Table 1 Examples of ex-ante and ex-post health technology assessments

An ex-ante assessment was conducted as part of a collaborative study undertaken by Myanmar’s Ministry of Health, WHO, and the Thai Ministry of Public Health between March 2010 and September 2011. The aim of the assessment was to collect information to guide the formulation and implementation of a demand-side financing mechanism for maternal and child health (MCH) services in Myanmar. The main objective of the MCH voucher scheme is to eliminate the financial barriers to maternal and child health care among poor households by providing support in the form of four antenatal visits, delivery by skilled birth attendants, postnatal care, transportation, food, and lodging. Using both qualitative and quantitative methods, including an economic evaluation, this collaborative research demonstrates that the use of demand-side financing for MCH services in Myanmar appears to be feasible and represents good value for money. The evidence suggested that the initiative was likely to garner support from community leaders and civic groups, and be accepted by target populations and health workers, because it removes many of the impediments that people currently Figure 1 Potential use of Health Technology Assessment (HTA) to enhance value for money of Global Fund initiatives. Teerawattananon et al. Globalization and Health 2013, 9:35 Page 5 of 9 http://www.globalizationandhealth.com/content/9/1/35 encounter when trying to access MCH services. Some of the most common barriers that people face when trying to access these services are the long distances between the residence of the mother and the nearest health facility, and the related high travelling costs (particularly in rural areas), the high cost of medicines (which for many is unaffordable).

In Myanmar, where the average number of pregnancies per year is 900,000, it is estimated that introducing the MCH voucher scheme would increase ANC coverage from 68% to 93% and delivery by skilled-birth attendants from 50% to 71%. The ex-ante assessment found that the MCH voucher scheme was likely to save a significant number of lives of mothers and infants, for whom the cost of ANC is currently prohibitive. The assessment also found that this could be done at a reasonable cost. The incremental costeffectiveness ratio (ICER), which in this case is the additional cost per life-year saved from introducing the MCH voucher scheme compared to the status quo, ranged from 376,548 to 452,110 kyats (475 kyats = 1 international dollar, in 2010). This represents good value for money, especially given the ceiling threshold of 1 time of GDP per capita of 413,800 kyats. The results of this study were presented to senior decision makers in Myanmar in March 2011 resulting in an agreement being reached to implement the MCH voucher scheme in one township commencing in November 2012 before scaling it up as a nationwide program.

Global Fund for a (Round 8) grant support of $75.46 million over five years, from July 2009 to May 2014. The three principal recipients (PRs) are the Thai Ministry of Public Health and two non-governmental organizations. This program aims to expand HIV preventive services for female sex workers (FSW), people who inject drugs (PWID), men who have sex with men (MSM), and migrant workers. Because there was concern among PRs about the sustainability of the program beyond the 5 years of the grant support, the Health Intervention and Technology Assessment Programme (HITAP) was invited by the Country Coordinating Mechanisms (CCM) to take part alongside PRs and Sub-PRs in an evaluation to assess the costs and cost-effectiveness of this ongoing program. The results of this study will be used to improve program performance and support policy decision making by the Thai government in terms of whether and how the program continues at the end of the period of Global Fund support.

Using routine administrative data, program costs and outcomes in terms of population reached by CHAMPION were estimated in international dollars at I$2,333/ PWID, I$270/FSW, I$162/MSM, I$161/migrant. These estimations were much higher than the cost per person in comparable programs for PWID in Bangladesh (I $727/PWID) and for FSW in India (I$129/FSW). The higher costs per person in Thailand may be explained by the shorter duration of the program (one and a half years for CHAMPION vs. three years for the Bangladesh project, and two years for the Indian project), which may have lead to higher fixed start-up costs that made up a significant proportion of the overall costs per person (a proportion which falls significantly for longer projects). Second, and more importantly, this higher cost may be due to Thailand’s lack of a harm reduction policy and the presence of harsh criminal sanctions for PWID, which made it more difficult to recruit PWID to the CHAMPION scheme. In its conclusion, the study suggests an urgent need to improve program performance if CHAMPION is to offer value for money in the Thai setting.