The 2000s have proven to be a period of substantial health reform in Thailand with impressive results for maternal and child health. In 1994, the HIV prevalence among women in antenatal clinics was 2%, and the rate of mother-to- child transmission (MTCT) of HIV was 24.2%. The MTCT rate has remarkably decreased to 1.9% with a 0.6% HIV prevalence among pregnant women in 2015.
In response to the generalized HIV epidemic in the 1990s, Thailand’s Ministry of Public Health (MoPH) rose to the challenge with the introduction of a national MTCT prevention policy in 2000. The policy was part of a wider push for healthcare reform driven by government and civil society actors. Over the next 15 years, the rate of MTCT decreased from 1000 children infected with HIV down to 85 children, and the rate of women who were newly infected with HIV decreased from 15,000 women to 1,900.
The current MTCT rate of 1.9% meets the World Health Organization’s (WHO) definition of elimination of MTCT as a rate under 2%. In June 2016, Thailand became the first country in the Asia & Pacific region to receive validation from the WHO for eliminating MTCT of HIV. Thailand is the first country with a generalized HIV epidemic to reach this milestone.
How did Thailand eliminate MTCT of HIV across both the general populations and within hard-to-reach or vulnerable populations? Further, what are the political and programmatic drivers and processes that have led to Thailand’s successful elimination of MTCT of HIV?
The why and how of Thailand’s through data-driven secondary research. To date, this has led to the identification of several important factors in explaining Thailand’s reach:
● Political will and engagement of diverse partners
● Social change in the form of public support
● Improved access to care through strong public health infrastructure
● Comprehensive monitoring & surveillance system
Political will includes government and civil society commitment to MTCT prevention and has played a key role in creating and supporting policy development and implementation. Physician and bureaucrat advocacy are important parts of of this story and played a key role in the healthcare reform process from the early 2000s. This policy continues to evolve based on emerging evidence and scientific advancements. This includes comprehensive guidelines and funding for antenatal care, HIV counselling & testing, and the provision of antiretroviral treatment.
Public support was essential for these policies to be introduced and swiftly adopted. Several broad norm changes took place over the past thirty years, which underpinned health reform efforts. These norm changes were influenced by activism related to the global HIV/AIDS movement. These movements concerned domestic actors within Thailand, including activist physicians, reformist bureaucrats, and patients’ rights groups. Public education campaigns also helped legitimize healthcare reform and mitigate social stigma around seeking testing and treatment for HIV.
Access to care is a fundamental part of Thailand’s success. Access to care refers to the availability and accessibility of antenatal care. HIV prevention activities - including counselling, testing, and treatment - are delivered through antenatal care provision. Increasing access to care is part of the larger health system evolution in Thailand, which has involved massive investments in infrastructure and human resources since the 1960s. This has led to extensive health care coverage in all areas of the country, especially rural areas. The Universal Health Coverage Scheme introduced in 2001 also helped improve access and has been updated regularly to promote equity among the population. The Universal Coverage Scheme is currently providing 99.5% of the population with access to healthcare insurance.
Provision of ART treatment is a key intervention to prevent MTCT of HIV. ART technology has been available since the 1990s, but remained inaccessible for many due to cost and coverage issues. With the introduction of the PMTCT policy, increasing ART use and coverage has been made possible through price reduction and compulsory licensing of ARV.
Lastly, part of the national policy is a robust monitoring & surveillance system which contributes to program accountability and also informs and evaluates ongoing HIV prevention activities on a national scale.
Closing the Gap
Overall, Thailand has demonstrated great success in eliminating MTCT; however there are still challenges with reach. This is particularly evident among sub-groups who face additional barriers to services, such as migrant workers and ethnic minorities (e.g. hill tribes). Additionally, while there is high antenatal care coverage, there appears to be a drop in postnatal care and postnatal interventions.