Sustainable Financing HIV/AIDS and ART Program

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

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

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

5. 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

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

7. Selected indicators, NAA, Thailand 2000-2003 Source: Teokul et al 2004

8. 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)

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

10. 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

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

12. 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 2nd line for ATC participants • GPO Vir FDC (D4T+3TC+ Nevirapine): 1,200 Bahtor 30 USD/month • D4T, 3TC,Efavirenz: 3,000 Bahtor 75USD/month) • D4T, 3TC,Boosted PI (Indinavir +Ritonavir): 4,500 Bah or 113USD/month

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

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

15. 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 2nd line regimen) • This results in high OOP in ART program

16. 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

17. Outcome of NAPHA--deaths are postponedSource Over et al 2005 Scenario A: Baseline Scenario D1: NAPHA Policy

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

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

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

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

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

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

24. 5. Summary

25. 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 2nd line drugs) is cost effective • If judged from 1 GNI per capita for one life year gain

26. 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 1st 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

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

28. More evidences needed in future • 2nd line drugs • Cost, toxicity and outcome (CEA, ICER of adding 2nd to the 1st line regimens) • Budget impact analysis and role of co-pay and equity implications • Ethical dimension • Health systems capacity to handle 2nd line drugs including lab capacity • Associated cost of lab monitoring (VL not CD4) for failure of treatment in order to early switch to 2nd 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

29. Thank you for your attention