Countries in transition The challenges of middleincome countries

Countries in transition – The challenges of middleincome countries 18 July 2016 AIDS 2016 in Durban, South Africa Sumet Ongwandee, MD MS MPH Bureau of AIDS TB and STI Department of Disease Control

Current Social Health Protection Schemes Social health protection schemes have covered all Thai citizen since 2002 Major Schemes Civil Servant Medical Benefit Scheme (CSMBS) Social Security Scheme (SSS) Universal Coverage (UCS) Introduced in 1960 s 1990 s 2002 Target beneficiaries Government employees & dependents, retirees Private sector employees: To whom which not covered by CSMBS nor SSS, Pop. Coverage 7% 16% 75% Funding Government budget Payroll contribution, Tripartite (Social Health Insurance) Government budget Capitation for OP & IP, DRG for Adjusted RW >= 2 Capitation for OP, DRG for IP (Tax) Payment to health facilities Fee-for-service for OP, DRG for IP (Tax) Source: Dr. Thaworn Sakunphanit, Health Insurance Research Office 2

ART Scaling up: Past and Present 1984 Firstly reported case of AIDS 1995 Double nucleoside regimens 1992 AZT mono therapy 2002 Fixed dose combination “GPO Vir”, Big cost reduction 2000 HAART under Access to Care project or NAPHA Introduction of ARVs and enhancing health facilities capacity to provide services nationwide under research project 2005 MOPH started transferring NAPHA to NHSO Launched national access to ART program by MOPH with partly supported by GF ART = Anti-Retroviral Therapy NHSO = National Health Security Office GPO = Government Pharmaceutical Organization NAPHA = National Access to Antiretroviral Program for People living with HIV/AIDS NHSO was established in 2003. Not until 2006, NHSO has completely adopted ART program and scaled up nationwide MOPH changed GF support to ART program for non-Thais 3

350. 0 Thailand National HIV/AIDS Expenditures by source of funding 1988 -2013 Domestic Other International Global Fund 250. 0 200. 0 150. 0 100. 0 50. 0 Source: National AIDS Spending Assessment, National AIDS Management Center 20 13 20 12 20 11 20 10 20 09 20 08 20 07 20 06 20 05 20 04 20 03 20 02 20 01 20 00 19 99 19 98 19 97 19 96 19 95 19 94 19 93 19 92 19 91 19 90 19 89 19 88 HIV/AIDS Expenditures (Million USD) 300. 0

Thailand’s ART Situation (2015) Estimated all PLHIV 438, 100 ARV clinic • Current PLHIV Diagnosed 391, 484 • # PLHIV in care 376, 987 CD 4 Lab • # receiving ART 283, 747 • # VL suppression 215, 058 Demands 1, 086 120 Viral load Lab 45 Genotype Lab 14 PCR Lab 16 Supplies Average newly ARV initiation before 2014 24, 000 Average newly ART initiation after 2014 32, 000 Source: Adapted from Dr. Sorakij’s presentation at ATFOA meeting in Mandalay, Myanmar, 2014 5

ART Program Budget under UHC (2007 -2013) • 58% ARV cost • 27% LAB cost ART program budget under UHC ran steadily around 100 m. USD for years. • 99% Domestic governmental fund • 1% Global Fund Source: Adapted from Dr. Sorakij’s presentation at ATFOA meeting in Mandalay, Myanmar, 2014 6

Unit cost of ARV per year (First & second line) USD Central procurement and compulsory licensing are important mechanisms in controlling ARV prices. 2, 500 2, 078 2, 090 1, 742 Second line ARV 1, 574 1, 487 1, 500 Compulsory licensing on EFV, LPV/Ritonavir 1, 000 1, 258 Global A 718 500 623 534 First line ARV RV price 478 continue s to drop 448 significan tly 387 0 2007 2008 2009 2010 2011 2012 Average unit cost of first and second line ARV falls to nearly 50% during past 5 years. Source: Adapted from Dr. Sorakij’s presentation at ATFOA meeting in Mandalay, Myanmar, 2014 7

Thailand’s unit cost for ART Program Items I. Drugs • ARV for Rx • Lipid drugs II. LAB • Basic lab • CD 4 • Viral load • Drug resistance Total (Drugs + Lab) *price in 2014 Unit cost $/pt/yr 280 3. 1 5. 7 21. 4 36. 7 5. 6 352. 5 Approx. 1$ /pt/day S. Bhakeecheep, MDSorakij’s presentation at ATFOA meeting in Mandalay, Myanmar, 2014 Source: Adapted from Dr. 8

Key components to UHC in ART Program • Standard ART service package: ARVs, regimens, lab test • ARV procurement and logistics system: central procurement, VMI • Financial mechanism: reimbursement system • Health system strengthening: a network of HIV experts, training program for health personnel, quality improvement program • Community involvement: Day care center • Management information system: NAP electronic data system • Monitoring and Evaluation, CQI, HIVDR surveillance Universal access to ART program is a public health service aiming to provide comprehensive, equitable and quality access to essential treatment for PLHIV

Acknowledgement • National Health Security Office • Thai-US Collaboration/US-CDC • National AIDS Management Center • Thai Network of PLHIV (TNP+)