Issue 12 Health Service Innovation May 2011 by Noviscape Consulting Group

TRENDNOVATION SOUTHEAST NEWSLETTER

LEADER

ISSUE 12 - HEALTH SEVICE INNOVATION

Healthcare is a huge and controversial sector. In general, trends in healthcare innovation have been focused on the manufacturing segment of the healthcare industry. Advancements in high technology research pave the way for the future of healthcare, e.g. the pharmaceutical industry, biotechnology, genomics/proteomics, medical devices and information technology. However, soft innovation or service innovation is increasingly influencing the whole healthcare system, ranging from accrediting health units to X-raying patients. It is intangible, more complicated, and individualized. Health service innovation combines and balances an interaction between the key roles of the ‘providers’ (physicians and healthcare staffs) and ‘users’ (patients and other beneficiaries) as the main sources of diffusing technological innovation in health systems. In this issue, TRENDNOVATION Newsletter illustrates a selection of emerging issues and signals for changes in health service innovation including changes in various attributes that would affect the poor, vulnerable people and medical staff (e.g. hospitals, research, logistics, health care policy, etc.). Driven by a regional economic transformation towards a manufacturing and service-oriented

By Dr.Pun-Arj Chairatana Principal investigator

economy, more people will live or migrate into megacities or other growth poles in Southeast Asia. In this issue, the contributors envisaged and interpreted the scenarios by portraying the future of the interactions and activity within health service in Southeast Asia. There are some improvements and lots of possible events that may change the way we perceive this particular section in a contemporary modernization. On the bright side, healthcare in Southeast Asia over the next decade will include more people being integrated into a standardizing health system; the physical infrastructure of health service will be expanded and better equipped; public welfare will become a norm for the regional government to pursue, while private healthcare will become more specialized and targeted. The individual will value a healthy life with a higher degree of application of digital healthcare innovation; and new preventive measures and treatments will be implemented with universal coverage. Uncertainties can be seen coming from such a grand scale of urbanization, health politics and a massive expansion of physical infrastructure. Aestheticism and individualism underline an increasing degree of complexity in health services, which is a very knowledge intensive activity. System failure, threats from biohazards, emerging and reemerging diseases, digital terrorism and intrusions, and user-provider conflicts will become new challenges within the hospital system and health policy implementation. This issue marks the first year of TRENDNOVATION Newsletter. The passage through twelve issues has been one amazing journey. I would like to thank you all: the audience, the Rockefeller Foundation, the contributors, and the team for such great support. The newsletter is entering its second year, and we commit to a futuristic goal of making this horizon scanning more robust and relevant. We won’t rest until we’ve reached that goal. TrendNovation is available online at http://www.trendsoutheast.org. As always, your comments and feedback are invaluable to us.

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Cognitive Zero Mile: A Work Space of Mind in Healthcare Development By Sadudee Vongkiattikachorn Senior Consultant @NCG

IDEA: Vulnerable people in Southeast Asia tends to have limited access to healthcare and proper services. For decades, the public investment in health systems that focused on the expansion of public health facilities and recruitment of sufficient staff to equally cover the entire population has been crucial to overcoming barriers with health scheme quality and equity of healthcare service provision. Public spending in national health services has reduced the legacy problem of “zero mile” through a provision of an easier access to better standards of treatment and new opportunities in the regional healthcare market. This physical gap is narrowing down, while a more complicated and intangible gap resulting from an implementation of those new schemes have raised an emerging new “cognitive zero mile” between the demand and supply sides through some interaction and communication.

Scenario: The concept of “cognitive space” uses the analogy of location in three dimensional (or higher) physical space to describe and categorize mental ideas. Cognitive spaces can be understood as “workspaces of the mind” (Baars, 1998). The dimensions of this space depend on information, participating and practicing, and finally on a person’s awareness. An availability of physical space facilitates an evolution of the relationship between cognitive space and communication. This is the case for health culture and communication at the bottom-of-the-pyramid (BoP) in many nations of Southeast Asia. The observation of an emergence of a “cognitive zero mile” can be

KEYWORDS: Cognitive spaces; zero mile; urbanization; ethics; universal coverage; health communication seen from perspectives of healthcare personnel, patients, and other key stakeholders (e.g. insurance sector, national security, etc.) towards an interaction within the health system, especially on their “expectations” against “realities”. In this article, two key changing elements will be elaborated as major pillars for the scenario, including health service convergence, and cognitive conflicts.

Referral Syndrome Convergence of Urbanization and Health Reforms:

Southeast Asia is the fastest urbanizing region in the world, which can be seen from the expansion of megacities, the establishment of new cities, and a trend in the decentralization of public administration in some countries. Reinvestment initiatives, changing demographics, and growth in urban areas are creating changes that offer new opportunities for improving health while requiring that health systems be adapted to meet residents’ health needs. Although this health policy is widely accepted as one of the most successful “pro-poor” policies, this policy has long been criticized for its quality, particularly the quality and equity of services such as medical treatment and medical professionals. The health scheme also has an inherent urban bias; emphasis on hospital curative medicine means that rural people must come into the cities for care and incur the extra cost and time demands. While the concept of universal health coverage (UC) is intending to lift financial burdens arising from healthcare costs, this could also be detrimental, especially for the poor. Obviously, the hospitals in rural areas with inadequacies of health personnel seem to provide lesser quality services to their clients due to the lack of medical facilities, which definitely affects the mostly poor residents. With globalization, ensuring of accessible health services or citizens is no longer the sole responsibility of the state; healthcare in the region is rapidly becoming an industry in the world market. For example, the Department of Health Services Promotion in Thailand indicated

Disclaimer : The opinions expressed herein are those of the authors and do not necessarily reﬂect the ofﬁcial positions of Noviscape Consulting Group or the Rockefeller Foundation. Copyright © Trendsoutheast 2009 - 2011. All Rights Reserved.

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that there has been an increase in the number of private hospitals and clinics operating in recent years. It seems that urbanization has improved healthcare service for the poor, but the problem of inadequate service still persists. New barriers—both financial and nonfinancial—have been identified as significant obstacles to access in the future, and are seen as important targets for change. Transportation is a commonly identified barrier to healthcare. It can be seen that although the cost of healthcare treatment is equal regardless of the domestic economy, patients from rural areas are affected when their cases have to be referred to a provincial hospital, because it is costly for them in terms of transportation, consumption of their time, and the opportunity cost for private hospitals. There will be more patients being referred from one hospital to another, regardless of whether all people have the right for healthcare coverage. When the healthcare market belongs to supply side, the poor will suffer from a “referral syndrome”!

Cognitive Conflicts between Physicians and Patients:

More interestingly, one problem that will occur more seriously in the near future is the knowledge gap and the misunderstanding that can develop between the health service provider and beneficiaries. As the beneficiaries have more demands and expectations on their own benefits while not realizing their actual rights, they would tend not to understand the standpoint of the physicians or other service providers. There will be more lawsuits against doctors. Although there is now more protection of patient rights, the people who can sue and get protection are still the urban rich. The rural and urban poor remain largely unprotected and vulnerable to medical malpractice. Physicians currently bear a huge burden by having to take care of a large number of patients with limited time. Some unintentional errors can result and turn into big problems. The ongoing conflicts between patients and physicians are becoming more serious, even though public policies have been designed in an attempt to enhance access to health services by the poor. This is due to the fact that each government has overemphasized a populist approach while neglecting the reality of finite resources.

The tremendously miserable consequence of rising lawsuits against doctors by the demanding service users has contributed to a rise in case transfers between hospitals, especially from remote district health centers to provincial hospitals. District service providers have become increasingly reluctant to perform their duties, e.g. surgical operations, as they do not want to risk getting litigated against by patients in case something goes wrong. Some patients have had to suffer more than before as a result, because they receive much slower treatment of their diseases. This

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could also in turn create an adverse turnaround effect against patients themselves in the medium to long term, as services provided to them would be more limited. Another recent event that occurred, very clearly reflecting such a problem, was the heated debate on the drafted Protection of Damaged Users of Health Services Act (B.E.) between the service providers, e.g. doctors, versus the service users and other supporters of the law, e.g. non-governmental organizations on human rights. On the user side, they lauded the prospect that the law would enhance the quality of health services provided by the hospitals and doctors, as they would have to be certain that their services were cautiously delivered to the patients. To the contrary, the service providers were skeptical about whether the law would really solve the problems. Unnecessary expenses would be increasingly incurred by hospitals to compensate for their alleged wrongdoing, as the law would stipulate that money be paid to plaintiffs immediately once lawsuits take effect. This could cause some of them to go bankrupt and become even more incapable of delivering the services. The law could also further demoralize physicians, as they would refuse to accept more difficult cases to care for. The UC Scheme has increased the opportunity for the poor to get access to healthcare services, though there are still limitations in terms of its benefits. However, it is a good sign of healthcare system improvement in Thailand. Nevertheless, the increased access to healthcare has led to patients using the service when it is not really necessary, causing a sometimes unbearable workload for hospital staff. Also, it has probably led to patients taking less care of themselves, as they know that they can go to hospital for free. People seem to be practicing less self-care in relation to their health after they had gained easier access to healthcare, which raises the concern of over-utilization further contributing to problems with the UC Scheme, such as increasing workloads for staff and financial difficulties that may adversely affect the quality of care and of medical facilities. There have also been some cases in which patients have requested medicine, and then sold this medicine to others.

About The AUTHOR: Sadudee Vongkiattikachorn Sadudee Vongkiattikachorn is a development economist with high level experience in policy research in a number of sectors. Mr. Sadudee holds a Master of Public Affairs (M.P.A.) degree from the School of Public and Environmental Affairs (SPEA), Indiana University, and a Bachelor of Economics (B.E.) degree from Thammasat University, Bangkok, majoring in monetary and international economics. In his most recent position as Senior Researcher at the Division of Policy Research and Development, Public Policy Development Office (PPDO), attached to the Prime Minister’s Office, Thailand, he authored a number of major policy research papers relating to economic, political and social development, poverty alleviation, and strengthening of Thailand’s research capabilities. He currently works with Noviscape Consulting Group as a senior consultant.

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Implications: •

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Innovation in healthcare information technologies will combine and enable the collection of more health data, which in turn will give individuals more control over their healthcare. There will be more discussion on the future of self-tracking and health data rights as the conflict between health service providers and clients will continue to emerge. Public health insurance, containing “pro-poor” policies, is required to realign and redress unequal access to healthcare. All citizens should be entitled to and should have equal access to quality care according to their needs, regardless of their socio-economic status and religion (Jongudomsuk, 2002). The ongoing health reforms still have to be implemented more comprehensively. The loopholes within the scheme that could be exploited by unethical practitioners and/or consumers will have to be eliminated. On the other hand, expectations of patients will also have to be adjusted and be based upon more accurate perceptions of what service providers are capable of accomplishing, and the providers should be allowed to have certain limitations to their responsibilities in carrying out their duties.

Early Indicators: • •

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Statistics show that the total number of private hospitals and clinics in Thailand rose from 18,312 in September 2009 to 18,819 in September 2010. Many hospitals have been unable to cope if they overspend, and many large hospitals around the country have been forced to cut back on staff and close beds amidst fears of bankruptcy. Complaints of substandard treatment are increasing. Patients may be referred to numerous different institutions as each in turn refuses to take them (Towse, 2003). In 2001, Thailand became the first developing country to introduce a UC scheme aiming to ensure equitable and high quality healthcare access for citizens. This was originally known as the “30 Baht treating all diseases project”. It is a means to improving the quality of life for the poor and to redress unequal access to health care.

Drivers and Inhibitors: Drivers: •

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Urbanization expanded physical spaces for the inflowing rural poor to get better access to healthcare and consequently has created their cognitive spaces in terms of rising expectations toward ideal services. Primary care is the first stop and is easy for the poor to access; there is a need to improve its quality and equity. Convenient public transportation could be the sup-

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portive infrastructure that mobilizes patients to reach more easily hospitals in different areas. Many hospitals focus on improving their health management systems to survive in a competitive market. Patents in developed countries / incubating for developing countries will create new entrants of service providers into the industry with higher value to patients. Decentralization to newly urbanized areas, leading to more accessibility but also more cost and redundant systems.

Inhibitors: • • • • • • • •

The average life expectancies among the population are much higher, causing more prevalence of long term diseases and increased costs. There is less medical staff available than is needed to meet the needs and demands from increased accessibility of populations. People’s perceived needs and expectations are much higher than the system can handle. Governmental budget is more restricted and not enough to cover all benefits and the level of quality of care. Wrong policy choices with too much emphasis on populism could turn health systems to be less effective. A gap of knowledge sharing will create barriers to patients in comprehending new advances and things in healthcare. Unpredictable technologies will leave patients further behind so that it becomes tougher for them to catch up. Uncertainties of protection system and management system when the private sector is taking over.

References Acuin, J. (2011). Southeast Asia: an emerging focus for global health. Retrieved from: http://www.cueid.org/component/option,com_docman/task,doc_download/gid,2757/ Itemid,42/ Baars, B. J. (1998). Consciousness and attention in the brain: A global workspace approach, Integrative Physiological and Behavioral Science, 33(1), pp.86-87. Butler, C.D. (2011). A stormy future for population health in Southeast Asia? Retrieved from: http://www.cueid.org/component/option,com_docman/task,doc_download/gid,2761/ Itemid,42/ Department of Health Services Promotion (2009-10). Statistics on Hospitals and Clinics. Retrieved from: http://www.mrd.go.th/ac/stat.asp Jongudomsuk, P. (2002). How do the poor benefit from the Universal Healthcare Coverage Scheme?: Thai experience, Health Systems Research Institute (HSRI), Thailand. Kai, H.P. (2011). Health and Healthcare Systems in Southeast Asia: Diversity and Transitions, Health in Southeast Asia, 377, p.429-437. Pannarunothai, S. and Patmasiriwat, D. and Srithamrongsawat, S. (2004). Universal health coverage in Thailand: ideas for reform and policy struggling, Health Policy, 68, p.17-30. Ratanawaraha, A. and Chairatana, P. –A. (2010). City Innovation Systems: The Next Horizon in Innovation Studies for Southeast Asia, paper presented at the 8th GLOBELICS International Conference: Making Innovation Work for Society: Linking, Leveraging, and Learning, November 1-3, 2010, University of Malaya, Kuala Lumpur; Malaysia. Satyapan, N. and others (2010). Herbal Medicine: Affecting Factors and Prevalence of Use of Thai Population in Bangkok. Department of Pharmacology, Phramongkutklao College of Medicine. World Health Organization, WHO (2010). Improving access to health services in urban areas, World health day 2010. Retrieved from: http://www.searo.who.int/ worldhealthday2010/linkifiles/Fact-Sheets/fs-5.pdf

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“Biodigital Jazz” in Digital Healthcare By Dr. Pun-Arj Chairatana Managing Director @NCG

IDEA: Digital healthcare, also known as e-Health or Health IT, is impacting the national health system, especially in health logistics, diagnostics, pharmacy, and in-patient monitoring. Currently, advanced and high tech health services are available in most of the world’s megacities. Unfortunately, these are only available to the more affluent members of these communities and basic medical care is still a problem for a large population at the bottom-of-the-pyramid (BoP). Countries in ASEAN aim to leverage the region into a vibrant economic zone with a better living standard by 2020. Many countries are spending a high proportion of their national budget to leverage national education standards, universal access to information, the Internet, and surely - healthcare. Singapore has taken the lead in digitizing their national health system, followed by Malaysia and Thailand. Other member states are struggling with modernizing their visibly inadequate health infrastructure.

Scenarios: This article illustrates the future of digital innovations in shaping a global healthcare system and a new social platform that may potentially affect vulnerable groups in the next 10 years with a special relevance to Southeast Asia. In this scenario, there are three issues for the future of health service innovations, which will come to dominate digital healthcare in the region: digitization of health infrastructure, new threats from connected Health IT, and a convergence of health information.

Digitizing hospitals:

The majority of information systems departments in the

KEYWORDS: Digital healthcare; public safety; green IT; digital health information typical Southeast Asian hospital are not web-oriented, and they are underfunded. There will be more use of the Internet as a replacement for and complement to existing information systems, communication infrastructures, and transaction services. Leading hospitals will compete with other industries for the talents of scarce web and graphic designers, program analysts, health technicians and engineers in their quest to modernize their health communications infrastructure and transaction services in order to gain smart hospital status. Electronic Medical Records (EMRs) will be widely implemented as the backbone to facilitate the “front end” of health service for a range of clinical systems. Local service providers will compete neck and neck with international firms—like Intel, Google Health, and Microsoft Health Vault—to win contracts from public hospital centers.

Infection, crime, and terrorism (ICT): Computer virus attacks in healthcare are on the rise, and the spread of computer viruses into medical devices has increasingly been causing damage and affecting the safety of the lives and health of the world’s population, while the majority of physicians are still unaware of this silent threat. These include risks to healthcare delivery and health promotion, including the reports of machine errors. Furthermore, there is the threat of the leakage of patient data from hospital information systems lacking adequate protection, including damage to vital patient information that has been altered or destroyed by hackers or computer viruses, which may result in erroneous decisions to treat as well. Even if some healthcare institutes have capacity to provide technologies to safeguard electronic health information (EHI), the perception of a lack of security and resistance to change will inhibit the use of the Internet for personal clinical information. In the near future, identity fraud and digital corruption affecting the

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healthcare budget will become more visible and more severe, especially attacks from Cryptovirus and Conficker virus1. Terrorism in Southeast Asia will also increase for two reasons: the region is one of the most important transportation hubs, and it has well-equipped medical facilities. An infected medical computer can cause an error in the treatment or a delay in treatment, and an intentional or unintentional medication prescription error on a pharmacy computer may cause patient death, both among a VIP group or in the public in general.

Creative eHealth Information: Some health problems occur more frequently in mega cities or are exacerbated by urban living, such as many mental health problems, drug and alcohol abuse, accidents, assaults including domestic violence, and illnesses arising from environmental degradation and air pollution. Some of the challenging issues in eHealth adoption and diffusion involve sociological and interpersonal aspects, rather than technology per se. Medical school curricula will have to be modified to prepare future physicians to use IT and blend it in with the art of treatment. There will be more demands placed on a different set of health related datasets, with unconventional interpretations needed. Regional health data analysis in the near future will require a broader range of non-traditional types of health related information: digital elevation maps, urban maps, cartography, maps of water bodies, vegetation maps, land surface temperature maps, and monitoring of windblown dust, for a tropical epidemic early warning system (e.g., for malaria and meningococcal meningitis), in planning fieldwork campaigns for research in the management of development projects in public health (Gemperli et al, 2006). A dataset from the Earth observation is related to the prevention and management of emerging infec-

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tious diseases (EIDs) as well as mega-natural disasters. This trilogy of changes will create a new legacy of sociotechnological improvisation - “a biodigital Jazz,” like a term coined by the actor Jeff Bridges in the movie TRON – LEGACY.

Implications: On greening health logistics: Similar to the more advanced countries and following their lead in health logistics, emergency medical care has become a major concern because of the lack of a comprehensive and accessible ambulance service, along with an increasing demand for adequate hospital accommodation for both general and specialized treatment, and for long-term care of the aged, especially in most megacities in the region. There will be a possibility for such gap to be widened through the application of digital technology in society at large. eHealth in this region should place emphasis on these issues.

Learning by interacting: Surprisingly, the status of digital healthcare development has been an under-represented issue for discussion, even among the majority of medical staffs. This will cause physician ambivalence when more equipment and processes become digitized. While the EMR is fast becoming a new hospital standard, it is still a long-term work-in-progress to make the regional health care personnel shift from their paper charts to a swipe tablet. A few comments from the early adopters shared in Southeast Asia show that they share a different view from their counterparts in the more advanced countries on the use of the Internet and electronic mail by healthcare professionals. In Southeast Asia, the email, and more specifically E-prescribing can be a technological innovation altering the physical doctor-patient relationship; while there will have to be more time-lag in the adoption of IT by physicians as the medical culture tends to be extremely conservative and cautious, especially when it comes to new technologies.

Cryptovirus is a cyber-intimidation and extortion threat that attacks the computer system, while Conficker, also known as Downup, Downadup and Kido, is a computer worm targeting the Microsoft Windows operating system that was first detected in November 2008.

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About The AUTHOR: Dr. Pun-Arj Chairatana Dr. Pun-Arj Chairatana is the Managing Director of NOVISCAPE CONSULTING GROUP and the Principal Investigator of TRENDNOVATION SOUTHEAST NEWSLETTER. He has been involved with various regional scenario buildings and exercises for the future since 2000. As a policymaker, he was Director of Policy Entrepreneur and Foreign Affairs Department at the Public Policy Development Office (PPDO), the Office of Cabinet Secretariat. He has a background in economics of technological change, innovation management, health and nuclear physics. His expertise is in the areas of strategic foresight, technology and innovation management, public policy, trend analysis and political economy.

Early Indicators: •

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There will be more major hospitals in ASEAN5 and Vietnam applying an electronic medical record (EMR) system within the next ten years, by the utilization of variously priced strategies offered from both international firms and local SMEs service providers. The Thai Controller’s General Department (CGD) experienced a Cryptovirus intrusion on public servant accounts as medical identity theft in 2009. There were more than 300 MRI machines around the world infected with the Conficker virus in the summer of 2009, according to a report of the Internet Storm Center. There are more than 300 human diseases found in the distribution of pathogens worldwide that are strongly linked to climate. The changes occurring in climate will lead to a massive increase in human vector-borne diseases, particularly in tropical regions which have high pathogen diversity and perfect weather conditions serving as key factors in disease transmission (Randerson, 2004).

Drivers & Inhibitors:

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The legacy from a lawsuit in a foreign country in which an error resulting from medical record mistakes occurred in the treatment of patients.

Inhibitors: •

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Lack of resources for computer emergency response teams, especially in university hospitals or large medical centers, in order to monitor an increasing treat to network security from computer viruses invading sophisticated electronic medical equipment. There are too many healthcare standards and price ranges. The differentiated nature of standards and investment in health IT will inhibit and delay the investment of less privileged healthcare unit to move into the smart hospital.

NOTE: The author would like to thank Thailand Chief Information Office 16 Forum and Dr. Arida Chandacham for the insights and comments on issues and trends on digital healthcare in Southeast Asia.

References Cain, M. and Mittman, R. (1999). The Future of the Internet Health Care: A Five-Year Forecast. Retrieved from http://www. chcf.org/documents/intreport.pdf Dedmo, R. E. (2008). US health care reform: reality and implications for Asian health care providers, administrators and policy makers, Asian Biomedicine, Vol. 2 No. 5, October 2008, p. 431-440. Retrieved from http://abm.digitaljournals.org/index. php/abm/article/viewFile/215/134 Gemperli A, Vounatsou P, Sogoba N, Smith T (2006) Malaria mapping using transmission models: Application to survey data from Mali. Am J Trop Med Hyg 163: 289–297. Retrieved from http://aje.oxfordjournals.org/content/163/3/289.full Rockefeller Foundation (2008). Making the eHealth Connection: Global Partnerships, Local Solutions. New York. Retrieved from http://www.rockefellerfoundation.org/media/download/ f3235b45-704f-412e-8ba6-20d92c82ef75 Tegart, G. and Jewell, T. (2001). Healthy Futures for AsiaPacific Megacities, Foresight, vol. 3, No. 6, December 2001, Emerald. Retrieved from http://www.technology.am/confickerworm-hits-hospital-devices-032629.html

Drivers: •

An increasing impact and effects of climate change on the tropical regions and the emergence and reemergence of infectious disease.

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Crescendo and Diminuendo of HIV Epidemics in Thailand and Southeast Asia By Pokrath Hansasuta, MD, DPhil (Oxon), FRCPath Chulalongkorn University

IDEA: Acquired Immunodeficiency Syndrome (AIDS) was first recognized in 1983 when scientists had no clue what the cause of AIDS was. Two years later the etiologic virus, Human Immunodeficiency Virus (HIV), was subsequently identified. HIV/AIDS began spreading into Southeast Asia only a few years after it was first described in the USA. However, the pattern for the predominant mode of transmission was and still is somewhat different from the West. Whilst HIV has been spreading in Europe and North America mostly among men who have had sex with other men (MSM), the virus is being effectively transmitted via heterosexual transmissions in Thailand and her neighboring countries. Although the Thai virus was once reported to have more efficiency in heterosexual transmission in vitro, there is no proof whether this enhanced efficiency can explain preferential heterosexual transmission in Thailand and other countries in mainland Southeast Asia (Indochina, Myanmar, and Malaysia). This article discusses the innovation shift in HIV/AIDS prevention and treatment, with special reference to the bridging population of commercial sex workers (CSW).

Scenario: In fact, bridging populations such as commercial sex workers (CSW), either male or female, may have played an essential role in shaping predominantly the heterosexual HIV epidemic in Thailand and other Southeast

KEYWORDS: Acquired Immunodeficiency Syndrome (AIDS); bridging population; commercial sex worker; HIV prevention and control strategies Asian countries (Figure 1). Information on these relationships is particularly useful for the good design of HIV prevention/control strategies.

Demand forunconventional preventive measures: Strategies for prevention of HIV transmission through sexual routes include behavior modification, safe sex practice, condom use, microbicide gel, circumcision, post-exposure HIV prophylaxis, and more recently preexposure HIV prophylaxis. A blood screening policy has been in place for more than 25 years and hence there is now effective prevention of HIV transmission through blood transfusion. Prevention of HIV infection in children born to HIV-infected mothers, using cocktail of anti-HIV drugs, has led to an ultra-low incidence of HIV acquisition in the new born. Whilst prevention of HIV transmission in blood/blood product recipients and in babies born

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to HIV-infected mother has been hugely successful, prevention strategies for reducing its sexual transmission are still tricky. In some countries, for instance Thailand, campaigns and free condom distribution has led to the control of HIV transmission to a plateau level, but the prevalence and new infection rate is still high (Fig 2). Interventions to further reduce the occurrence of new infections are still on the loose.

in the HIV load, and hence decreases the probability of HIV transmission to uninfected sexual partners. In theory, if the virus load of all HIV-infected persons is fully suppressed by anti-HIV drugs, their partners are very unlikely to contract HIV from them.

Perhaps conventional prevention measures of sexually transmitted diseases (STD) per se are not sufficient to prevent against HIV transmission.

tive HIV vaccine, we have observed only one successful, though marginally successful, story. The level of protection in vaccinated persons is only slightly more than 30 percent above that of non-vaccinated subjects.

An alternative strategyimmunization by vaccine: a medical service innovation? The quantity of HIV (HIV load) is known to be a key factor for the successful transmission. Treatment of HIV/ AIDS by anti-HIV drugs leads to a significant reduction

Despite several billions of dollars in global investment and some 25 years in the quest for a safe and effec-

There may be a light at the end of the tunnel, even after Merck’s HIV trial failed to improve the efficacy a few years ago. While we are waiting for a more effective HIV vaccine, other interventions are indispensible for slowing down the epidemic, particularly in the young. We still do not know how long this diminuendo of the HIV epidemic will go on, but hopefully the epidemic will not begin a new crescendo in a new risk group.

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Implications: •

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A combination prevention strategy should no longer be limited to a campaign, education and condom use program anymore. Newer interventions such as circumcision, prophylaxis by anti-HIV drugs, and early HIV treatment may need to be included and discussions amongst policy makers, clinicians, scientists and HIV activists are urgently needed in order to reach more effective control of HIV transmission. However, a treat-all strategy may not be realistic due to the expense, particularly for developing countries, as well as the adverse side-effects of the anti-HIV drugs. Successful stories from combating other viruses would suggest for us an alternative strategy: immunization by vaccine.

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Inhibitors: •

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Early Indicators: •

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Education, behavior modification sessions and HIV/ AIDS campaigns have long been operating in all countries, but we are still observing approximately 2.7 million new cases a year (UNAIDS/WHO). The number of HIV/AIDS patients and those who likely died of AIDS has been decreasing; patients live longer and have better quality of life. As a result, AIDS patients and deaths from AIDS have dropped by more than in the past through better treatment and innovation of health services.

The frequency of multiple sexual interactions and sexual abuse could change the equation.

ontinued disapproval of contraception, and condom C use in particular, on religious or cultural grounds, and by the younger generation. Superstitions and urban legends about HIV infection persist. Uncertainty on funding for HIV/AIDS prevention and treatment programs from the government in Southeast Asia. Malpractice from alternative medicine and patient misbehavior. A strong social stigma against those with HIV/AIDS prevents some from seeking effective treatment. A lack of political support for new more effective control measures.

References www.aidsthai.org (in Thai) www.unadis.org

Drivers and Inhibitors: Drivers: •

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An increase in the regional HIV infection rates, and the number of infections per day amongst the younger generation, are indicators of the re-emergence of the problem. Regional progress in the development of HIV/AIDS vaccines and drugs could help reduce the spread of the virus. An increase of international philanthropic and intergovernmental funding for HIV/AIDS prevention and research programs has occurred.

About The AUTHOR: Dr. Pokrath Hansasuta Dr. Pokrath Hansasuta is Assistant Professor at the Department of Microbiology, Faculty of Medicine, Chulalongkorn University. He received a Doctoral Degree in Clinical Medicine from the University of Oxford, the United Kingdom. His main research interests are in HIV Immunology and universal flu vaccine development.

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Interview with

Dr. Thiravat Hemachudha By Dr. Pun-Arj Chairatana and Ms. Nartrapee Wongseangchundr

Q: In your opinion, how does the current situation stand for Southeast Asia’s health services? “Access to health services is always a key determinant of development. Within Southeast Asia, the countries with the most efficient delivery of health services are Malaysia and Singapore. I think that one of the trends in the region is that health services in developing countries often end up a casualty of populist politics, and are used as a tool to maximize votes. Sadly, politicians neglect their responsibilities under their social contract. The result is overly complex and underfunded national health systems, longer waiting lists and inefficient service delivery.” “Moreover, preventive healthcare campaigns in the community have not generally met with success. Patients more frequently present with more severe symptoms than previously. Moreover, severe cases (imposing high treatment costs) are frequently transferred by physicians to central or provincial hospitals, provoking a ‘knock-on’ budgetary problem and higher total costs of service delivery.” “The result is conflict between patients and physicians, longer queues at hospitals, and heavier pressure on medical professionals in Bangkok and provincial cities. With the threat of lawsuits always at

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hand, many doctors have resigned from their posts at government hospitals to work in the better resourced and less bureaucratic private hospitals instead. This certainly worsens the situation and drains the system of precious human resources.” “In addition, conflicts have grown within the profession itself over the policy of allowing doctors to choose only from an official list of cheaper drugs under the health insurance system. Often the best and most effective medicines are expensive out-oflist patented and imported drugs, e.g. medicines for Alzheimer’s disease or cancer. However, the situation may be improving as the committee of the National Drug Formulary or essential drug program, Thai FDA, started implementing policies that state that drugs to be used in Thailand under the national welfare program should fulfill criteria of efficacy, safety and accessibility. Drugs that save lives or disease-modifying drugs, even those with high cost, have also been included. However, there are rigid inclusion criteria, such as for whom to use, when to initiate, for how long, when to consider a drug is not effective, and which institutions are capable of handling such patients.” “If we don’t do something radical, the conflicts throughout all levels of Thailand’s health system will worsen: conflicts between service providers and patients, budgetary conflicts, demoralized and declining medical professionals. The situation will be exactly what countries in South Asia, i.e. India, Nepal, and Bangladesh, are also now being faced with.”

Q: How will the increasing intensity of movement of people, goods, and animals across the region affect health service delivery? “Thailand is under close watch for human trafficking and illegal trade across borders. This is because the country was formerly a hub for trade in endangered species, and labor migration, both legal and illegal. Diseases are easily transmitted across borders in this way, and emerging diseases often have this etiology, with the close animal-human contact facilitating the jump from animal to human. Looking ahead,

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increasing trade liberalization surely will exacerbate these risks, so I expect to see new emerging diseases arise more frequently. Increasing treatment costs will therefore place higher burdens on health services all around the region.”

Q: Which innovations might offer a high impact solution to enhance access to health services for vulnerable and marginalized groups? “Service innovation in healthcare is needed to address these system failures. We need to facilitate universal access based on an understanding of social change, the drivers of the existing system, budgetary constraints, and the supply of medical professionals. Thailand’s universal health care scheme offers a useful case study in this regard. The main target of universal healthcare schemes is to offer free healthcare services to all. Thailand’s strategy has been to allocate budgets to local health service providers such as health centers and district hospitals. Preventive care strategies complement this effort, using campaigns to raise awareness to help individuals stay healthy and prevent sickness, in theory reducing the patient burden at hospitals. (As I mentioned earlier, approaches to preventive health have so far not met with much success and need to be rethought). Scientists and sociologists must work together to solve these complex problems, so that research can deliver meaningful answers to real-life problems rather than just for academic advancement.” “Thailand might benefit from approaches of other countries in balancing the workload of medical professionals between research teaching and patient care. For instance, the United States categorizes medical manpower, giving clear separation to these roles, and minimizing the need for trade-offs, between medical research and the work of physicians. System design is the key to sustaining a relevant research agenda; specialization creates the risk of a silo mentality; players need to have a broad understanding of the needs and challenges of other actors in the healthcare system.” “In countries like Malaysia and Singapore and China, a “semi-dictated” policy might not be that bad.

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A unified well-structured system and policy, topped down from the government with stringent control and monitoring to keep things in place proves effective. Scientists and physicians can be teachers. They can simplify things considered as complicated to the students. Good science starts even at the primary school level. Each then knows how to “learn” and to acquire knowledge by his or her own and not by spoon-feeding.” “In Thailand, the problems are that policymakers do not know what has been going on and each and every sector (knows this), and they tend to freely operate like an unguided missile with collateral damage, with time and national budget loss. Decentralization as in Thailand is not a problem. It is that all levels do not know what to do and which direction to go. Thailand is just like the jigsaw pieces not knowing when to complete the image.” “We also need to take a more rational look at the cost-effectiveness of drugs. Locally-manufactured generic drugs of proven quality must be considered first. There is no need to spend more (it can be up to 10-30 times higher) for original imported drugs whose patents have already expired. Dramatic budget savings can be achieved in this way. Also, we should not be blinded by technology in seeking solutions: the public has to be continuously educated on how to stay healthy. Eating vegetables 3-5 times a day helps prevent stroke and cancer, whilst dietary supplements are a fraud. Eating right and daily exercise can yield massive reductions in total need for prescription drugs, and so healthcare systems should start right there. Finally, we may have to think whether co-payments by the patients who can afford it can be possible to make this national welfare system sustainable.”

About Dr. Thiravat Hemachudha, MD, FACP: Dr. Thiravat is Professor of Neurology at the Department of Medicine and Molecular Biology, Center for Neurological Diseases, Chulalongkorn University Hospital. He is Director of WHO Collaborating Center for Research and Training on Viral zoonoses and was former Director, WHO Collaborating Center for Research on Rabies Pathogenesis and Prevention. He is Member of WHO Expert Advisory Panel on Rabies, and a columnist on health issues and “Detox Thailand” in Matichon and Bangkok Business newspaper, among others.

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Decision Modeling and Foresight Methodologies By Sadudee Vongkiattikachorn Senior Consultant@NCG

Professor Ahti Salo initiated the research group on Decision Modeling and Foresight Methodologies, which is based at the Systems Analysis Laboratory of the Helsinki University of Technology. Decision analysis as well as decision making and risk management have been among the key issues that the group wanted to make progress on. They were run in collaboration with the Helsinki School of Economics as of 1995. The activities have been enabled through basic and applied research projects funded by organizations such as the National Technology Agency (Tekes), the Academy of Finland, Ministries of the Finnish Government, industrial firms and the European Union. With respect to decision modeling, the most relevant focal research topic is the modeling and exploitation of incomplete information in decision support pro-

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cesses. The topic is motivated by the realization that information on the performance of decision alternatives or the relative importance of the decision criteria can be difficult, impossible or prohibitively expensive to acquire. It is thus pertinent to examine how useful and defensible recommendations can be developed on the basis of the information that can be obtained through decent efforts. The research group is directed by Prof. Ahti Salo of the Department of Mathematics and Systems Analysis, in Aalto University. The group develops decision analytic methods and tools; it also deploys these in the context of applied research projects carried out in collaboration with decision and policy makers on topics in relation to science, technology and innovation. In terms of methodology, particular attention is given to participatory approaches for technology foresight and assessment, as well as methods for addressing uncertainties in innovation management (e.g., prioritization of research themes). The research group consisted of Prof. Salo, four full-time researchers, three Master’s Thesis students, and two part-time research assistants. In recent years, the main projects in relation to S&T decision and policy making were “robust portfolio modeling in innovation management” (a research project on the use of portfolio approaches in technology foresight, funded by Tekes and industrial firms); “A participatory exploration of business opportunities for the environmental cluster of Ylä-Savo” (carried out together with Savonia Polytechnic); “A resource allocation model for standardization activities at a telecommunication company” (Nokia); and “Decision Analysis in Project Portfolio Optimization” (Academy of Finland). Elaborating in further details pertaining to the above projects, the methods being developed and utilized were built on the well-established frameworks for value tree analysis and some hierarchical weighting models. Four important methods can be investigated:

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PAIRS & PRIME: these methods are to accommodate incomplete information about the model parameters by way of set inclusion. For example, the lower and upper bounds may be placed on the alternatives’ scores and criteria weights may be constrained through linear constraints. With the assistance of relevant dominance concepts and decision rules, such information can be synthesized to convey a) which alternatives can be definitely recommended on the basis of all feasible combinations of model parameters; and b) what alternatives are supported by decision rules that can transform incomplete information into corresponding decision recommendations. Preference Programming: methods are promising as they support interactive learning processes. They also can reduce the costs of information elicitation and may increase decision modeling commitment to the particular decision support process. Rank Inclusion in Criteria Hierarchies (RICH): the method extends preference programming methods to the analysis of incomplete ordinal information. A related decision support tool, called RICH Decisions, also emerged on the basis of RICH to be employed in the selection of risk management methods and the development of priorities for a research program. Such practices were found being applied to an energy utility and a program in Scandinavia, respectively. Moreover, the RICHER method, or so called RICH with Extended Rankings, offers even more flexible preference elicitation modes. It applies such modes of RICH to the comparison of alternatives. Thus, for any given subset of alternatives, the model may specify a subset of rankings that these alternatives may assume in relation to a single evaluation criterion, several criteria, or even all criteria. Robust Portfolio Modeling (RPM): the devel-

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opment came from the works at the juncture of preference programming and multi-criteria project portfolio selection. The method makes it possible for foresight manpower to determine a) which core projects are included in all nondominated portfolios; b) which exterior projects are not included in any non-dominated portfolios; c) which intermediate projects are included in some but not all non-dominated portfolios. Based on the analyses, the model can be advised to select core project while rejecting trivial ones. Furthermore, subsequent information elicitation efforts can be focused on intermediate projects, which helps reduce the costs of information elicitation. Contrasting to the earlier literature on robustness, RPM is considered unique in that it offers decision recommendations about individual projects instead of offering a ‘single’ optimal portfolio on some selected robustness measure, e.g. max-min. This makes it appropriate for interactive group decision support processes where considerations that are less amenable to formal modeling efforts can be addressed through judgmental considerations, e.g. project interactions. Pragmatically, a wide range of RPM projects have been carried out in various contexts, including road asset management, formulation of a product strategy in a high-tech firm, scanning of innovation ideas, development of a strategic research agenda, and ex post evaluation of an innovation program. In relation to RPM, the group is actively working on the development of decision support tools for the computation (RPM-Solver) and internet-based dissemination of RPM results (RPM-Explorer).

References Salo, Ahti. Decision Modeling and Foresight Methodlogies. Retrieved from www. inescc.pt/~ewgmcda/GrSalo.html Helsenki Institute of Science and Technology Studies. Research Group on Decisionmaking Models and Foresight Methods. Retrieved from http://www.valt.helsinki.fi/blogs/hist/post29.htm

Mr.Sadudee Vongkiattikachorn Dr.Pun-Arj Chairatana Dr.Pokrath Hansasuta Dr.Thiravat Hemachudha

Principal Investigator