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.

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.

Selecting topic areas for developing quality standards in a resource-limited setting.

Variation in practices of and access to health promotion and disease prevention (P&P) across geographical areas have been studied in Thailand as well as other healthcare settings. The implementation of quality standards (QS)-a concise set of evidence-informed quality statements designed to drive and measure priority quality improvements-can be an option to solve the problem. This paper aims to provide an overview of the priority setting process of topic areas for developing QS and describes the criteria used. Topic selection consisted of an iterative process involving several steps and relevant stakeholders. Review of existing documents on the principles and criteria used for prioritising health technology assessment topics were performed. Problems with healthcare services were reviewed, and stakeholder consultation meetings were conducted to discuss current problems and comment on the proposed prioritisation criteria. Topics were then prioritised based on both empirical evidence derived from literature review and stakeholders' experiences through a deliberative process. Preterm birth, pre-eclampsia and postpartum haemorrhage were selected. The three health problems had significant disease burden; were prevalent among pregnant women in Thailand; led to high mortality and morbidity in mothers and children and caused variation in the practices and service uptake at health facilities. Having agreed-on criteria is one of the important elements of the priority setting process. The criteria should be discussed and refined with various stakeholders. Moreover, key stakeholders, especially the implementers of QS initiative, should be engaged in a constructive way and should be encouraged to actively participate and contribute significantly in the process.

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.

Health Technology Assessment capacity development in low- and middle-income countries: Experiences from the international units of HITAP and NICE.

Health Technology Assessment (HTA) is policy research that aims to inform priority setting and resource allocation. HTA is increasingly recognized as a useful policy tool in low- and middle-income countries (LMICs), where there is a substantial need for evidence to guide Universal Health Coverage policies, such as benefit coverage, quality improvement interventions and quality standards, all of which aim at improving the efficiency and equity of the healthcare system. The Health Intervention and Technology Assessment Program (HITAP), Thailand, and the National Institute for Health and Care Excellence (NICE), UK, are national HTA organizations providing technical support to governments in LMICs to build up their priority setting capacity. This paper draws lessons from their capacity building programs in India, Colombia, Myanmar, the Philippines, and Vietnam. Such experiences suggest that it is not only technical capacity, for example analytical techniques for conducting economic evaluation, but also management, coordination and communication capacity that support the generation and use of HTA evidence in the respective settings. The learned lessons may help guide the development of HTA capacity in other LMICs.

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.

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.

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.

Patterns of public participation.

Purpose - The paper summarizes data from 12 countries, chosen to exhibit wide variation, on the role and place of public participation in the setting of priorities. The purpose of this paper is to exhibit cross-national patterns in respect of public participation, linking those differences to institutional features of the countries concerned. Design/methodology/approach - The approach is an example of case-orientated qualitative assessment of participation practices. It derives its data from the presentation of country case studies by experts on each system. The country cases are located within the historical development of democracy in each country. Findings - Patterns of participation are widely variable. Participation that is effective through routinized institutional processes appears to be inversely related to contestatory participation that uses political mobilization to challenge the legitimacy of the priority setting process. No system has resolved the conceptual ambiguities that are implicit in the idea of public participation. Originality/value - The paper draws on a unique collection of country case studies in participatory practice in prioritization, supplementing existing published sources. In showing that contestatory participation plays an important role in a sub-set of these countries it makes an important contribution to the field because it broadens the debate about public participation in priority setting beyond the use of minipublics and the observation of public representatives on decision-making bodies.

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.

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.

Coverage Decisions and the Court: A Public Health Perspective on Glucosamine Reimbursement in Thailand.

-Thailand achieves universal health coverage through the introduction of three benefit schemes: the Civil Servant Medical Benefit Scheme (CSMBS), Social Security Scheme, and Universal Coverage Scheme. The primary benefit package of these schemes includes all medicines referenced in the National List of Essential Medicines. However, the CSMBS pays for nonessential drugs (NEDs) for particular conditions. The CSMBS's cost escalation prompted the Ministry of Finance to tightly control drug expenditure. In 2010, glucosamine-an NED-was prohibited from CSMBS reimbursement. Subsequently, a dispute was lodged at the Administrative Court by two CSMBS beneficiaries. The court ruled that glucosamine reimbursement should be reinstated in the CSMBS scheme based on two grounds: the Royal College of Orthopedic Surgeons of Thailand's clinical practice guidelines and an argument with reference to Article 78(8) of the 2007 Constitution mandating the state to provide appropriate benefits to government and state officials. Our comments are based on two factors: (1) the integrity of evidence that the Court applied and (2) the ruling with reference to Constitution Article 78(8) as it conflicts with Article 51, which aims to ensure equal rights to health services by all citizens. Because court cases concerning health care coverage in Thailand may expand in the future, we call upon the public to discuss the following issue: whether the court should rule on the inclusion of particular interventions or whether it should focus on the integrity of the coverage decision-making process. Similar lessons can be drawn from the experiences of countries in Latin America and Europe. In any case, all concerned parties including the court should be equipped with a good understanding of the complexity of the country's health systems in either option.

Accounting for Technical, Ethical, and Political Factors in Priority Setting.

Abstract-This article investigates two cases of priority setting to explore how, in addition to technical considerations, ethical and political factors shape the allocation of health resources. First, we discuss how Thai authorities adjudicated a coverage decision for HLA-B*1502 screening, which meets the national cost-effectiveness threshold for only some of the conditions it can detect. Second, we consider England's Cancer Drugs Fund to investigate the interplay of technical decision making and political reality. Our findings suggest four concluding observations for policy makers and others considering priority-setting processes. First, we observe that different methods can produce conflicting recommendations, which makes priority setting very complex. Second, we suggest that robust processes for generating and weighing political, ethical, and technical evidence are essential because there is no absolute standard by which resource allocation decisions can be made. Third, priority setting is inherently political, and improving its technical and ethical validity means constructing political importance for these other factors. Fourth, we argue that transparency in the trade-offs required to set priorities is important ethically and can help build support politically.

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.

Economic evaluation of 3-drug antiretroviral regimens for the prevention of mother-to-child HIV transmission in Thailand.

The current program for prevention of mother-to-child HIV transmission in Thailand recommends a 2-drugs regimen for HIV-infected pregnant women with a CD4 count >200 cells/mm(3). This study assesses the value for money of 3 antiretroviral drugs compared with zidovudine (AZT)+single-dose nevirapine (sd-NVP). A decision tree was constructed to predict costs and outcomes using the governmental perspective for assessing cost-effectiveness of 3-drug regimens: (1) AZT, lamivudine, and efavirenz and (2) AZT, 3TC, and lopinavir/ritonavir, in comparison with the current protocol, AZT+sd-NVP. The 3-drug antiretroviral regimens yield lower costs and better health outcomes compared with AZT+sd-NVP. Although these 3-drug regimens offer higher program costs and health care costs for premature birth, they save money significantly in regard to pediatric HIV treatment and treatment costs for drug resistance in mothers. The 3-drug regimens are cost-saving interventions. The findings from this study were used to support a policy change in the national recommendation.