Universal Access to Antiretroviral Therapy in Thailand : An Analysis of the Policy Process
Tantivess, Sripen ; (2006) Universal Access to Antiretroviral Therapy in Thailand : An Analysis of the Policy Process. London School of Hygiene & Tropical Medicine. DOI: 10.17037/PUBS.01440241
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ABSTRACT 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, - 2 - 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.
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