Countries in transition – The challenges of middle-income 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 1960s 1990s 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 (Tax) Payroll contribution, Tripartite (Social Health Insurance) Payment to health facilities Fee-for-service for OP, DRG for IP Capitation for OP & IP, DRG for Adjusted RW >= 2 Capitation for OP, DRG for IP Source: Dr. Thaworn Sakunphanit, Health Insurance Research Office

ART Scaling up: Past and Present 1984 Firstly reported case of AIDS 1992 AZT mono therapy 1995 Double nucleoside regimens 2000 HAART under Access to Care project or NAPHA 2002 Fixed dose combination “GPO Vir”, Big cost reduction 2005 MOPH started transferring NAPHA to NHSO In 1992, the National AIDS committee launched the national policy to subsidize the provision of ARV for free of charge to people. It was AZT monotherapy that could cover 150 patients in that year. In 1995, the regimen was changed to double therapy, the combination of AZT+ddI or AZT+ddC. In that year, the central supply also included OI drugs and free condom to distribute. In 2000, the MOPH initiated the concept of Access to care by implementing the principles of equal accessibility to Highly Active Anti-Retroviral therapy (HAART), besides free ARV, there were the improvement of quality services, a holistic care. The program also included PLWHA and community to involve in the process of HIV care. In 2002, this was the great year that Thai GPO can produce a fixed dose combination or GPO vir (a combination of d4T, 3TC, NVP). The cost of ARV was down in great number and the country can scale up more people under treatment from 1,700 to 13,000 in the year later. In 2004, it was a year that the government fully committed itself to provide ARV for all Thai PLWHA. The MOPH had transferred the NAPHA program to the NHSO which was established in 2000. However, it was until 2006 that the NHSO could fully function the National AIDS program nation-wide. Introduction of ARVs and enhancing health facilities capacity to provide services nationwide under research project Launched national access to ART program by MOPH with partly supported by GF NHSO was established in 2003. Not until 2006, NHSO has completely adopted ART program and scaled up nationwide 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 MOPH changed GF support to ART program for non-Thais

Source: National AIDS Spending Assessment, National AIDS Management Center

Thailand’s ART Situation (2015) Estimated all PLHIV 438,100 Current PLHIV Diagnosed 391,484 # PLHIV in care 376,987 # receiving ART 283,747 # VL suppression 215,058 ARV clinic 1,086 CD4 Lab 120 Viral load Lab 45 Genotype Lab 14 PCR Lab 16 Demands 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

ART Program Budget under UHC (2007-2013) This graph shows the number of PWHA and budget of ART program in UHC The number of PWHA is increasing over time. While the number of PWHA receiving ART increase more than 2.7 times since implementation, average ART program budget remains stable at around 100 mUSD. 58%  ARV cost 27%  LAB cost 99%  Domestic governmental fund 1%  Global Fund ART program budget under UHC ran steadily around 100 mUSD for years. Source: Adapted from Dr. Sorakij’s presentation at ATFOA meeting in Mandalay, Myanmar, 2014

Unit cost of ARV per year (First & second line) Central procurement and compulsory licensing are important mechanisms in controlling ARV prices. Second line ARV Compulsory licensing on EFV, LPV/Ritonavir Global ARV price continues to drop significantly The major components of ART budget is ARV drugs. In Thailand, about 75% of ART program contributes to ARV drugs, 20% to lab, and the rest 5% to others. Normally, the global ARV prices itself continue to drop gradually. As a result of Thailand’s compulsory licensing on EFV and Lopinavir+Ritonavir, cost of ARV falls dramatically. Average unit cost of first and second line ARV falls to nearly 50% during past 5 years. Accordingly, central procurement and compulsory licensing are the most important mechanisms in controlling ARV prices. First line ARV 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

Thailand’s unit cost for ART Program Items Unit cost $/pt/yr I. Drugs ARV for Rx 280 Lipid drugs 3.1 II. LAB Basic lab 5.7 CD4 21.4 Viral load 36.7 Drug resistance 5.6 Total (Drugs + Lab) 352.5 In 2013, the average unit cost of ART program, including drugs and lab, is 352 USD/yr or less than 1 USD/day *price in 2014 Approx. 1$ /pt/day Source: Adapted from Dr. Sorakij’s presentation at ATFOA meeting in Mandalay, Myanmar, 2014

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+)