1. International Health Policy Program -Thailand 1 Thailand National Aids Account 2000-2003 Waranya Teokul* Walaiporn Patcharanarumol** Chitpranee Vasavid** Pornpimol Cheewacheun* Viroj Tangcharoensathien** * National Economics and Social Development Board, Office of Prime Minister ** International Health Policy Program-Thailand 5 September 2005

2. International Health Policy Program -Thailand 2 Outline for presentation Background and HIV/AIDS situation in Thailand Objectives Methodology Results: HIV/AIDS expenditure by – Financing agencies – Healthcare functions – Healthcare function and financing agencies Policy implication Recommendation

3. International Health Policy Program -Thailand 3 Background GDP per capita was 2,060 US$ or 7,010 PPP US$ (2002), with a growth rate of 2.9% (average for 1990-2001). HDI in 2002 was 0.768; rank 76th (Human Development Report 2004) 2001 achieved Universal Health Care Coverage NHA well-established, 3 dimensional matrix for 1994-2001 are available Current Health Expenditure (CHE) High burden from HIV/AIDS: Disable Adjusted Life Year (DALY) loss = 17% among men and 9% among women in 1999

4. International Health Policy Program -Thailand 4 HIV/AIDS situation in Thailand PMTCT covered 85% of HIV pregnancies, pediatric HIV 98% and breast milk substitution 88% (Dept of Health 2004) ART: 350 US$ per patient year, target = 5-60,000 pt in 2004 number HIV infections (adults and children)1,033,424 Deaths (adults and children) 1 398,367 PWHA 1 635,057 New HIV infections in 2002 1 23,676 New AIDS cases in 2002 1 51,738 Orphans due to AIDS 2 (2001)289,000 Source: 1 Thai Working Groups on HIV/AIDS Projection 2001 2 Children on the Blink 2002, UNAIDS Estimated cumulative numbers of HIV/AIDS in the year 2002

5. International Health Policy Program -Thailand 5 Objectives To develop methodological approaches for the construction of NAA. To construct NAA for four years, 2000-2003, in order to estimate total HIV/AIDS expenditure by finance agencies and healthcare functions. To provide policy recommendations on financing HIV/AIDS.

6. International Health Policy Program -Thailand 6 Conceptual Framework Based on the principle of Thailand National Health Account (NHA) which was adapted from OECD’s System of Health Account Tracking HIV/Aids expenditure flow on two dimensions – Financing Agencies (FA) – Healthcare Function (HC) The third dimension of health care provider (HP) was dropped, as most of HIV/AIDS services were provided by public providers

7. International Health Policy Program -Thailand 7 Sources of Financing Agencies 5 Government agencies – Ministry of Public Health – Other ministries – Local Government – Civil Servant Medical Benefit Scheme (CSMBS) – Social Security Scheme (SSS) 2 Non Government Agencies – Out of Pocket Payment – Rest of the World (ROW)

8. International Health Policy Program -Thailand 8 Categories of Healthcare Function I.Current Health Expenditure – Curative Services e.g., OI treatment, STI treatment, ART – Preventive Services e.g., PMTCT, VCT, safer sex practices, blood safety II.Healthcare Related Expenditure – Education and Training – Research and Development Capital Formation on AIDS program can be inserted here (Dropped from this version) III.Memorandum Items – Impact mitigation of AIDS (care for orphan, protecting rights of PLWA and social supports) – Social research

9. International Health Policy Program -Thailand 9 Categories of Healthcare Function I.Current Health Expenditure – Curative Services Inpatient care (mostly OI treatment) Day care services Comprehensive continuum of care at home (ccc) Outpatient care (mostly OI treatment) STI OI treatment and monitoring ART program (CD4, viral load, drug resistance test and ARV) Long term care (Hospice)

10. International Health Policy Program -Thailand 10 Categories of Healthcare Function I.Current Health Expenditure (Cont.) – Preventive Services PMTCT (laboratory, ARV, breast milk substitution) General VCT Blood safety services AIDS education & Life skill development Safe sex practices (condom distribution) Services for IVDU (detoxification and other prevention) Program surveillance (sero-sentinel and behavioral surveillance) Program Administration

11. International Health Policy Program -Thailand 11 NAA matrix (FA x HC)

12. International Health Policy Program -Thailand 12 Methodology Scope – Actual expenditure – not budget figures – Only recurrent expenditure included, capital investment excluded. Data source – Secondary data collection on actual expenditure where available – Government agencies report on the use of budget – Where 2 nd data is not available Estimate based on PQ approach Unit cost of services Total services rendered

13. International Health Policy Program -Thailand 13 Existing database The weekly Epidemiological Surveillance Report (WERS) – Covers almost all public health facilities – OI incidence and profile PMTCT program – PMTCT enrolees and program outcome – By Department of Health of the MOPH Government budget in all concerned ministries on HIV/AIDS activities, several years – Comptroller General Department (CGD) The annual sero-sentinel and sex behaviour sentinel – Updated HIV prevalence among different groups – Bureau of Epidemiology, several years

14. International Health Policy Program -Thailand 14 Key Findings from NAA in Thailand 2000 - 2003

15. International Health Policy Program -Thailand 15 Selected indicators on HIV/AIDS expenditure (current year price) 2000200120022003 Population (million) 61.962.363.163.7 No. of PHA 695,000665,000635,000604,000 HIV/AIDS expense (million baht) 3,1423,4483,7814,479 Exchange rate, Baht per USD 40.244.543.041.5 Expenditure on HIV/AIDS  Baht per PHA 4,5235,1825,9547,417  USD per PHA 113117138179 Expenditure on HIV/AIDS  Baht per capita population 50.855.359.970.4  USD per capita population 1.31.21.41.7 Current Health Expenditure (CHE), million baht 157,228161,752188,099199,679  CHE Baht per capita population 2,540.92,596.02,979.03,136.8  CHE USD per capita population 63.358.469.375.5 HIV/AIDS expense as % CHE 2.00%2.13%2.01%2.24%

16. International Health Policy Program -Thailand 16 HIV/AIDS expenditure by financing agencies Public source through MOPH, other ministries and local govt played a major role (60-74%) CSMBS and SSS was small and stable (~2-3%) Household OOP spending played a substantial role (16-26%) ROW played an increasing role when GF stepped in in 2003 (13.5%)

17. International Health Policy Program -Thailand 17 HIV/AIDS expenditure by healthcare functions Spending on OI and ART take major share to total current spending Trade off between OI and ART – OI 48.6% - 32.8% (2000 - 2003) – ART 19.3% - 45.6% (2000 - 2003) Decreasing trend of spending on preventions

18. International Health Policy Program -Thailand 18 Major Functions2000200120022003 OI treatment (OP and IP) 48.645.137.832.8 STI treatment 1.91.81.61.3 ART 19.323.132.845.6 PMTCT 6.79.513.33.1 VCT 0.90.80.60.9 Blood Safety 2.72.42.21.9 Condom 1.61.01.80.9 IDU-Detoxification & Rehab 3.21.11.6 Surveillance 0.60.50.40.3 IE&C 6.03.70.83.2 R&D 4.36.13.36.6 Mitigating Impact 2.72.52.21.8 Program Administration 1.42.21.20.0 Total (%)100.0 Total (million baht) 3,141.53,447.83,781.14,479.2 Total (million USD) 78.277.587.9107.9 Exchange rate, Baht per USD 40.244.543.041.5 HIV/AIDS expenditure by healthcare functions

19. International Health Policy Program -Thailand 19 Public and Household Spending on OI treatment Household expenditure on OI was then significantly reduced UC in 2001  no financial barrier to access health care services 30 Baht (0.75 USD) per visit or admission for any treatment including OI was very minimum to household income.

20. International Health Policy Program -Thailand 20 Financing ART program by sources of financing agencies Households shouldered a significant proportion of expenditure on ART. The universal ART program started with naive PHA (the inexperienced cases) where the first line regimen was provided free. The financing of the ongoing ART patients (the experience cases) was more expensive as most of them were on the second line regimens, and not fully provided by the National ART program.

21. International Health Policy Program -Thailand 21 AIDS expenditure, selected Countries, 2003 Thailand spending on HIV/AIDS was considerable low compared to the first leading Burden of Diseases attributed to HIV/AIDS and unsafe sex practices. The larger part was spent on ART and OI treatment Compared to other countries, Thailand spending on prevention was the lowest (10%) and household shouldered the highest portion. Countries Adult HIV prevalence % AIDS spending, per capita population, USD % spending on prevention Government % Household % ROW % Thailand 1.31.71060.021.313.5 Belize 27.04170.010.017.0 Burkina Faso 6.52.03410.020.070.0 Costa Rica 0.62.48245.013.0- El Salvador 1.05.03948.019.06.0 Ghana 3.01.3n.a.33.07.059.0 Panama 1.54.42820.116.03.0 Sources, UNAIDS (2004) selected countries

22. International Health Policy Program -Thailand 22 Policy implication NAA – Invaluable information on resource tracking – The stepping stones for future investment and financial re- orientation of national AIDS program To renew prevention efforts Universal ART  Increasing investment in VCT – To ensure safe sex among those not yet infected. – To identify asymptomatic HIV for early recruit for better clinical outcome and survival – To ensure adherence to ARV Effective program of monitoring ARV resistance requires financial support and high skill human resources

23. International Health Policy Program -Thailand 23 Recommendation To develop NAA in country – Consensus on dummy table, – Starting with a simple two dimension matrix (FA and HC) – FA: Public and Donor Expenditure (the major share of total spending) The process of NAA development – Local initiative to ensure ownership – Capacity strengthening of local scientists to maintain and routine update – Technical supports from international agencies such as WHO, UNAIDS and others – A regional collaboration can be one of the entry points to stimulate and support such development

24. International Health Policy Program -Thailand 24 Acknowledgments – We wish to acknowledge the following The predecessors who contributed to the development of NHA in Thailand whereby NAA lends itself on their experiences. Researchers and partners inside and outside the MOPH for their contributions towards the development of NAA. Long term institutional grant to IHPP by Thailand Research Fund UNAIDS supports to this Project Peer reviews by UNAIDS, WHO and SIDALAC

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