Using cost-effectiveness analyses to inform policy: the case of antiretroviral therapy in Thailand.

BACKGROUND: Much emphasis is put on providing evidence to assist policymakers in priority setting and investment decisions. Assessing the cost-effectiveness of interventions is one technique used by policymakers in their decisions around the allocation of scarce resources. However, even where such evidence is available, other considerations may also be taken into account, and even over-ride technical evidence. Antiretroviral therapy (ART) is the most effective intervention to reduce HIV-related morbidity and prolong mortality. However, treatment provision in the developing world has been hindered by the high costs of services and drugs, casting doubts on its cost-effectiveness. This paper looks at Thailand's publicly-funded antiretroviral initiative which was first introduced in 1992, and explores the extent to which cost-effectiveness evidence influenced policy. METHODS: This article reviews the development of the national ART programme in Thailand between 1992 and 2004. It examines the roles of cost-effectiveness information in treatment policy decisions. Qualitative approaches including document analysis and interview of key informants were employed. RESULTS: Two significant policy shifts have been observed in government-organised ART provision. In 1996, service-based therapy for a few was replaced by a research network to support clinical assessments of antiretroviral medication in public hospitals. This decision was taken after a domestic study illustrated the unaffordable fiscal burden and inefficient use of resources in provision of ART. The numbers of treatment recipients was maintained at 2,000 per year throughout the 1990s. It was not until 2001 that a new government pledged to extend the numbers receiving the service, as part of its commitment to universal coverage. Several elements played a role in this decision: new groups of dominant actors, drug price reductions, a pro-active civil society movement, lessons from experience on treatment benefits, and global treatment advocacy. Unlike previous policy discourse, human rights, ethics and equity notions were explicitly raised to support therapy extension. CONCLUSION: In the early decision, moving from a relatively limited ART service to a research network was clearly influenced by cost-effectiveness data. But in the 2001 decision to include ART in the universal coverage package, cost-effectiveness arguments were over-ruled by other considerations. Thai ART policy was shaped by many factors, and was not a simple rational process which relied on evidence

Universal Access to Antiretroviral Therapy in Thailand: An Analysis of the Policy Process

Antiretroviral therapy (ART) is effective in reducing HIV morbidity and mortality as well as improving patients' quality of life. However, because of several hurdles, resource-poor countries have provided treatment to only a few people in need. Thailand is unusual in having opted to offer universal coverage for therapy. This thesis aims to understand the process by which ART reached the Thai Government agenda, and to explore the lessons learned from the design and implementation of the publicly-organised treatment programme. This study suggests that Thailand's ART programme was influenced by the networks and learning of several actors which evolved over time. During a period of policy continuity between 1992 and 2000, the policy process developed within a relatively closed subsystem dominated by health officials in the Disease Control Department and HIV experts. The cost of antiretrovirals was the major factor restraining treatment coverage. The dramatic shift in ART service towards universal access took place in 2001, as a consequence of drug price reduction and political transformation that allowed participation of new Health Minister, health financing reformists, and an alliance of non-governmental organisations (NGOs). Apparently, local and external treatment experiences inspired these actors to pursue similar paths in Thailand. The rapid policy formulation process was facilitated by common interests, shared experience, previously established collaboration, as well as awareness of interdependency among members of the Ministry of Public Health's Technical and Administration Panels. Learning about the intricacy in ART administration, especially from existing programmes and research studies in the country, played a crucial role in devising treatment expansion plans. The individual expertise of clinical specialists, researchers, health officials, NGOs and PL WHA helped to accelerate lesson drawing from policy feedback, anticipating future obstacles and selecting appropriate policy options. At the sub-national level, the process by which the universal ART policy was translated into action involved another set of actors, comprising hospital administrators, health professionals, officials in the Health Ministry's Regional and Provincial Offices, local NGOs and PLWHA groups. A key feature of policy in this phase was that the front-line workforce struggled to carry out the tasks prescribed by national policy makers. The discrepancy between the programme's expectation and actual therapy delivered in two study provinces was significant, resulting from insufficient number of experienced health personnel, increased workload as an effect of parallel reforms in the health and public administration systems, and stigma attached to HIV. To counter these impediments, treatment execution networks of government staff and civic groups were instigated. Collective learning among service providers, supporters and clients had an important role in ART scaling up. Different coping strategies were implemented in study hospitals, aiming to balance the contradictory goals of achieving the allocated targets while maintaining treatment quality. This thesis demonstrates that to understand policy development in such a complex circumstance governments cannot unilaterally deal with particular problems. Employing a policy network concept to address the partnership between state and non-state actors is not only useful but essential as the policy environment has expanded beyond merely state actions, to depend, to some extent, on non-state actors. Moreover, the integration of policy learning model into policy analysis framework can provide insights into the increasingly dynamic interactions between actors, context and processes of public policy in focus

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

<p>Abstract</p> <p>Background</p> <p>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.</p> <p>Methods</p> <p>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).</p> <p>Results</p> <p>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.</p> <p>Conclusions</p> <p>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.</p

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

Contains fulltext : 108744.pdf (publisher's version ) (Open Access)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

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

National Health Insurance in South Africa: Relevance of a national priority-setting agency

With evidence mounting that universal health coverage can be a costly exercise, informed priority-setting will be key to ensuring that public financing for health is used effectively, efficiently and equitably

National Health Insurance in South Africa: Relevance of a national priority-setting agency

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Patterns of public participation: opportunity structures and mobilization from a cross-national perspective

Purpose: The paper summarizes data from twelve countries, chosen to exhibit wide variation, on the role and place of public participation in the setting of priorities. It seeks 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

Scaling up health policies and services in low- and middle-income settings

"Scaling up" effective health services is high on the policy agendas of many countries and international agencies. The current concern has been driven by growing recognition both of the challenges of achieving the health-related Millennium Development Goals (MDGs) in many countries, and of the need to ensure that the increased resources for health channelled through disease-specific health initiatives are able generate health gain at scale. Effective and cost-effective interventions exist to address many of the major causes of disease burden in the developing world, but coverage of many of these services remains low. There is a substantial gap between what could be achieved and what is actually being achieved in terms of health improvement in low- and middle-income countries

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

Contains fulltext : 87849.pdf (publisher's version ) (Open Access)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-a-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