1. 1 Sustainable Financing HIV/AIDS and ART Program Viroj Tangcharoensathien MD. Ph.D. International Health Policy Program-Thailand www.ihpp.thaigov.net The 10 th National AIDS Conference 15 July 2005

2. 2 Acknowledgements  National Partners Chureerat Bovornpatanawong, the leading ART clinician Patients, hospital staffs and Provincial Health Offices of Udonthani, Chonburi, Nakornsrithammarat and Lampang Department of Disease control, Ministry of Public Health National Economic and Social Development Board  Funding agencies Thailand Research Fund for Senior Research Scholar Program grant (1998-2005) Health Systems Research Institute for institutional grants of iHPP- Thailand

3. 3 Objectives 1.Background 2.Financing HIV/AIDS program 2000-2003 3.ART and financing ART in 2004-2020 4.Cost effectiveness analysis and financial forecast ART program, 2004-2020 5.Summary

4. 4 Thailand  HDI 2002 0.768; rank 76 th (UNDP2004) GDP per capita 7,010 PPPUS$, 2,060 USD(2002), adult literacy 92.6%, school enrolment rate 73%,,  Poverty headcounts: <2% (1$/day), 13.1% (national poverty line)  Adult HIV prevalence 2003: 1.5% (0.8-2.8), IMR24, U5MR28, MMR44  Universal Coverage achieved October 2001 Low cost capitation contract model and health systems efficiency  Current Health Expenditure 254 PPPUS$, 76USD (2003) Health Exp.2000200120022003 USD per capita63587076 As % GDP3.2% 3.5% Source: Tangcharoensathien et al 2004 NHA

5. 5 Enormous current benefits of prior prevention efforts Red line represents what might have been if behaviors had not changed Infections prevented

6. 6 Evolution on treatment and ARV adoption  1991 Treatment of OI (TB, PCP, Toxoplasmosis, cryptococcal)  1992 Mono-therapy ART(AZT) initiated  1995 Evaluation of mono-therapy, not affordable  1996 Dual therapy (AZT+ddI versus AZT+ddC), small scale 1,500 cases,  1997 HIV clinical research network, limited scale on ART  2000 Access to Care-limited triple drugs, and nation-wide PMTCT adopted – build up capacity, regimen development, HS preparation  2002 Universal Access to public funded ART – key determinants Local production of low cost generic drugs, 350USD per person-year Budget impact analysis indicated affordability, no evidence on Cost Effectiveness Analysis prior to decision on adoption national ART program Health systems capacity for a large scale up, Trade-off of ART and OI cost savings Advocates by NGO, CBO and PHA network to adopt ART  2004 July IAC, full implementation of universal ART program  2005 Preparedness for future challenges and changing context

7. 7 Outcome of PMTCT 2000 Infection rate 6-8% if AZP+NVP infection rate would be 2% Paediatric AIDS cases 1984 – 2003 MOPH Thailand, Epidemiology Division, May 2003

8. 8 2. Financing HIV/AIDS program 2000-03 Source Teokul et al 2004 National AIDS Account 2000-2003

9. 9 Selected indicators, NAA, Thailand 2000-2003 Source: Teokul et al 2004 Selected indicators2000200120022003 Population (1,000)61,87962,30963,14263,656 No. of PHA (1,000)695665635604 Current Health Expenditure USD per capita 63.358.469.375.5 Expenditure on HIV/AIDS USD per capita 1.31.21.41.7 Expenditure on HIV/AIDS USD per PHA 113117138179 HIV/AIDS expense as % HE 2.0%2.1%2.0%2.2%

10. 10 Total expenditure on AIDS 2000/01 Source: 1 Martin 2003 Data of 2000/2001, 2 Teokul et al 2004 Data of 2001

11. 11 National AIDS expenditure profile, 2000-2003 Source: adjusted from Teokul et al 2004, Prevention (STI, PMTCT, VCT, Blood safety, condom, surveillance); Rehabilitation (IDU detoxification & rehabilitation, mitigating impact) 2000200120022003 Total current expenditure on HIV/AIDS, million USD, nominal term 78.277.587.9107.9 % distribution prevention20.419.720.711.6 curative OI ART 67.9 48.6 19.3 68.2 45.1 23.1 70.6 37.8 32.8 78.4 32.8 45.6 Rehabilitation5.93.63.83.4 R&D4.36.13.36.6 Program administration1.42.21.20

12. 12 Financing sources for HIV/AIDS, Thailand 2000-2003 Source: adjusted from Teokul et al 2004

13. 13 Summary NAA 2000-2003  HIV/AIDS expenditure increased significantly, 38% in nominal term in 2000-2003  Expense per PHA was high compared to other developing countries,  Foresee increasing trend of expenditure per PHA due to mature ART program and OI cost saving does not keep pace to offset ART expenditures  ART and OI treatment took the lion share, 78% in 2003 need to revisit program effectiveness  Public is the major source, increasing role of GF in 2003 observed, attention on financial sustainability  In the ART era, decreasing trend of spending on prevention observed, in term of percentage of Total Expenditure on HIV/AIDS

14. 14 3. ART program and financing ART in 2004-2020 Source Tantivess and Tangcharoensathien 2004 Teokul et al 2004 National AIDS Account 2000-03

15. 15 Financing sources of ART program  Largest source: National Access to ARV for PHA (NAPHA, MOPH Budget + GF) – main features Program start up – training of cadres of HCW Central purchasing ARV (mostly generic ARV), lab reagent, flow cytometer. Allocation of non-labour operating to MOPH healthcare systems.  Other sources Civil Servant Medical Benefit Scheme Social Health Insurance OOP by households  NAPHA Provides non-labour operating, labour operating expenditure was mostly cross-subsidized by UC budget and other sources of revenue ART integrated with existing healthcare systems (mostly public rural district hospitals with referral for laboratory monitoring to Provincial hosp)  First line drug regimens for NAPHA, with limited 2 nd line for ATC participants GPO Vir FDC (D4T+3TC+ Nevirapine): 1,200 Baht or 30 USD/month D4T, 3TC, Efavirenz: 3,000 Baht or 75USD/month) D4T, 3TC, Boosted PI (Indinavir +Ritonavir): 4,500 Bah or 113USD/month

16. 16 Financing sources of ART, Thailand 2000-2003 Source: Teokul et al 2004

17. 17 Generic ARV–main driver: GPO products 1995-2004

18. 18 Summary financing ART  NAPHA implemented in 2002, when some 10,000 PHA were on triple drugs (ATC, CSMBS, SHI and OOP) for several years and mostly required 2nd line drugs.  But NAPHA offers only first line drugs in 2002 One 2nd line can purchase 7-10 1st line – affordability problem Initially, NAPHA offers to most PHA who did not access ART (naïve cases)– equity considerations for those who were already on ART for some years (and required 2 nd line regimen) This results in high OOP in ART program

19. 19 4. Cost effectiveness analysis, financial forecast ART program, 2004-2020 Source Lertiendumrong et al 2004 Cost and consequence of ART policy in Thailand: Economic evaluation of Anti-retroviral policy MOPH-WB joint study 2004 Expanding Access to ART in Thailand

20. 20 Outcome of NAPHA--deaths are postponed Source Over et al 2005 Scenario A: Baseline Scenario D1: NAPHA Policy

21. 21 And more life years saved Source: Lertiendumrong et al 2004

22. 22 And orphan years averted Source: Lertiendumrong et al 2004

23. 23 And cost savings from OI treatment averted Source: Lertiendumrong et al 2004

24. 24 ART program cost and cost savings from OI Source: Lertiendumrong et al 2004

25. 25 Forecast public expense on ART 2004-20 Source: Adjusted from Panpanich et al 2004, Lertiendumrong et al 2004, Thai working group 2001

26. 26 Cost effectiveness analysis, ART program Cohort analysis, 2004-2020, Adherence 0.8, not allow for 2 nd line ARV Source: Lertiendumrong et al 2004 Cost per life year saved is 0.3 of GNI per capita

27. 27 After 2010, most costs are 2 nd line drugs Source: MOPH WB joint study 2004

28. 28 ART externalities Source: M.Over, et al (2004)

29. 29 5. Summary

30. 30 Lessons learned  Context ART introduced in a mature comprehensive HIV program  Major determinants of adoption of universal access to ART Government affordability due to low cost generic ARV Health systems readiness and capacity to scale up rapidly, now more than 80% coverage of eligible PHA, to date >70,000 on ART in >600 sites of District and provincial hospitals, and other centres District and provincial hospitals are major hubs of ART delivery  Key program configurations After ART enrolment, free at point of service, prior recruit --expenses on CD4 shouldered by PHA NAPHA provide first line drugs for most PHA not access, and limited second line for ATC participants Result in significant role of OOP in ART  ART (not allow 2 nd line drugs) is cost effective If judged from 1 GNI per capita for one life year gain

31. 31 Current and future challenges  Demand side Ensure early recruit for better outcome Ensure adherence and prevent dis-inhibition behaviour Minimize stigma, provide job opportunities and economic productivity among ART enrolees  Supply side Economic growth, internal brain drain from public to private, fortunately international brain drain is not a serious problem!! Universal Coverage increased significant workload and tension, burn-out HCW home visit for lose to follow up ART enrolees ARV paediatric formulation — pipe line production by GPO Strengthening IT and MIS, survival probability and forecast prevalence of PHA enrolee  financial project, MTEF and resource mobilization  Financing Ensure longest durability of 1 st line regimens, honey-moon period should be >5 years Future decisions on public funded second line regimens and salvage treatment? Maintain high level of prevention spending in ART era

32. 32 Sex behaviour: impact of ART program N 562 in 4 PH 13 DH in 4 provinces, 2004 Source: Lertiendumrong et al 2004

33. 33 More evidences needed in future  2 nd line drugs Cost, toxicity and outcome (CEA, ICER of adding 2 nd to the 1 st line regimens) Budget impact analysis and role of co-pay and equity implications Ethical dimension Health systems capacity to handle 2 nd line drugs including lab capacity Associated cost of lab monitoring (VL not CD4) for failure of treatment in order to early switch to 2 nd line Multi-site vigilance of resistance  In order to stimulate demand and early enrolment Demand for VCT among general population and high risk group Demand for ART among asymptomatic HIV Supply side assessment of VCT – major entry point for effective ART program  Negative externality of ART Sex behaviour surveillance among ART enrolees

34. 34 Thank you for your attention