1. 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

2. 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

3. 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 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 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

4. Source: National AIDS Spending Assessment, National AIDS Management Center

5. 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

6. ART Program Budget under UHC
( )
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

7. 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

8. 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

9. 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

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