This Thai case study illustrates a number of critical factors in the problem, policy and political streams that encouraged the rise of cervical cancer screening onto the governmental agenda – the process that led to authoritative decisions and eventually, the 116-Day initiative in 2008. In line with Kingdon’s [14
] agenda setting model, we recognise the discovery and distribution of the HPV vaccine as a focusing event – an obvious, sudden, relatively uncommon event that highlights a problematic issue and/or a solution to which policy authorities and the public pay attention. Without this discovery and its distribution, policymakers and other key policy stakeholders in Thailand, and around the world, might not have recognised the cervical cancer burden and available prevention measures. In particular, since the newly-introduced technology was unaffordable for poor countries, screening tests were revisited and discussed by international and national health organizations, as effective alternative means of curbing the disease. Health authorities and experts in most settings did not recommend HPV vaccination as a substitute for screening services, but as a complementary measure.
Policy researchers in the Health Ministry played a significant role both in generating evidence concerning the cost-effectiveness of cervical cancer screening services and HPV vaccination, and in disseminating the research findings to policymakers and administrators in responsible agencies. Such actions by these policy entrepreneurs enabled the coming together of the problem and policy streams. These actions did this by getting the leaders of national health authorities to recognize the magnitude of cervical cancer burdens and become aware of the room for improvement in the screening program. All this happened while the country was faced with a political crisis in which members of the Cabinet needed to present the public with their successful policies in order to gain the popularity that would help secure their government’s position. It is noteworthy that despite catching the attention of researchers, health officials and politicians, the issue of cervical cancer and screening tests did not reach the attention of the general public, which means that most Thai people, including those targeted by the services, were not involved in the policy shift. Indeed, the analysis also illustrates that the policy shift was influenced by a limited number of actors based solely in the MoPH, with other interests, such as the media and NGOs, playing no role.
Although agenda setting generally involves the rise of interest in a policy problem and, in some instances, its corresponding solutions, this process does not guarantee success in subsequent stages of policy formulation and implementation [34
]. The political rhetoric and top down instructions associated with the 116-Day initiative were inadequate to achieve the extended target for cervical cancer screening. Following Hanson et al [36
], the scaling up of essential health services requires several elements, some of which did not exist for this initiative. These included, in particular, those defined as strategic management factors such as involvement and collaboration between key actors in decision making and implementation units, as well as decentralized mechanisms for policy formulation, planning and administration. Hanson et al. also argue that the constraints to extending public health program coverage may involve contextual factors such as political instability and weak governance. Key informants in this study certainly maintained that the shortfalls in the 116-Day initiative resulted mainly from the chaotic political situation as this did not allow sufficient preparation and engagement between the central departments and local service providers.
The findings of this analysis are in line with existing literature which highlights the crucial role of political factors, including policy elites, not only in facilitating and impeding policy shifts but also in guiding the success or failure of the innovations in particular settings [37
]. An analysis of health financing policy in South Africa and Zambia demonstrates, meanwhile, the undesirable consequences of rapid policy changes underpinned by political drivers, as they may fail to carry forward through policy formulation and implementation [39
]. These African experiences also emphasize the general importance of management strategies in successfully translating policy prescriptions into action [16
]. These include the needs for relevant technical capacity, effective design of proposals and clear communication of policy changes. In the scaling-up of cervical cancer screening services in Thailand, although the capacity to conduct technical analysis existed in the Health Ministry, research institutes and even in peripheral health facilities, this expertise was not consulted in devising the ambitious campaign.
An important limitation of this research is that it does not explore the process of scaling-up cervical cancer screening at the peripheral level. Therefore, the real problems faced by health providers in implementing the MoPH’s 116-Day campaign to strengthen the cervical cancer screening services have not been identified. It is also worth noting that official statistics indicate little extension of services during the program implementation period. However, given that a top-down model of policy implementation was applied, it is not surprising that this initiative was not successful. An extraordinarily short period was available to develop this national-scale campaign protocol and lessons learned from past experience related to the screening program were not drawn on as inputs in formulation of the policy. Without action to counter the already known obstacles to service provision, it was clearly difficult to meet the campaign’s ambitious target.
Fortunately, though, the current development of Thailand’s cervical cancer screening program indicates subsequent improvement regarding its coverage, effectiveness and efficiency. The continuing advocacy for HPV vaccination provides a conducive context for the government to strengthen the screening service provision as it is the only affordable choice currently available. Furthermore, from early 2009 the MoPH’s Department of Health, in collaboration with other organizations, including the Department of Medical Services, has been introducing a pilot program which offers cervical cancer screening, with the operational strategy as recommended by the IHPP-HITAP study, in a number of provinces. Meanwhile, the NHSO and the MoPH are implementing a plan to enhance existing databases and reporting systems related to cervical cancer control. All of these actions may, to some extent, help to ensure better performance of the screening program which will be gradually scaled up in the future.
It is often argued that the main obstacles to health system development in resource-limited settings are inadequate financial and human resources, as well as the lack of relevant and reliable evidence to guide proper policy decisions. This Thai case study shows that even though scientific evidence concerning the safety, efficacy, effectiveness and value for money of policy options for prevention and control of cervical cancer were available, with political will, adequate financial support and a well-established infrastructure, the scaling up of the screening service in Thailand did not achieve its promise in its explicit phase of implementation. This suggests the need for policy managers to have a better understanding of the processes of policy development, including insight into the roles of stakeholders, their interests, and interactions with the health system context. However, analysis of health policy is rarely recognized and applied in developing countries’ academic institutes and health administrative authorities [40