1. 1 Scaling-up ART in Thailand: the role of policy networks Sripen Tantivess International Health Policy Program, Thailand CREHS Data Analysis Workshop, Chennai, 29 March 2007

2. 2 ART recipients under public programmes, 1992-2006 Source: Bureau of AIDS, Tuberculosis and Sexually-transmitted Infections Universal ART policy AZT monotherapy Clinical Research Network Access to care programme

3. 3 ActorsPolicy networks Context Process Agenda setting Formulation Implementation Policy outcomes Specific objectives: 1. To explain the shift in the agenda towards universal ART access and the processes of policy adoption, formulation and implementation. 2. To analyse actor involvement in each policy stage. 3. To assess the context that influenced policy development and implementation. 4. To identify networks of actors and examine their roles in treatment policy. Conceptual framework:

4. 4 Agenda setting & policy adoption Local production of generic ARVs Drug price reduction Campaigns run by NGOs Instigation of universal health coverage (UC) programme Global mainstream to promote ART access Changes in actor networks 1992-2000: MOPH officials (Disease Control Department) and HIV specialists 2001: new Health Minister, MOPH officials (health economists and financing reformists), NGOs/PHA groups

5. 5 Policy formulation New programme configurations and preparation required MOPH appointed administration and technical panels Policy network members: STATE: Disease Control Department, HIV experts, health workers, health financing researchers NON-STATE: NGOs and PHA groups Resource exchange STATE: authority, technical expertise, management skills NON-STATE: experience on HIV care (and expected collaboration in the next stage) Common interest: rapid ART expansion, increased access to treatment

6. 6 General context of policy implementation 1. Parallel reforms: Universal Health Coverage Scheme  increased workload Health promotion programme  HP services in community Public administration reforms  reallocation and early retirement of health officials/workers 2. Inadequate experienced health workers 3. HIV-related stigma  impediments in treatment & care delivery 4. ART extension as priority, urgent policy  pressures on implementers

7. 7 Policy implementation Activities: patient enrollment; counseling; drug information; laboratory; ARV prescribing; follow-up; home visits; psychological support Influence of general/local context (obstacles) Coping strategies: Treatment networks of provincial and district providers Public-civic partnerships Nurse and pharmacist prescribing in uncomplicated cases Exchanging information – sharing experience Drawing lessons on clinical research and existing ART programmes

8. 8 Policy implementation networks Policy network members: STATE: health officials; health professionals; lab. scientists; social workers NON-STATE: local HIV NGOs and patient groups Resource exchange STATE: authority, clinical & technical expertise, management skills NON-STATE: capacity and experience on HIV care Common interest: rapid ART expansion, increased access to treatment

9. 9 Local context: Strong NGOs and PHA networks Existing public-civic collaboration well-accepted by hospitals self-funded ART Local context: Weak NGOs and PHA networks Existing public-civic collaboration hospital-led PHA groups Rapid turnover of district hospital GPs Strong participation of NGOs/PHA in ART extension Provincial-district professional networks for training and consultations Province AProvince B

10. 10 Impediments Increased demands Changes in objectives More resources needed Policy community Extended policy network (issue network?) small number professional members consistent relationship common values & background hierarchical  some actors dominated the policy relatively large number different values & background imbalanced relationship different capacity & power common purpose & interests Lessons learned: