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

Experiences and challenges of pre-exposure prophylaxis initiation and retention among high-risk populations: qualitative insights among service providers in Thailand

Objectives

Pre-exposure prophylaxis (PrEP) has been an essential element of the national combination prevention package and included in the Universal Health Coverage (UHC) of Thailand since 2019. As a part of the national monitoring and evaluation framework, this qualitative study aims to describe experiences and barriers concerning PrEP initiation and retention among service providers from both hospital and Key Population Led Health Service (KPLHS) settings under the country's UHC roll-out.

Methods

Between September and October 2020, ten focus group discussions with PrEP service providers from both hospitals and KPLHS across Thailand were conducted of which there were six hospitals, one health service center, three KPLHS. All interviews were recorded and transcribed verbatim to identify providers' experiences, attitudes, and perceived barriers regarding PrEP service delivery in Thailand.

Results

Among the 35 PrEP service providers, most of them reported positive attitudes toward PrEP and believed that it is an effective tool for HIV prevention. Men who have sex with men were perceived to be the easiest group to reach while PrEP uptake remains a challenge in other key populations. Integration of a PrEP clinic with other HIV services at hospitals made most healthcare providers unable to adopt an active approach in recruiting new clients like at KPLHS settings. Challenges in delivering PrEP services included lack of public awareness, high workload, limited benefit package coverage, structural and human resources.

Conclusion

Additional services to address different health needs should be considered to increase PrEP uptake among harder-to-reach populations. Novel approaches to PrEP service integration and close collaboration between hospitals and KPLHS would be essential in optimizing PrEP uptake and retention. Support regarding raising awareness, expanding service coverage and access, improving facilities and workforce, and providers' capacities are crucial for the success of the national PrEP programme.

International Trade and Health in Thailand: A Scoping Review

International trade has become more complicated and is now related to more aspects of health and the health system. As Thailand is active in international trade and health, understanding what knowledge exists and determining the knowledge gap is essential for generating the necessary evidence in order to promote better understanding and allow evidence-based policy decisions to be made. This study reviewed the existence of knowledge on international trade and health issues in a scoping review, focusing on Thailand during the period 1991-2020. In total, 156 studies from seven databases and manual searching were included. Of these, 46% were related to trade in health services and 39% were linked to intellectual property, particularly access to medicines. This review found only a very small amount of research on other issues and did not identify any study on trade policies or products related to health and international trade and the environment. We therefore recommend that further studies should be carried out to provide more critical evidence-in particular, more research focusing on the impacts of trade on health-related goods and the analysis of the positive and negative impacts of international trade on industry is needed. Furthermore, better knowledge management through the publication of research findings and making them searchable on international databases will increase the visibility of international trade, increase our knowledge of health issues, and provide supporting evidence.

Understanding of for whom, under what conditions and how the compulsory licensing of pharmaceuticals works in Brazil and Thailand: A realist synthesis

When pharmaceuticals are not fully available mainly due to the high cost of medicines, a government can issue compulsory licensing (CL). It is well documented that Brazil and Thailand have notably attempted CL. A realist review was undertaken to understand the identical social interventions in comparative settings, and to draw practical implications for attempting CL relevant for middle-income countries in the era of high-cost medicines. CL is not only a politically well-devised measure to achieve universal health coverage, but also a tentative commitment, which is determined both at the country level and at the global level. At the country level, political will, with catalytic roles of civil activism, is important in order to guarantee the right to health. Through this will, the governments can achieve universal health coverage. In addition, electoral systems, political leaders, and a constitution are necessary to attempt CL. In addition, CL should operate along with other policy instruments, including a comprehensive essential medicines list, CL-friendly phrasing in patent law, and a competent pharmaceutical industry. At the global level, the balance of power between the WTO regime and the global justice movement is critical. This provides global-level context that can either encourage or prevent CL.

Cost-effectiveness analysis of the national implementation of integrated community case management and community-based health planning and services in Ghana for the treatment of malaria, diarrhoea and pneumonia

BACKGROUND

Ghana has developed two main community-based strategies that aim to increase access to quality treatment for malaria, diarrhoea and suspected pneumonia: the integrated community case management (iCCM) and the community-based health planning and services (CHPS). The aim of the study was to assess the cost-effectiveness of these strategies under programme conditions.

METHODS

A cost-effectiveness analysis was conducted. Appropriate diagnosis and treatment given was the effectiveness measure used. Appropriate diagnosis and treatment data was obtained from a household survey conducted 2 and 8 years after implementation of iCCM in the Volta and Northern Regions of Ghana, respectively. The study population was carers of children under-5 years who had fever, diarrhoea and/or cough in the last 2 weeks prior to the interview. Costs data was obtained mainly from the National Malaria Control Programme (NMCP), the Ministry of Health, CHPS compounds and from a household survey.

RESULTS

Appropriate diagnosis and treatment of malaria, diarrhoea and suspected pneumonia was more cost-effective under the iCCM than under CHPS in the Volta Region, even after adjusting for different discount rates, facility costs and iCCM and CHPS utilization, but not when iCCM appropriate treatment was reduced by 50%. Due to low numbers of carers visiting a CBA in the Northern Region it was not possible to conduct a cost-effectiveness analysis in this region. However, the cost analysis showed that iCCM in the Northern Region had higher cost per malaria, diarrhoea and suspected pneumonia case diagnosed and treated when compared to the Volta Region and to the CHPS strategy in the Northern Region.

CONCLUSIONS

Integrated community case management was more cost-effective than CHPS for the treatment of malaria, diarrhoea and suspected pneumonia when utilized by carers of children under-5 years in the Volta Region. A revision of the iCCM strategy in the Northern Region is needed to improve its cost-effectiveness. Long-term financing strategies should be explored including potential inclusion in the National Health Insurance Scheme (NHIS) benefit package. An acceptability study of including iCCM in the NHIS should be conducted.

The health impact of trade and investment agreements: a quantitative systematic review and network co-citation analysis

BACKGROUND

Regional trade agreements are major international policy instruments that shape macro-economic and political systems. There is widespread debate as to whether and how these agreements pose risks to public health. Here we perform a comprehensive systematic review of quantitative studies of the health impact of trade and investment agreements. We identified studies from searches in PubMed, Web of Science, EMBASE, and Global Health Online. Research articles were eligible for inclusion if they were quantitative studies of the health impacts of trade and investment agreements or policy. We systematically reviewed study findings, evaluated quality using the Quality Assessment Tool from the Effective Public Health Practice Project, and performed network citation analysis to study disciplinary siloes.

RESULTS

Seventeen quantitative studies met our inclusion criteria. There was consistent evidence that implementing trade agreements was associated with increased consumption of processed foods and sugar-sweetened beverages. Granting import licenses for patented drugs was associated with increased access to pharmaceuticals. Implementing trade agreements and associated policies was also correlated with higher cardiovascular disease incidence and higher Body Mass Index (BMI), whilst correlations with tobacco consumption, under-five mortality, maternal mortality, and life expectancy were inconclusive. Overall, the quality of studies is weak or moderately weak, and co-citation analysis revealed a relative isolation of public health from economics.

CONCLUSION

We identified limitations in existing studies which preclude definitive conclusions of the health impacts of regional trade and investment agreements. Few address unobserved confounding, and many possible consequences and mechanisms linking trade and investment agreements to health remain poorly understood. Results from our co-citation analysis suggest scope for greater interdisciplinary collaboration. Notwithstanding these limitations, our results find evidence that trade agreements pose some significant health risks. Health protections in trade and investment treaties may mitigate these impacts.

Global cancer surgery: delivering safe, affordable, and timely cancer surgery

Surgery is essential for global cancer care in all resource settings. Of the 15.2 million new cases of cancer in 2015, over 80% of cases will need surgery, some several times. By 2030, we estimate that annually 45 million surgical procedures will be needed worldwide. Yet, less than 25% of patients with cancer worldwide actually get safe, affordable, or timely surgery. This Commission on global cancer surgery, building on Global Surgery 2030, has examined the state of global cancer surgery through an analysis of the burden of surgical disease and breadth of cancer surgery, economics and financing, factors for strengthening surgical systems for cancer with multiple-country studies, the research agenda, and the political factors that frame policy making in this area. We found wide equity and economic gaps in global cancer surgery. Many patients throughout the world do not have access to cancer surgery, and the failure to train more cancer surgeons and strengthen systems could result in as much as US $6.2 trillion in lost cumulative gross domestic product by 2030. Many of the key adjunct treatment modalities for cancer surgery--e.g., pathology and imaging--are also inadequate. Our analysis identified substantial issues, but also highlights solutions and innovations. Issues of access, a paucity of investment in public surgical systems, low investment in research, and training and education gaps are remarkably widespread. Solutions include better regulated public systems, international partnerships, super-centralisation of surgical services, novel surgical clinical trials, and new approaches to improve quality and scale up cancer surgical systems through education and training. Our key messages are directed at many global stakeholders, but the central message is that to deliver safe, affordable, and timely cancer surgery to all, surgery must be at the heart of global and national cancer control planning.

Policies and programs to facilitate access to targeted cancer therapies in Thailand

BACKGROUND

Increasing access to clinically beneficial targeted cancer medicines is a challenge in every country due to their high cost. We describe the interplay of innovative policies and programs involving multiple stakeholders to facilitate access to these medicines in Thailand, as well as the utilization of selected targeted therapies over time.

METHODS

We selected two medicines on the 2013 Thai national list of essential medicines (NLEM) [letrozole and imatinib] and three unlisted medicines for the same indications [trastuzumab, nilotinib and dasatinib]. We created timelines of access policies and programs for these products based on scientific and grey literature. Using IMS Health sales data, we described the trajectories of sales volumes of the study medicines between January 2001 and December 2012. We compared estimated average numbers of patients treated before and after the implementation of policies and programs for each product.

RESULTS

Different stakeholders implemented multiple interventions to increase access to the study medicines for different patient populations. During 2007-2009, the Thai Government created a special NLEM category with different coverage requirements for payers and issued compulsory licenses; payers negotiated prices with manufacturers and engaged in pooled procurement; pharmaceutical companies expanded patient assistance programs and lowered prices in different ways. Compared to before the interventions, estimated numbers of patients treated with each medicine increased significantly afterwards: for letrozole from 645 (95% CI 366-923) to 3683 (95% CI 2,748-4,618); for imatinib from 103 (95% CI 72-174) to 350 (95% CI 307-398); and for trastuzumab from 68 (95% CI 45-118) to 412 (95% CI 344-563).

CONCLUSIONS

Government, payers, and manufacturers implemented multi-pronged approaches to facilitate access to targeted cancer therapies for the Thai population, which differed by medicine. Routine monitoring is needed to assess clinical and economic impacts of these strategies in the health system.

Evidence-informed frameworks for cost-effective cancer care and prevention in low, middle, and high-income countries

Evidence-informed frameworks for cost-effective cancer prevention and management are essential for delivering equitable outcomes and tackling the growing burden of cancer in all resource settings. Evidence can help address the demand side pressures (ie, pressures exerted by people who need care) faced by economies with high, middle, and low incomes, particularly in the context of transitioning towards (or sustaining) universal health-care coverage. Strong systems, as opposed to technology-based solutions, can drive the development and implementation of evidence-informed frameworks for prevention and management of cancer in an equitable and affordable way. For this to succeed, different stakeholders-including national governments, global donors, the commercial sector, and service delivery institutions-must work together to address the growing burden of cancer across economies of low, middle, and high income.

Five-year trends in antiretroviral usage and drug costs in HIV-infected children in Thailand

BACKGROUND

As antiretroviral treatment (ART) programs mature, data on drug utilization and costs are needed to assess durability of treatments and inform program planning.

METHODS

Children initiating ART were followed up in an observational cohort in Thailand. Treatment histories from 1999 to 2009 were reviewed. Treatment changes were categorized as: drug substitution (within class), switch across drug class (non nucleoside reverse-transcriptase inhibitors (NNRTI) to/from protease inhibitor (PI)), and to salvage therapy (dual PI or PI and NNRTI). Antiretroviral drug costs were calculated in 6-month cycles (US$ 2009 prices). Predictors of high drug cost including characteristics at start of ART (baseline), initial regimen, treatment change, and duration on ART were assessed using mixed-effects regression models.

RESULTS

Five hundred seven children initiated ART with a median 54 (interquartile range, 36-72) months of follow-up. Fifty-two percent had a drug substitution, 21% switched across class, and 2% to salvage therapy. When allowing for drug substitution, 78% remained on their initial regimen. Mean drug cost increased from $251 to $428 per child per year in the first and fifth year of therapy, respectively. PI-based and salvage regimens accounted for 16% and 2% of treatments prescribed and 33% and 5% of total costs, respectively. Predictors of high cost include baseline age ≥ 8 years, non nevirapine-based initial regimen, switch across drug class, and to salvage regimen (P < 0.005).

CONCLUSIONS

At 5 years, 21% of children switched across drug class and 2% received salvage therapy. The mean drug cost increased by 70%. Access to affordable second- and third-line drugs is essential for the sustainability of treatment programs.