Thailand - World Health Organization

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Mar 23, 2010 - antiretroviral therapy (ART), lab technician training for CD4 and viral load, .... As we have more than 50 nursing colleges and 15 medical schools, both public ..... including physician doctor, nurse, counselor, pharmacist and ...
Human Resources for Health Implications of Scaling Up For Universal Access to HIV/AIDS Prevention, Treatment, and Care: Thailand Rapid Situational Analysis March 2010 Ms. Thidaporn Jirawattanapisal, Ministry of Public Health, Thailand Dr. Suwit Wibulpolpraset, Ministry of Public Health, Thailand Dr. Sombat Thanprasertsuk, WHO Country Office, Thailand Dr. Thidakorn Noree Ministry of Public Health, Thailand

GLOBAL HEALTH WORKFORCE ALLIANCE TECHNICAL WORK GROUP SECRETARIAT: INTRAHEALTH INTERNATIONAL

TABLE OF CONTENTS EXECUTIVE SUMMARY.................................................................................................................. 1 BACKGROUND AND INTRODUCTION ......................................................................................... 2 METHODOLOGY FOR RAPID SITUATIONAL ANALYSIS............................................................. 3 FINDINGS ....................................................................................................................................... 3 Promising Mechanisms and Practices ................................................................................................................ 3 Gaps and Challenges ................................................................................................................................................ 6 Critical Interventions to Address Challenges ................................................................................................... 7 Leadership Action and Partner Support Needed ........................................................................................... 7 Key Messages................................................................................................................................. 8 Recommended Actions for the Near Term ...................................................................................................... 8 Recommended Actions for the Long Term ...................................................................................................... 9 Appendix A: List of Key Informants Interviewed ..................................................................... 10 Appendix B: List of Steering Committee Members ................................................................. 11 Appendix C: Background Data Collected.................................................................................. 12 Appendix D: Key Documents Reviewed .................................................................................... 33

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EXECUTIVE SUMMARY The Global Health Workforce Alliance (GHWA) Task Force commissioned a multicountry rapid situation analysis of the human resources for health (HRH) implications for scaling up to universal access to HIV prevention, treatment, care, and support. This report presents the findings and key messages for Thailand. Thailand has been hit hard by the AIDS epidemic since the mid 1980s.The HIV incidence in the early 1990s was more than 100,000 per year. With effective preventive measures, especially the 100% condom usage among commercial sex workers started in late 1980s, the epidemic was halted and the trend reversed. The incidence in 2009 was only around 14,000 per year. This greatly exceeds the target set forth in the Millennium Development Goals. In October 2003, universal access to antiretroviral (ARV) drugs was approved as the national policy and was achieved rapidly. Since 2006, it has been integrated into the universal health insurance scheme and mainly based on local resources. There have been four important factors that have contributed to Thailand’s success: 1) strong multisectoral political commitment and leadership, 2) a strong civil society organizations (CSOs) movement, 3) long-term continuous investment in health care systems, and 4) early on aggressive actions to prevent the spread of HIV. Remaining challenges There are still gaps in preventing the emerging trend from casual sex, especially among teenagers and married men, men who have sex with men (MSM), and intravenous drug users (IVDUs). Access to counseling and testing is still low. This results in most patients starting to receive specific treatment at very low CD4 level. There is also a need to provide appropriate care to asymptomatic positive people. Compliance to the first-line ARVs, although quite high (more than 75%) requires close monitoring to ensure continuity to avoid ARV resistance. Retention of health workers in the rural and hardship areas is difficult. The rapid turnover, especially among medical doctors, requires continuous training and retraining on HIV/AIDS and task shifting. Transmission and access to care among more than 4 million migrants, especially illegal migrants, as well as half a million stateless people is difficult. Recommendations 1. The Ministry of Public Health should seriously estimate the future shortage of human resources for health (HRH) in the rural areas and increase the production in an appropriate manner.

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2. The Ministry of Public Health and related partners should ensure the continuity of and improve the regular in-service training programs on HIV/AIDS care. 3. The Ministry of Public Health should ensure the long-term continuous investment in the health infrastructures and health workers. This is essential to maintain the universal access to HIV/AIDS prevention, treatment, and care. 4. The National Health Security Office should enroll the clearly defined stateless people into the universal health coverage program as soon as possible. Funding support from GFATM and other donors should be mobilized to provide highest access to essential prevention, treatment, and care services to the unregistered stateless people, and the mobile illegal migrant workers. Special effective and comprehensive long-term programs, based on local resources, should be formulated and implemented among the illegal migrants. 5. The health and education sectors should work with all partners to promote safe sex based on the Healthy Sexuality concept among youth, and greatly expand access to counseling and testing services.

BACKGROUND AND INTRODUCTION GHWA, in recognition that HRH are a major obstacle to the scale-up of HIV services for universal access as well as achieving the health-related MDGs, established the Task Force on HRH Implications of Universal Access to HIV Prevention, Treatment, Care, and Support. The main purpose of the Task Force is to: Develop evidence-based key messages for a global strategic direction to guide the process and approaches needed to meet country-level HRH requirements to achieve national targets for scaling up toward universal access that enhance other national health delivery systems Make strategic key messages that will inform, contribute to, and influence political and policy discussion and action at global, regional, and country levels to address the HRH crisis and assist countries in implementing key messages. Six countries accepted the invitation to participate in this initiative: Cote d’Ivoire, Ethiopia, Haiti1, Mozambique, Thailand, and Zambia. Rapid situational analyses conducted at the country level obtained up-to-date information on: a) country-specific promising practices that promote scaleup toward universal access to HIV/AIDS services, b) gaps and challenges that relate to country goals/targets for HIV/AIDS, c) critical interventions that will address challenges and lead to effective scale-up, and d) leadership action and partner support required to enable critical interventions. Ministries of health and the World Health Organization (WHO) country offices

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Due to the devastating earthquake in January 2010, Haiti is not included in this initiative.

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were asked to join with GHWA international HRH specialists to carry out the work in the six countries. The results of this country-level fieldwork forms the content of this final report and provides global strategic direction to guide decision-makers for how to address the HRH challenges to scale up HIV/AIDS services. This report outlines the findings and key messages resulting from the rapid situational analysis in Thailand.

METHODOLOGY FOR RAPID SITUATIONAL ANALYSIS The Task Force developed a common protocol to be followed in each country. Basic elements of this protocol are the following: 1. Specific, but focused, information at the country level will be collected on HIV epidemiology, HIV program indicators, actual strength of the health workforce, national HRH system including HRH plans and strategies, and progress on implementation of task-shifting policies. 2. Select key informant interviews focusing on these four questions: a. What promising practices exist that have a positive impact on scale-up? b. What are the HRH gaps or challenges that relate to the country goals/targets for HIV services? c. What are the most critical interventions to address these challenges and lead to effective scale-up? d. What leadership action and partner support are required to enable implementation of HRH scale-up? 3. A small steering group will be formed from national HRH and HIV experts, representatives from the MOH and other appropriate ministries or stakeholder groups, selected key informants, and international partners. This group will meet with the field team to provide guidance and input into the rapid analysis and will continue to engage with the government and partners to use the key messages and recommendations coming from this fieldwork to strengthen national responses to the HRH crisis that impedes universal access to HIV/AIDS services. 4. The report of the rapid situational analysis for each country was made available incountry and provided to the Task Force. Two members of each country team were invited to attend the final Task Force meeting in Geneva on March 23 and 24, 2010 to present their findings.

FINDINGS Promising Mechanisms and Practices HRH implications of scaling up for universal access to HIV/AIDS prevention, treatment, and care: Thailand

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Strong multisectoral political commitment and leadership. In 1990 the Thai cabinet approved the establishment of a National AIDS Committee (NAC), chaired by the Prime Minister (PM). This multisectoral committee includes all relevant sectors, academics, civil society organizations, community of people living with the disease, and the private sector. The committee has been able to push for several important intersectoral movements in the prevention and control of the disease since the epidemic’s early phases, including an intensive social campaign and the 100% condom coverage among commercial sex workers program. The PM and the cabinet also approved the universal access to ARVs advocated by the CSOs, beginning in October 2003. Several in-service trainings for counselors, training for doctors on antiretroviral therapy (ART), lab technician training for CD4 and viral load, and procurement and distribution of ARVs are part of the program. However, as a committee appointed by the cabinet, it is automatically dissolved when there is a change in the government. The reappointment usually takes a several months, which has resulted in the discontinuity of the committee’s work. In 2003, the cabinet approved the Office of the Prime Minister’s Regulation on AIDS Control. This regulation establishes a more permanent, three-year term for the NAC. It allows the NAC to work continuously without being subject to change in the government. Strong Civil Society Organizations Movement. Since the early days of the epidemic, many CSOs were established. To date, there are approximately 440 AIDS-related CSOs. The CSO networks play instrumental roles in destigmatization of people living with HIV, accessing the difficult groups like IVDUs and MSM, as well as the movement toward universal access to ARVs. The CSOs leaders were included in the NAC from the beginning. At the moment there are two CSOs approved by the Country Coordinating Mechanism to be the principle recipients of the Global Fund in Thailand. The first one was approved in 2003. Leaders of CSOs are also appointed as members of the sub-committee on HIV/AIDS to oversee the implementation of the universal access to ARV program. The CSOs actively pushed for the implementation of the government use of patent to allow universal access to the second-line ARVs. They proposed to the minister of public health in 2000 to implement the government use of patent on the drug DDI. It was in November 2006 that the first government use of patent was issued for Efavirenz, followed by the second one for Lopinavir/Ritonavir in January 2007. The Ministry of Public Health has provided direct financial support to CSOs on health, especially HIV/AIDS since 1992, with an annual budget of around $US 2 million (now reduced to $US 1 million). Furthermore, there is also budgetary support from the National Health Security Office and GFATM to the CSOs. Long-term, continuous investment in health systems and human resources for health at all levels. This continuous investment has resulted in the universal coverage of basic essential HRH implications of scaling up for universal access to HIV/AIDS prevention, treatment, and care: Thailand

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health services since the late 1980s. The rural health infrastructure was gradually implemented beginning in the 1950s, starting with the 100% coverage of the provincial hospitals. Then 100% coverage of rural district hospitals and health centers in late 1970s to late 1980s. In early 1980s, when there was serious economic downturn due to two oil shocks, the government made a bold decision to freeze all new capital investment in the urban health facilities so that the limited budget could be reallocated to build up the rural health infrastructure. The inadequate HRH was addressed by extensive training of public health workers and technical nurses, both with two years of education after senior high school. Since 1972, new medical graduates were also mandated to work for the government mainly in the rural health facilities for three years. Reorientations of health professional education were also extensively implemented, especially during the PHC eras in 1980s. These curricula now also include subjects on HIV/AIDS. These movements have built adequate health infrastructures and HRH throughout the country. These investments reduced greatly the geographical barriers in response to emerging epidemics, including HIV/AIDS. Currently, there are around 1,100 hospitals, including more than 700 rural district hospitals designated to provide ARV treatment. The universal health insurance coverage in 2002 further eliminated the financial barriers to essential health care, including ARV treatment. Since October 2003, anyone who needs ARV treatment now will have no barrier to access (Wibulpolprasert 2007). In the first three years, the program was partially funded by GFATM grants. Since October 2006, it was incorporated into the universal health insurance systems and based entirely on local resources. The strong health care system, with adequate and qualified health workers, is one of the most important factors for the achievement of universal access to HIV prevention, treatment, and care. Early on aggressive actions to prevent the spread of HIV. The very effective supply side intervention of 100% condom coverage among sex workers program (Rojanapithayakorn W and R 1996), supported by strong social campaigns, has rapidly reduced the HIV incidence by almost 10 times in less than 20 years. In the late 1980s and early 1990s, the incidence of HIV infection was at its peak with more than 100,000 new infections per year. Effective prevention programs brought the figure down to less than 14,000 new infections per year in 2009 (BOE 2009). Successful prevention of mother-to-child transmission (PMTCT) programs, with more than 97% coverage, also contribute to much less vertical transmission—from 33% in 1999 to less than 5% in 2009 (Sirinirun P, Danthumrongkul V et al. 2008) The rapid reduction of incidence, together with the high mortality in 1990s due to lack of effective treatment, have reduced prevalence. This resulted in a reduced number of patients requiring ARVs, less financial burden, and less strain on health care facilities. It was estimated that the universal access to ARV treatment program requires less than 2% of total full-time equivalent of doctors and nurses (Jirawattanapisal 2009). Even in the hard hit provinces, the infrastructure and health workers are adequate to cope with the universal access program.

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Supervision and coaching system. A strong stepwise supervision and coaching system to support effective ARV programs has been established. The twelve technical Regional Disease Prevention and Control Offices (under the Disease Control Department), work closely with the twelve financial regional offices of the National Health Security Offices, to supervise and support the provincial ARV advisory networks. The provincial network provides close supervision and coaching, technical support, and supplies to all health facilities that provide universal access to prevention, treatment, and care.

Gaps and Challenges

There are still gaps in preventing the emerging trend from casual sex, especially among teenagers, MSM, and IVDUs; these are considered difficult to reach groups. Although the stigmatization of MSM is not that significant in Thailand, it is not easy to reach their community. The IVDUs group is also quite stigmatized. Methadone replacement treatment, although available, is not widely distributed enough for easy access. It was not part of the universal health insurance systems in the beginning and was just put into the systems in 2009. We now see the worrisome increasing trend of unsafe sex among teenagers, which resulted in increasing unplanned teenage pregnancies, and higher incidence of HIV. The access to counseling and testing, both voluntary and provider-initiated, is still low. As a result, most patients start to receive specific ARV treatment at very low CD4 level, or after the symptoms of opportunistic infections occur. The universal access program targeted a voluntary counseling and testing (VCT) service of 500,000 cases in 2008, but could achieve only 51.5% of the target (NHSO 2009). The obstacles are still stigmatization, inadequate advocacy, inadequate number of counselors, and the lack of availability of provider-initiated counseling and testing. Among all necessary cadres to provide access to ARVs, the largest shortage is the counselors. Furthermore, there is a need to provide appropriate care to those who tested positive for HIV but are still asymptomatic. This requires close follow up on their CD4 level as well as counseling services, which require extensive availability of the comprehensive quality ARVs services all over the country. The compliance to the first-line ARVs, although quite high (over 75%), require close monitoring to ensure continuous high compliance to avoid resistance. This is a big challenge to the universal access program. Due to the seriousness of the disease, it seems that the patient compliance is quite high among Thais who have the rights to the universal access program. There is, however, a big problem among the approximate 2-3 million illegal migrant workers and the half a million so-called stateless people. For its sustainable economic growth, Thailand depends on illegal migrant workers who work for low wages. These workers come from neighboring countries, including Myanmar, Laos, Cambodia, and Vietnam. The compliance to ARVs among this group of people is quite low, due to financial burden as well as the high rate of migration. The retention and motivation of health workers in the rural health infrastructure, especially in the hardship areas is a problem. The rapid turnover, especially among medical doctors and nurses, requires continuous training and retraining on HIV/AIDS care as well as task shifting to HRH implications of scaling up for universal access to HIV/AIDS prevention, treatment, and care: Thailand

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lower-level cadres. In spite of the fact that there are very high financial incentives, there are still wide gaps in HRH distribution (Thammarangsri 2000; Thammarangsri 2005; Noree T, Chokchaichan H et al. 2008). The mushrooming of private hospitals and the rapid influx of foreign patients complicate this problem. The private health facilities share more than 25% of the health professionals, but less than 20% of outpatient visits, and less than 15% of the inpatient load. Public sector reforms, with downsizing of civil servant positions in rural facilities, also contribute to the difficulties in retention (BHSSD 2007; Wibulpolprasert 2007).

Critical Interventions to Address Challenges

There are five factors that have been the most critical interventions made in Thailand to address HRH challenges to HIV scale-up: 1. Innovative prevention programs are supported, through the subcommittee on HIV preventions with a budget of more than US $15 million. Support from GFATM grants also contributes to the access among those difficult to reach groups. 2. Huge financial and non-financial incentives have been given to health professionals in rural areas. Doctors in the remote rural district hospitals can now earn higher monthly income than even the health minister and can be promoted to the same level of the provincial chief medical officers or the deputy DG of a central department. 3. Increased production of health professionals (i.e., medical doctors, nurses, and allied health personnel) with a special focus on rural recruitment, local training, and home town placement, e.g., the One District One Doctor program. 4. Regular training and retraining on universal access to ARVs to relevant health professionals as well as allowing trained nurses to deliver ARVs for follow-up patients. 5. Approval of the adequate financial support to the HIV-Qual T project by the National Health Security Office, to sustainably improve the quality of ARVs services, particularly on the psychosocial dimension.

Leadership Action and Partner Support Needed

It would be very beneficial if GFTM grants and donors would support universal access to HIV prevention, treatment, and care among illegal migrant workers and stateless people, which the Thai national budget cannot support. It is important to support more aggressive and effective solutions and services to MSM and IVDUs. It is important that national leaders and partners support all the measures to retain essential health workers in the rural and underserved settings and further strengthen primary care units. It is important to support the continuous and effective prevention program among all age groups, especially the youth.

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KEY MESSAGES Recommended Actions for the Near Term

The Ministry of Public Health should immediately and continuously carry out estimates on the future shortage of HRH in the rural areas, especially doctors and nurses. Plans to increase the production, in response to the shortage in the rural areas, should be effectively implemented. As we have more than 50 nursing colleges and 15 medical schools, both public and private, we should be able to scale up production quickly, without having to build new colleges. The standards, especially the number and quality of teaching staff, should be very carefully prepared, however. This increase in production should be based on the rural recruitment, local training, and hometown placement concepts. This will ensure higher retention in the rural areas. The problem of inadequate posts in the public sector and the impact of the Public Sector Reform policy should also be resolved. The medical council and the nursing council, the legal bodies that oversee standards and licensing, should be consulted. All the current financial and non-financial incentives to ensure higher retention of HRH in the rural areas should be maintained and effectively implemented. The Ministry of Public Health, via the Disease Control Department, in collaboration with the National Security Office, should ensure the continuity of and improve the regular inservice training programs on HIV/AIDS care for the five cadres of HRH that are essential to deliver the services for universal access to AIDS prevention, treatment, and care. These include medical doctors, nurses, counselors, pharmacists, and laboratory technicians. There should be additional training of nurses to become counselors with more focus on those hard hit areas. Enroll those clearly defined stateless people into the universal health coverage program. There are half a million so-called clearly defined and registered stateless people, mainly living in the mountainous areas. They are allowed to have permanent or temporary residence, but no right to free access of essential health care. Providing services to this group is relatively simple and should be implemented immediately. Before 2001 these people were covered with the lowincome card scheme; however, they were refused coverage in the universal health insurance program in 2003. Currently, they are not covered for universal access to ARVs, not covered by the tuberculosis and malaria programs, and do not have free access to other essential health care. These are mainly low-income people who have to pay out of pocket, according to their ability to pay, when they come to the health facilities for services. Secure continuous funding support from the Global Fund and other donors to ensure highest access to essential prevention, treatment, and care services for stateless people, mobile illegal migrant workers, and difficult to reach high-risk groups (especially MSM and IVDUs via CSO networks). These high-risk groups are either outside of the national universal access program, or difficult to reach by normal public services. Thailand spends around $US 250 million to deliver universal access to AIDS prevention, treatment, and care; 20% or HRH implications of scaling up for universal access to HIV/AIDS prevention, treatment, and care: Thailand

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around $US 50 million are supported by the GFATM grants. These Global Fund budgets are mainly for prevention and delivery of essential services to illegal migrants and stateless people.

Recommended Actions for the Long Term

Long-term continuous investment in health care infrastructures and qualified health workers is the most important essential determining factor for the long-term sustainable success of the universal access to HIV/AIDS prevention, treatment, and care. Vertical programs should not be expected to be the mechanism for long-term investment on health care systems. Thus, Thailand must ensure adequate long-term commitment to further strengthen the health care infrastructure. The current Stimulation Package 2 (SP2) by the Thai government, in response to the financial crisis, would be an excellent opportunity to further invest on health infrastructure, focusing at primary care level. Universal access to HIV/AIDS prevention, treatment, and care should continue to be integrated as part of Universal Access to overall essential health care, based on primary health care and should not be treated separately. The budget to provide universal access should be part of the universal health insurance systems so that it has firm commitment and can be allocated appropriately along with the budget for other essential health services. Furthermore, the intersectoral NAC should be energized and its secretariat fully capacitated and supported. The current secretariat, which is under the Disease Control Department of the Ministry of Public Health, creates the feeling of health sector dominance. Furthermore, the NAC should have regular meetings and should be energized to effectively perform its function as the main body for national intersectoral collaboration. Intensive prevention program on healthy sexuality to promote safe sex among youth, and extensive expansion of counseling and testing should be planned for and carried out. Training on life skills and healthy sexuality should be an essential part of the curricula in all high schools, with the support of good learning materials and resources. This movement would, in the long run, help address the problems of unplanned teenage pregnancies, HIV/AIDS and sexually transmitted infections, and violence against women. Special long-term, sustainable, continuous, effective, socially acceptable, and comprehensive solutions, integrated within the health care delivery programs, should be formulated and implemented among the high risk groups such as youth, MSM, IVDUs, and migrants and stateless people. Operational research should be established to test innovative effective solutions to be implemented among youth, MSM, and IVDUs. The knowledge gained should then be channeled into the national policies and the actions under the universal health care coverage scheme as soon as possible. The 4 million migrant workers are a high risk but neglected group of people that may spread the disease beyond the national boundaries. Both legal and illegal migrant workers should be provided with adequate social and health care services, including AIDS care. Provision of services to the legal migrant worker has already been implemented. The quality of services needs to be improved. The provision of essential services to the illegal groups is quite challenging, as they are both illegal and also highly mobile. HRH implications of scaling up for universal access to HIV/AIDS prevention, treatment, and care: Thailand

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APPENDIX A: LIST OF KEY INFORMANTS INTERVIEWED Representative of: A. Health System

Name Dr. Vichai Chokewiwat Dr. Siriwat Tiptaradol Dr. Suwit Wibulpolprasert

B. Policy maker and policy advocators

Dr. Petchsri Sirinirun Dr. Sombat Thanprasertsuk Dr. Sorakij Bhakeecheep Mr. Nimit Tienudom Mr. Bripat Donmorn Ms. Supathra Nakapue

C. AIDS experts

Dr. Praphan Phanupak Dr. Kulkanya Chokephaibulkit

D. HRH expert

Dr. Thinakorn Noree Dr. Somkuen Hanpattanchaiyakul

E. Universities and institutes

Dr. Narin Hiransuthikul Dr. Suthiporn Pattarachayakul Dr. Pathom Sawanoanyalert

Dr. Penpak Utid Ms. Lisa Kantamala

HRH implications of scaling up for universal access to HIV/AIDS prevention, treatment, and care: Thailand

Positions and organization Senior advisors on health system, MOPH Deputy permanent secretary, MOPH Senior advisor on health system and Disease control, MOPH Senior advisor on HIV/AIDS , MOPH AIDS expert, WHO Thailand Manager of fund and management on AIDS, NHSO Chair of access foundation Chair of AIDS networks NGO AIDS network: Foundation for AIDS right: (FAR) Director of AIDS research center, Thai Red Cross Senior expert of pediatric infectious disease, Mahidol University International HRH expert, International Health Policy Program Acting director of Praboromrachanok Insitute of Health Workforce Development Professor, Faculty of Medicine,Chulalongkorn University Assistant professor, Faculty of Pharmacy, Prince Songkla University Acting director of the National Institute of Health, Department of Medical Sciences, MOPH Assistant professor, Faculty of Nurse, Mahidol University Senior counselor, Bureau of AIDS, TB and STIs, Department of Disease Control,MOPH

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APPENDIX B: LIST OF STEERING COMMITTEE MEMBERS Name Dr. Suwit Wibulpolprasert Dr. Petchsri Sirinirun Dr. Sombat Thanprasertsuk Dr. Sorakij Bhakeecheep Dr. Thinakorn Noree Ms. Thidaporn Jirawattanapisal

Positions and Organization Senior advisor on Disease control and Health system, MOPH Senior advisor on HIV/AIDS , MOPH AIDS expert, WHO Thailand Manager of fund and management on AIDS, NHSO International HRH expert, International Health Policy Program Senior HIV/AIDS specialist, MOPH

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APPENDIX C: BACKGROUND DATA COLLECTED 1. a.

HIV epidemiology HIV prevalence and trends

b.

Number of PLHA

c.

Estimated number in need of ART (pediatric and adult)

Source: Epidemiological Fact Sheet 2008 on HIV and AIDS (UNAIDS and WHO 2009)

Source: Epidemiological Fact Sheet 2008 on HIV and AIDS (UNAIDS and WHO 2009)

Source: Epidemiological Fact Sheet 2008 on HIV and AIDS (UNAIDS and WHO 2009)

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d.

Number of HIV+ pregnant women per year

e.

HIV prevalence in TB patients

Source: Epidemiological Fact Sheet 2008 on HIV and AIDS (UNAIDS and WHO 2009)

Source: Country TB Profile Thailand 2008 (UNAIDS) f.

Estimated number of HIV and TB/HIV deaths, trends

Source: Epidemiological Fact Sheet 2008 on HIV and AIDS (UNAIDS and WHO 2009)

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g.

HIV prevalence in most-at-risk populations (CSW, IDU, MSM, other)

h.

HIV prevalence in HCW’s mortality

2. a.

Source: UNGASS Country Report Thailand 2008 It is unknown the size of infections in Thai health workers.HIV infections are prevalent among lower socio-economic groups; infections among health professionals are extremely low. The estimated prevalence in health workers should be lower than that of the general adult population, 0.2% among blood donors in 2007(Sirinirun P, Danthumrongkul V et al. 2008).Among the total 160,000 total health work force in Thailand, the estimate infections would be around 320; this small number has no effect on the loss of health workers. HIV program indicators Universal/nati Universal/national targets for care/ART (adult and peds), onal targets For the treatment action plans, Thailand committed to universal access to treat PLHIV since for care/ART October 2003. In early 2008, there were 161,582 PLHIV enrolled in the ART program (NHSO (adult and 2009) which the coverage is about over a half of estimated target size (2006 and 2007 are 41.0 peds), and 52.9 %, respectively (Sirinirun P, Danthumrongkul V et al. 2008). According to the national counseling ART, treatment for either symptomatic or asymptomatic with CD4 lower than 200 cell/cubic and testing, mm.; Denominator also included asymptomatic. If denominator include only symptomatic, the PMTCT, coverage will be 69.8% and 84.8% in 2006 and 2007, respectively. According to Thailand TB/HIV, male standards, PLHA is checked for CD4 every 6 month. circumcision, OVC, MARPS, PMTCT (CSW, IDU, HIV vertical transmission prevention among pregnant women by PMTCT program is a success MSM, other) story with high coverage(Sirinirun P, Danthumrongkul V et al. 2008).High ANC coverage, 98% in 2000-2006, high level of skilled attendant at delivery, 97% in 2000-2006, and high level of institutional care, 97% in 2000-2006(DOH 2008; Sirinirun P, Danthumrongkul V et al. 2008).The number of HIV+ in pregnant women has decreased markedly from 7,811 cases in 2001 to 6,106 in 2005. The infection rate of this risk group fell dramatically from 1.18 in 2001 to 0.82 in the middle of year 2006 (DOH 2008). The figure 4 shows the HIV infection rate of pregnant women in 2005.

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The number of HIV+ pregnant women from 2001 2006

%

1.2 1.15 1.1 1.05 1 0.95 0.9 0.85 0.8

1 .1 8 1 .1 2 1 .0 4 0 .9 7 0 .9 0 .8 2

2001

2002

2003

2004

2005

2006 (until June)

Source: Department of Health, The Ministry of Public Health: Ninthaburi, 2008 (DOH 2008) TB/HIV The 13—17% of TB cases were HIV-infected (Jittimanee S, Vorasingha J et al. 2008); in 2008 Thailand report for 32.60% of Patient infected both TB/HIV will be treated with ARV when CD4 is lower than 250 cell/cu.mm (Sirinirun P, Danthumrongkul V et al. 2008). Male circumcision There is no policy for male circumcision in Thailand MARPS Percentage of most-at-risk populations that have received an HIV test in the last 12 months and who know their results; sex worker and MSM are 52.60 and 34.90%, respectively. However, IDU is not available (Sirinirun P, Danthumrongkul V et al. 2008). OVC Percentage of orphaned and vulnerable children aged 0–17 whose households received free basic external support in caring for the child 2008 report is not available (Sirinirun P, Danthumrongkul V et al. 2008). Thailand has HIV prevalence in pregnant women < 5%. Survey of Multiple Indicator Survey (MICS) conducted in 2005-2006 Orphaned and vulnerable of all causes being supported 21.1% b.

Number (%) provided counseling and testing last year

HIV Counseling and Testing is the entry point of access to care. According to the 2006 National Sexual Behavioral Survey of Thailand, it was found that general population, age 18-49 both men and women who were HIV tested and knew the result in the last 12 months were 19.1%. The percentage on women being HIV tested and knew the result was more at 21.8% while men were tested and knew the result was at 16.3%. Partly, women were tested at the ante-natal care (ANC). Among most-at-risk populations, according to the behavioral surveillance, FSW, MSW and MSM had more exposure to HIV who were tested and knew the result in the last 12 months were at 52.4% 54.2% and 34.9% respectively (Sirinirun P, Danthumrongkul V et al. 2008).

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c.

Number of PLHA on ART, trends (pediatric and adult)

Source: Epidemiological Fact Sheet 2008 on HIV and AIDS (UNAIDS/WHO) Number of PLHIV receiving ART in 2008

Source: Jirawattanapisal T. Workforce requirements for ensuring universal access to antiretroviral therapy in Thailand: 2008 to 2015. Nonthaburi, Thailand, Ministry of Public Health, Thailand.(Jirawattanapisal 2009) Resource from: 1. Monthly report for the progress of ART program Thailand. 2009, National Health Security Office: Nonthaburi (NHSO 2009) 2. The progress report of number of patient receiving Antiretroviral treatment in National AIDS Program January 2009. 2009, Social Security Office: Nonthaburi, Thailand(SSO 2009). d.

Providerinitiated counseling and testing policy, guidelines, status of implementati on

The national plan for strategic and integrated HIV and AIDS prevention and alleviation 20072011(MOPH 2007) indicate to have an active promotion on developing the service , creating knowledge and raising awareness about VCT in all groups of people, in particular youth, and people in reproductive age was implemented. The campaign should be performed as raising health conscious for individual basic health care. At the meantime, quality of VCT should also be improved.

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e.

% who understand modes of HIV transmission

HRH implications of scaling up for universal access to HIV/AIDS prevention, treatment, and care: Thailand

17

HRH implications of scaling up for universal access to HIV/AIDS prevention, treatment, and care: Thailand

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f.

% who used condoms with casual partner

Source: UNGASS Country Report Thailand 2008 (Sirinirun P, Danthumrongkul V et al. 2008) Data from the National Sexual Behavioral Survey of Thailand 2006; sample group is male and female youth of aged 18-49, reported the percentage of women and men aged 15–49 who had more than one sexual partner in the past 12 months reporting the use of a condom during their last sexual intercourse is 50.9 (Sirinirun P, Danthumrongkul V et al. 2008).

HRH implications of scaling up for universal access to HIV/AIDS prevention, treatment, and care: Thailand

19

g.

Number (%) of pregnant women tested, HIV+ women/infant pairs who receive ARV drugs

Source: Epidemiological Fact Sheet 2008 on HIV and AIDS (UNAIDS/WHO) (UNAIDS and WHO 2009) h.

Number (%) of TB patients tested for HIV

i.

Number of HIV patient in care/ART per HCW (doctor,

Source: Country TB Profile Thailand 2008 (UNAIDS 2008) The projection was conducted as from 2008 to the next seven years, as figure below. In total, the FTE staff for the universal access of ART is projected to be increase significantly from 495 to 720, at the end of 2015.Professional nurses were expected to be the most requirements, following with doctors, counselors and laboratory technicians in range between 50 to over 200 FTE staff,

HRH implications of scaling up for universal access to HIV/AIDS prevention, treatment, and care: Thailand

20

nurse, health officer, etc) in representativ e health facilities and trend

over the period. The estimation of professional staff for all PLWHA on ART: 2008-2015 800

700

600

FTE staff

500 Doctor Nurse Pharm. Counselor Lab. Tecnhician Total

400

300

200

100

0 2008

2009

2010

2011

2012

2013

2014

2015

Year

j.

Resources available (host government, PEPFAR, GF, other) for ARV drugs

Source: Jirawattanapisal, T, Workforce requirements for ensuring universal access to antiretroviral therapy in Thailand: 2008 to 2015. Study report 2009, Ministry of Public Health: Nonthaburi. (Jirawattanapisal 2009) Budget of ARV drugs for Universal access to ART (Million USD)

Source: 1.MOPH, Thailand UNGASS country progress report: reporting period January 2006-December 2007. 2008, National AIDS Prevention and Alleviation Committee: Nonthaburi, Thailand(Sirinirun P, Danthumrongkul V et al. 2008). 2. NHSO, Monthly report for the progress of ART program Thailand. 2009, National Health Security Office: Nonthaburi.(NHSO 2009) 3. MOPH, The Global Fund Budget for Antiretroviral treatment Program 2009, PR, DDC,MOPH: Nonthaburi, Thailand. (BOE 2009) k.

Resources available (host government, PEPFAR, GF, other) for HRH (inservice training, pre-

HRH implications of scaling up for universal access to HIV/AIDS prevention, treatment, and care: Thailand

21

service, salaries, contracts, incentives, other)

Budget of In-service Training programs for Universal access to ART (Million USD)

Source: 1.MOPH, Thailand UNGASS country progress report: reporting period January 2006-December 2007. 2008, National AIDS Prevention and Alleviation Committee: Nonthaburi, Thailand (Sirinirun P, Danthumrongkul V et al. 2008). 2. NHSO, Monthly report for the progress of ART program Thailand. 2009, National Health Security Office: Nonthaburi(NHSO 2009). 3. MOPH, The Global Fund Budgegt for Antiretroviral treatment Program 2009, PR, DDC,MOPH: Nonthaburi, Thailand (PR-DDC 2009). l.

Impact of HIV scale-up on reduced hospitalizatio ns, mortality

There are the needs to intensively study the impact of HIV scale-up on reduced hospitalizations. However, there are information of impact to mortality from some studies as the two figure

ART

60,000 50,000 40,000 30,000 20,000 10,000

20 25

20 20

20 15

20 10

20 05

20 00

19 95

19 90

0

Source: Peerapatanapokin W and Thailand Team and Thai Working Group of HIV/AIDS projection, Thailand, Projections for HIV/AIDS in Thailand: 2000-2025. 2007: Bangkok HRH implications of scaling up for universal access to HIV/AIDS prevention, treatment, and care: Thailand

22

NO ART

20 25

20 20

20 15

20 10

20 05

60,000 50,000 40,000 30,000 20,000 10,000 0

20 00

Number of infection

(Peerapatanapokin W and Thailand Team and Thai Working Group of HIV/AIDS projection 2007) Under ART, deaths are postponed

Baseline (with ART)

Source: Peerapatanapokin W and Thailand Team and Thai Working Group of HIV/AIDS projection, Thailand, Projections for HIV/AIDS in Thailand: 2000-2025. 2007: Bangkok (Peerapatanapokin W and Thailand Team and Thai Working Group of HIV/AIDS projection 2007) 3. Actual strength of health workforce a. Number of The Thai healthcare system allows any healthcare workers to provide ART services in workers hospitals. Then we could not record the number of workers delivering the services delivering HIV specifically, but total professions as shown in the annual production capacity of main services cadres (Public and Private), 1997-2015 (planned and actual); geographical distribution; ratio of patients to providers (snapshot?); different cadres; information about CHWs?

Projection of supply and requirement of main cadres in 2015

Source: (1) Sirikanokwilai N, S WIbulpolprasert and P Pengpaiboon. Modified population to physician ratio method to project future physician requirement in Thailand. Human Resource Development HRH implications of scaling up for universal access to HIV/AIDS prevention, treatment, and care: Thailand

23

b.

Skills, competencies documented to provide HIV services, yes/no, describe.

Journal. 2(3): p. 197-209. (Sirikanokwilai N, WIbulpolprasert S et al.) (2) Leksomboon D and Punyashingh K, Supply projection for dentists, Thailand (2000-2030). Human Resource Development Journal, 2000. 4(2): p. 94-105.(Leksomboon D and Punyashingh 2000) (3) Payanantana N, Sakolchai S, Pitaknitinun K, Palakornkul K andThongnopnua N, Faramnuayphol P, Ekachampaka P, Taverat R, et al, Future Human Resources Balance for Pharmacy and Health Consumer Protection Services in Thailand. . Human Resource Development Journal 1998. 3(Sep-Dec). (Payanantana N, Sakolchai S et al. 1998) (4) Srisuphan W, Senaratana W, KunaviktikulW, Tonmukayakul O, Suwannakij T, Ccharoenyuth C, and Sirikanokwilai, Supply and Requirement Projection of Professional Nurses in Thailand over the Next Two Decades (1995 -2015 A.D.). Human Resource Development Journal 1998. 3(Sep-Dec). (Srisuphan W, Senaratana W et al. 1998) Thailand studies for the standard of the healthcare units to provide the quality services. Department of Disease Control, Thailand Ministry of Public Health (MOPH), Thai MOPH-U.S. Collaboration (TUC) and National Health Security Office have contributed a joint activity for assessment a performance of Antiretroviral treatment services in Thailand. The result of performance measurement by HIV-QUAL-T in Thailand, during 2002 – 2005 shown as the figure.

Source: http://www.hivqual.org/index.cfm/5271

HRH implications of scaling up for universal access to HIV/AIDS prevention, treatment, and care: Thailand

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c.

Vacancy rates by cadre; distribution, especially to remote and rural areas; perceived retention issues Distribution of main cares of HRH by region, 2000 (Thammarang sri 2000)

d.

4. National HRH system including HRH plans and strategy a. Costed-plan developed and disseminated (yes/no, Thailand has pluralistic healthcare systems where private sector shares around 20-25% of the describe HRH, mainly in the urban areas. The public sector consists of MOPH and non-MOPH.MOPH has including around 50% of the HRH while non MOPH has around 25-30% of HRH (Faramnuayphol P, status of Ekachampaka P et al. 2007).Then Thailand does not have specific costed-plan developed and implementati disseminated, but integrated into all healthcare systems themselves. on) b. HRH Plan takes Universal Access into consideration (yes/no, describe), specific HRH requirements HRH plan has not been taken for Universal Access but Thailand has implemented Universal (different Access policy into the strong existing healthcare systems. However, the recommendation to cadres) for have at least five cadres of HRH for ART scale up has been advocated as the national standard HIV scale up of practices. c. HRM units exists in the MOH, staffed by people who are professionally qualified in the discipline of HRM; strategically aligned within MOH; able to HRH implications of scaling up for universal access to HIV/AIDS prevention, treatment, and care: Thailand

25

d.

e.

negotiate effectively with Ministry of Finance, PSC, MOE, etc. Specific plans to scale-up HR cadres; describe current status of plans, especially focusing on degree of implementati on and current actions

The Office of Personnel management of each Department in MOPH is responsible for the personnel management in each Department, majority of the MOPH staff are within the Office of Permanent Secretariat. In the past, there were four major increases in the production of doctors. The first was in 1979, with 200 enrolled medical students. The second was in 1993, the additional production were 340 enrollees, annually. In 1995, the collaborative Project to Increase Production of Rural Doctors (CPIRD) was proposed to enroll 300 medical students annually to respond shortage of doctors in rural areas it is 500 a year beyond the time (Thammarangsri 2005). The last big increase was in 2004, the government decided to support an increase production of 700 students annually to achieve additional 10,000 medical doctors in next 15 years. The existing system for HRH scaling up in Thailand, the Bureau of Human Resource Development; Praboramrachachanok Institute is responsible for pre-service and in-service training of HRH in the MOPH focusing at the provincial health facilities. The Bureau of HRD collaborates with the Bureau of Health Policy and Strategy is responsible for HRH planning for the MOPH and the country to specify plans to scale-up HR cadres follow the strategic Plan for the Decade of National Human Resources for Health Development in Thailand (2007 -2016) (Jindawatthana A, Noree T et al. 2007) for multi cadres of HRH are produced in Thailand, as the country development. Most healthcare cadres are planned and expected for the annual production including physician doctors, dentists, pharmacists and nurses which are about 2,000, 700, 1,700 and 5,600 people per year since 2009 to 2015, respectively (Sirikanokwilai N, WIbulpolprasert S et al. ; Payanantana N, Sakolchai S et al. 1998; Srisuphan W, Senaratana W et al. 1998; Leksomboon D and Punyashingh 2000).

Link between service delivery needs and production including HRH preservice training and trends for HIV (and which cadre); plans and reality

f.

National budget for HRH preservice training and trends g. Specific steps taken to increase capacity or

It has already integrated in plans and productions for medical schools and academic institutes. Several essential issues on HIV/AIDS have been incorporated into the basic curriculum of the health personnel training. Medical students: Virology, pathology of HIV/AIDS, ARV treatment, Opportunistic Infection

HRH implications of scaling up for universal access to HIV/AIDS prevention, treatment, and care: Thailand

26

pre-service training by cadre (doctors, nurses, laboratory, pharmacy and others).

treatment in HIV infected patients, and Clinical Microbiology, have been included in the rd th curriculum for 3 , and 4 year medical students in at least around 10–15 hours in total.They will get more knowledge and skill by observing and practicing with the attending physicians in their th final 6 internship year (Bowonwatanuwong C and al 2008; Kasemsup 2008; Tachasatit 2008). rd

th

th

The pharmacy students: They take 10 - hour HIV/AIDS curriculum in the 3 -5 , and/or 6 year of their studies in Patho-physiology, Pharmaceutical Care and Pharmacotherapy, Principles of infectious diseases and Laboratory for diagnosis and monitoring of infectious diseases, and infections in immuno-compromised host.Furthermore, they will take more specific in the Pharmaceutical in the Principles of Drug Therapy and Drugs Used in Infectious Diseases (Pattarachayangkul 2008). The nursing students:They take the HIV/AIDS curriculum in the Pathology, Pharmacology and rd Phamaco-theraputic courses in the 3 year of their studies.BothPharmacy and nursing students will get more knowledge and skill by observing and practicing in the health facilities during their final year of education (Maneesriwongkul 2008).

h.

i.

J.

k.

Specific approaches for retention and productivity, workplace safety, improved morale by providing services (ART), including financial and non financial incentives and work climate improvement interventions; any evidence such strategies are working or not working Bonding post training present, yes/no, describe Human resource information system, yes/no, describe HIV/AIDS

Significant financial and non financial incentives are provided to health workers who work in the rural areas, in general and those working on HIV/AIDS.New medical graduates work in the remote districts can earn up to USD 2,500 per month equal to the salary of a Permanent Secretary. Those who stay long enough can be promoted up to the level of a deputy governor or a deputy director general of a central department.The National Health Security Office established a special fund to compensate for the health workers, who got any occupational injury from providing the medical services, including affected by AIDS.

The compulsory three years of public work contract was started at 1972, in response to severe external brain drain to USA. All new graduated doctors must work in public hospitals, particularly in rural district hospitals, for the first three years. If they breach the contract, they would have to pay a fine of 10,000 USD. The compulsory complied for another profession with difference condition including nurse, dentist and pharmacist.

The Office of Personnel management of each Department in MOPH is responsible for the personnel information and human resource information system in each Department, majority of the MOPH staff are within the Office of Permanent Secretariat. Healthcare workers access to prevention, care and ART with the same standard or higher then

HRH implications of scaling up for universal access to HIV/AIDS prevention, treatment, and care: Thailand

27

policy/strateg y for HCWs, access to prevention, care, and ART

another group of people such as the free of charge of ART and etc for the need of the treatment. Task Shifting a. National policy/guidelines in place (yes/no, describe); extent to which policy has been implemented (0%, 25%, 50%, etc.) National practice guideline recommends some professions to have task shifting. Nurses are allowed from the physician to screen the symptom and status of patients and prescribe the ARV drugs, on behalf of team of healthcare providers, for the patients have no complications or have the same treatment regimens. b. Training curricula and materials by program area and worker availability (yes/no, describe) The National practice guideline composes the training curriculum as the material for healthcare workers including to provide ART services with the same standard over the country. The training is set as in-service training for healthcare worker at least once to two times a year. c. Supportive supervision in place (yes/no, describe) The twelve Regional Disease Prevention and Control Offices, responsible for technical support, work closely with the twelve regional offices of the National Health Security Offices, responsible for financing the universal access program, to supervise and support the provincial advisory networks.The provincial network provides close supervision and coaching, technical support, and supplies to all health facilities that provide universal access to prevention, treatment and care.Regular supervisory visits and coaching, as well as effective referral systems help to strengthen the network. d. Types of cadres included, government and non-government, health and nonhealth care providers. National practice guideline recommends for at least five cadres to provide ART services including physician doctor, nurse, counselor, pharmacist and laboratory technician. Allocation of task to five cadres of professionals was studies. The results of tasks allocation for the ART services physician and professional nurse and counselors take most responsibility for the ART services in all three phases of the services of which range 10- 80% and 10-50%, respectively whereas pharmacist and laboratory technician provide the services with the moderated proportion of all tasks.More workloads for nurses should be addressed.The task shifting was implicitly generated among professional nurse for other activities including counseling. The skill mix capability is also generally found in nurse (Jirawattanapisal 2009). e. Mapping of task-shifting at facility level The preliminary study (Jirawattanapisal 2009) found that the task shifting was implicitly generated among professional nurse for other activities including counselling.The skill mix capability is also generally found in nurse. However, there is the need to have intensively study of mapping of task-shifting at facility level. f.

The task shifting table may be a helpful way to quickly document task shifting practices.

HRH implications of scaling up for universal access to HIV/AIDS prevention, treatment, and care: Thailand

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Task

Prevention Counsels pregnant women Performs rapid HIV testing for pregnant women Prescribes ARVs

Allowed (Y/N)

Cadres included (eg nurse, health officer, lay counsellor, CHW, etc)

Existing number of cadres trained to perform the task

Number needed

Y

Professional counsellor, nurse Laboratory technician

Not available All hospitals

For all hospitals For all hospitals

Not available

Not available

Not available

Not available

N

Y

Provides condoms

Y

For stable patient, nurse or pharmacist are allow to refill ARV drugs Any healthcare staff

Provide targeted education and support (name target groups)

Y

Any healthcare staff

Not available

Not available

PEP

Y

Doctor, nurse, counsellor

Not available

Not available

Care and treatment Performs rapid HIV testing

N

Laboratory technician

All hospitals

For all hospitals

Provides pre/post test counselling Collects specimen for DBS

Y

Counsellor, nurse

All hospitals

N

Laboratory technician

All hospitals

For all hospitals For all hospitals

Orders CD4 test

N

Laboratory technician

All hospitals

Performs CD4 test

N

Laboratory technician

All hospitals

Orders other lab tests for bio clinical monitoring Performs lab tests

N

Laboratory technician

All hospitals

N

All hospitals

For all hospitals

Prescribes Isoniazid

N

Laboratory technician, laboratory technician assistant Physician doctor

All hospitals

Prescribes STI drugs

N

Physician doctor

All hospitals

Prescribes other OI drugs

N

Physician doctor

All hospitals

For all hospitals For all hospitals For all hospitals

HRH implications of scaling up for universal access to HIV/AIDS prevention, treatment, and care: Thailand

For all hospitals For all hospitals For all hospitals

29

Initiates AR T (adult/paediatric) Prescribes ART refills

N

Physician doctor

All hospitals

Y

Doctor, nurse, pharmacists

Not available

Changes ART regimens Prescribes therapeutic nutrition Performs male circumcision (that is preventative) Refers to specialist for…

N

Physician doctor

All hospitals

N

Physician doctor

All hospitals

N

Physician doctor

Not available

Not available

N

Physician doctor

Not available

Not available

Refers to support groups

Y

Any health care staff

Not available

Not available

Refers for nutritional support Provides adherence counselling Dispenses ARV drugs

Y

Any health care staff

Not available

Y

Doctor, nurse, counsellor, pharmacist Pharmacist, pharmacist assistant, nurse

All hospitals

Not available For all hospitals For all hospitals

Dispenses CTX, OI drugs

Y

Pharmacist, pharmacist assistant, nurse

All hospitals

Y

All hospitals

For all hospitals Not available For all hospitals For all hospitals

For all hospitals

The answer for question No.5-6 should be conducted for the study to measure impacts of GHI to HRH because in the Thai context, GHI has been integrated with the governments performs into the existing healthcare system in Thailand. There are many involved factors need to be concerned. 5. Intended consequences (specific examples) a. Evidence that Increased number: Not available GHI and Better distribution : Not available national AIDS Increase retention : Not available responses Evidence that HRH improvements have improved coverage have towards Universal Access : Not available improved Evidence that HRH improvements have benefited other aspects of health system HRH delivery – MCH, FP/RH, chronic disease management, etc: Not available How have TB, HIV, and malaria resources worked synergistically to advance HRH? : Not available 6. Unintended consequences (specific examples)

HRH implications of scaling up for universal access to HIV/AIDS prevention, treatment, and care: Thailand

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6 a.

Evidence that GHI have diverted HRH from other priorities: Not available Evidence that GHI have created HIV exceptionalism, e.g. different salaries, free-of-charge services as opposed to user fees e.g. for MCH services: Not available How have TB, HIV, malaria resources worked in competition with or against one another: Not available 7.Pre-service and in-service training 7 a.

It is likely that data for this category will be hard to determine and there may not be enough time to collect it.If there is data readily available, the following information could be collected: a. Is HIV education integrated in appropriate ways?At what levels and how? Yes, the specific steps have been taken to increase capacity or pre-service training by cadre (doctors, nurses, laboratory and pharmacist). The several essential issues on HIV/AIDS have been incorporated into the basic curriculum of the health personnel training.However, there is the need to in-service train to update and gain knowledge of benefit packages of ART services which are available in the country. b. Number of cadres per year and trends The Bureau of Planning and Strategy (BPS) is responsible for HRH planning for the country. The BPS works collaboratively with Praboramrachachanok; Institute which is responsible for preservice and in-service training of HRH in the MOPH, focus at the provincial health facilities) and Human Resources for Health: Research and Development Office to plan and project cadres per year and trends(Jindawatthana A, Noree T et al. 2007; Noree T, Chokchaichan H et al. 2008). c. Plans for new cadres The Bureau of Human Resource Development and Praboramrachachanok Institute is responsible for pre-service and in-service training of HRH in the MOPH focusing at the provincial health facilities. The Bureau of HRD collaborates with the Bureau of Health Policy and Strategy is responsible for HRH planning forthe MOPH and the country to specify plans to scale-up HR cadres follow the strategic Plan for the Decade of National Human Resources for Health Development in Thailand (2007 -2016) (Jindawatthana A, Noree T et al. 2007) for multi cadres of HRH are produced in Thailand. d. What is required for tutors?What is the plan for scale up? Thailand has the twelve Regional Disease Prevention and Control Offices, and the twelve regional offices of the National Health Security Offices are responsible for tutors for the ART programs with the strong networks over the country. e. f. Number of schools available and location?

Source: Wibulpolprasert, S, Thailand Health Profiles. 2007, Ministry of Public Health: Nonthaburi, Thailand. (Wibulpolprasert 2007) g.

Is in-service training sufficient?

HRH implications of scaling up for universal access to HIV/AIDS prevention, treatment, and care: Thailand

31

In-service training alone is not sufficient for the Thai ART services, but need another mechanism including pre-service training, supervision and coaching from the twelve regional offices of Department of Disease Control, the twelve regional office of National Health Security Office and the Provincial Health Offices. h.

Supportive supervision in place (yes/no, describe)

The twelve Regional Disease Prevention and Control Offices, responsible for technical support, work closely with the twelve regional offices of the National Health Security Offices, responsible for financing the universal access program, to supervise and support the provincial advisory networks.The provincial network provides close supervision and coaching, technical support, and supplies to all health facilities that provide universal access to prevention, treatment and care.Regular supervisory visits and coaching, as well as effective referral systems help to strengthen the network. i. Types of cadres included, government and non-government, health and nonhealth care providers. National practice guideline recommends for at least five cadres to provide ART services including physician doctor, nurse, counselor, pharmacist and laboratory technician to work closely with the network of NGOs. Then in total, there are at least six key peoples in the HIV clinic to provide services.

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APPENDIX D: KEY DOCUMENTS REVIEWED BHSSD (2007). The number and proportion of outpatients by level of MOPH health facilities: From reverse to upright triangle: PHC utilization (OP visits). Nonthaburi, Rural Health Division, Bureau of Health Service System Development, Ministry of Public Health, Thailand BOE (2009). Results of national sero-sentinel for HIV prevalence, various rounds. Nonthaburi, Bureau of E pidemiology, Ministry of Public Health, Thailand Bowonwatanuwong C and e. al (2008). In-depth interview for estimation of the health workers requirement in response to ARV treatment and care, Chonburi hospital, Office of Permanent Secretary, the Ministry of Public. . DOH (2008). PMTCT Policy 2007 - 2011. Nonthaburi, Department of Health, Ministry of Public Health, Thailand. Faramnuayphol P, Ekachampaka P, et al. (2007). Health service systems in Thailand. Nonthaburi, Ministry of Public Health. Jindawatthana A, Noree T, et al. (2007). The strategic Plan for the Decade of National Human Resources for Health Development in Thailand (2007 -2016). M. Human Resources for Health Development Office. Nonthaburi, Thailand, Human Resources for Health Development Office, MOPH. Jirawattanapisal, T. (2009). Workforce requirements for ensuring universal access to antiretroviral therapy in Thailand: 2008 to 2015. Nonthaburi, Thailand, Ministry of Public Health, Thailand. Jittimanee S, Vorasingha J, et al. (2008). "Tuberculosis in Thailand: epidemiology and program performance, 2001—2005." International Journal of Infectious Diseases 679: 1-7. Kasemsup, V. (2008). HIV/AIDS and related curricula for Medical student Mahidol University, Thailand: Ramathibodi hospital; Faculty of Medicine. Leksomboon D and K. Punyashingh (2000). "Supply projection for dentists,Thailand (20002030)." Human Resource Development Journal 4(2): 94-105. Maneesriwongkul, W. (2008). In-depth interview for HIV/AIDS and related curricula for nurse student. Bangkok, Mahidol University, Thailand: Ramathibodi hospital and Nurse Faculty. MOPH (2007). Book1 The National Plan for Strategic and Integrated HIV and AIDS Prevention and Alleviation 2007-2011: Key Contents. Nonthaburi, Thailand, The National Committee for HIV and AIDS Prevention and Alleviation Drafting Working Group on National Plan for Strategic and Integrated HIV and AIDS Prevention and Alleviation 2007-2011. HRH implications of scaling up for universal access to HIV/AIDS prevention, treatment, and care: Thailand

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NHSO (2009). Monthly report for the progress of ART program Thailand. Nonthaburi, National Health Security Office, Thailand. Noree T, Chokchaichan H, et al. (2008). Abundant for the few, shortage for the majority: the inequitable distribution of doctorsin Thailand. Nontaburi, International Health Policy Program, Ministry of Public Health, Thailand. Pattarachayangkul, S. (2008). HIV/AIDS and related curricula for Pharmacy student. Songkla, Prince of Songkla University, Thailand: Faculty of Pharmaceutical Sciences. Payanantana N, Sakolchai S, et al. (1998). "Future Human Resources Balance for Pharmacy and Health Consumer Protection Services in Thailand." Human Resource Development Journal 3(Sep-Dec). Peerapatanapokin W and Thailand Team and Thai Working Group of HIV/AIDS projection, T. (2007). Projections for HIV/AIDS in Thailand: 2000-2025. Bangkok. PR-DDC (2009). Global fund budget for Antiretroviral treatment program 2009. Nonthaburi, DDC, MOPH. Rojanapithayakorn W and H. R (1996). "The 100% condom program in Thailand" AIDS 10: 10-17. Sirikanokwilai N, WIbulpolprasert S, et al. "Modified population to physician ratio method to project future physician requirement in Thailand." Human Resource Development Journal. 1998 2(3): 197-209. Sirinirun P, Danthumrongkul V, et al. (2008). Thailand UNGASS country progress report: reporting period January 2006-December 2007. Nonthaburi, National AIDS Prevention and Alleviation Committee, Ministry of Public Health, Thailand. Srisuphan W, Senaratana W, et al. (1998). "Supply and Requirement Projection of Professional Nurses in Thailand over the Next Two Decades (1995 -2015 A.D.)." Human Resource Development Journal 3(Sep-Dec). SSO (2009). The progress report of number of patient receiving Antiretroviral treatment in National AIDS Program. Nonthaburi, Social Security Office: Nonthaburi, Thailand. Tachasatit, V. (2008). In-depth interview for HIV/AIDS and related curricula for Medical student. Bangkok, Mahidol University, Thailand: Siriraj hospital; Faculty of Medicine. Thammarangsri, T. (2000). The popuplation and housing census 2000. Nonthaburi, National statistical office, Rural Health Devision, Office of Perment Secretary, Ministry of Public Health, Thailand.

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Thammarangsri, T. (2005). Geograhical distribution of doctors under universal coverage scheme. Nonthaburi, International Health Policy Program, Ministry of Public Health, Thailand. UNAIDS (2008). Country TB Profile Thailand 2008 UNAIDS UNAIDS and WHO (2009). Epidemiological Fact Sheet 2008 on HIV and AIDS (UNAIDS/WHO), UNAIDS/WHO. Wibulpolprasert, S. (2007). Thailand Health Profiles. Nonthaburi, Ministry of Public Health, Thailand.

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