions suggests that in allocating its resources to subsidise particular services, the UC authority took into account not only cost-effectiveness, but also budget impacts, equity and solidarity. These social values competed with each other and, in many instances, the prioritisation of benefit candidates was not led solely by evidence, but also by value judgments, even though transparency was recognised as an ultimate goal of reform. RESEARCH LIMITATIONS/IMPLICATIONS: The study findings indicate room for improvement and for future research--the current conceptual framework is inadequate to capture all the crucial elements which influence health prioritisation, as well as their interactions with social values. ORIGINALITY/VALUE: The paper fills a gap in literature as it enhances understanding of the effects of social value judgments in real-life health prioritisation.

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

BACKGROUND: Between 2006 and 2008, Thailand's Ministry of Public Health (MOPH) granted government use licenses for seven patented drugs in order to improve access to these essential treatments. The decision to grant the government use licenses was contentious both within and beyond the country. In particular, concerns were highlighted that the negative consequences might outweigh the expected benefits of the policy. This study conducted assessments of the health and economic implications of these government use licenses. METHODS: The health and health-related economic impacts were quantified in terms of i) Quality Adjusted Life Years (QALYs) gained and ii) increased productivity in US dollars (USD) as a result of the increased access to drugs. The study adopted a five-year timeframe for the assessment, commencing from the time of the grant of the government use licenses. Empirical evidence gathered from national databases was used to assess the changes in volume of exports after US Generalized System of Preferences (GSP) withdrawal and level of foreign direct investment (FDI). RESULTS: As a result of the granting of the government use licenses, an additional 84,158 patients were estimated to have received access to the seven drugs over five years. Health gains from the use of the seven drugs compared to their best alternative accounted for 12,493 QALYs gained, which translates into quantifiable incremental benefits to society of USD132.4 million. The government use license on efavirenze was found to have the greatest benefit. In respect of the country's economy, the study found that Thailand's overall exports increased overtime, although exports of the three US GSP withdrawal products to the US did decline. There was also found to be no relationship between the government use licenses and the level of foreign investment over the period 2002 to 2008. CONCLUSIONS: The public health benefits of the government use licenses were generally positive. Specifically, the policy helped to increase access to patented drugs, while the impact of the US GSP withdrawal did not adversely affect the overall export status. Because the levels of benefit gained from the government use licenses varied widely between the seven drugs, depending on several factors, this study makes recommendations for the future implementation of the policy in order to maximise benefits.

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

BACKGROUND: Screening tests for cervical cancer are effective in reducing the disease burden. In Thailand, a Pap smear program has been implemented throughout the country for 40 years. In 2008 the Ministry of Public Health (MoPH) unexpectedly decided to scale up the coverage of free cervical cancer screening services, to meet an ambitious target. This study analyzes the processes and factors that drove this policy innovation in the area of cervical cancer control in Thailand. METHODS: In-depth interviews with key policy actors and review of relevant documents were conducted in 2009. Data analysis was guided by a framework, developed on public policy models and existing literature on scaling-up health care interventions. RESULTS: Between 2006 and 2008 international organizations and the vaccine industry advocated the introduction of Human Papillomavirus (HPV) vaccine for the primary prevention of cervical cancer. Meanwhile, a local study suggested that the vaccine was considerably less cost-effective than cervical cancer screening in the Thai context. Then, from August to December 2008, the MoPH carried out a campaign to expand the coverage of its cervical cancer screening program, targeting one million women. The study reveals that several factors were influential in focusing the attention of policymakers on strengthening the screening services. These included the high burden of cervical cancer in Thailand, the launch of the HPV vaccine onto the global and domestic markets, the country's political instability, and the dissemination of scientific evidence regarding the appropriateness of different options for cervical cancer prevention. Influenced by the country's political crisis, the MoPH's campaign was devised in a very short time. In the view of the responsible health officials, the campaign was not successful and indeed, did not achieve its ambitious target. CONCLUSION: The Thai case study suggests that the political crisis was a crucial factor that drew the attention of policymakers to the cervical cancer problem and led the government to adopt a policy of expanding coverage of screening services. At the same time, the instability in the political system impeded the scaling up process, as it constrained the formulation and implementation of the policy in the later phase.

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

BACKGROUND: Although a sizeable budget is available for HIV/AIDS control in Thailand, there will never be enough resources to implement every programme for all target groups at full scale. As such, there is a need to prioritize HIV/AIDS programmes. However, as of yet, there is no evidence on the criteria that should guide the priority setting of HIV/AIDS programmes in Thailand, including their relative importance. Also, it is not clear whether different stakeholders share similar preferences. METHODS: Criteria for priority setting of HIV/AIDS interventions in Thailand were identified in group discussions with policy makers, people living with HIV/AIDS (PLWHA), and community members (i.e. village health volunteers (VHVs)). On the basis of these, discrete choice experiments were designed and administered among 28 policy makers, 74 PLWHA, and 50 VHVs. RESULTS: In order of importance, policy makers expressed a preference for interventions that are highly effective, that are preventive of nature (as compared to care and treatment), that are based on strong scientific evidence, that target high risk groups (as compared to teenagers, adults, or children), and that target both genders (rather than only men or women). PLWHA and VHVs had similar preferences but the former group expressed a strong preference for care and treatment for AIDS patients. CONCLUSIONS: The study has identified criteria for priority setting of HIV/AIDS interventions in Thailand, and revealed that different stakeholders have different preferences vis-à-vis these criteria. This could be used for a broad ranking of interventions, and as such as a basis for more detailed priority setting, taking into account also qualitative criteria.