ASEAN plus Three UHC Network and

HIV/AIDS Services under UHC : Thailand Experience

Dr. Sorakij Bhakeecheep, Director,

National Health Security Office Region 1, Chiang mai, THAILAND

June 23rd, 2014

Mandalay, Myanmar

Outline

• Overview of Universal Health Coverage

• Establishment of ASEAN +3 UHC Network

• Thailand’s ART program in brief

National Health Security Office

Thailand’s Paradigm Shift after National Health Security Act in 2002

National Health Security Office

People asking for health services support

People has right accessing to health services

CHANGE From …

To …

UHC changed the way we perceive people’s health

Civil Servant Medical

Benefit Scheme

(CSMBS)

Social Security

Scheme

(SSS)

Universal Coverage

(UC)

Introduced in 1960s 1990s 2002s

Target beneficiaries Gov. employees & dependents, retirees

Private sector employees:

To whom which not

covered by CSMBS nor SSS,

Pop coverage 8% 15% 75%

Funding Gov. Budget Payroll contribution, Tripartite

Gov. budget

Benefit package

•Premium grade

•Cover most of care

services but not

prevention &

promotion

•No explicit exclusion

•Cover care services

with some limited

condition

•No prevention &

promotion services

•Cover care services

with some limited

condition

•Include prevention &

promotion services

Payment to health facilities

Fee-for-service for OP, and DRG for IP

Capitation

(use DRG in risk adjusted part)

•Capitation for OP &

PP

•DRG for IP

Current Social health protection schemes

Scheme

Universal Health Coverage, Why and how?

8.17

4.82

3.74 3.65

2.872.57 2.45

1.991.64

1.27

4.58

3.673.29

2.782.38 2.22 2.06

1.68 1.551.27

2.05 1.95 1.69 1.66 1.74 1.68 1.66 1.83 1.742.18

0

1

2

3

4

5

6

7

8

Dec

ile 1

Dec

ile 2

Dec

ile 3

Dec

ile 4

Dec

ile 5

Dec

ile 6

Dec

ile 7

Dec

ile 8

Dec

ile 9

Dec

ile 1

0

Healt

h p

aym

en

t :

Inco

me (

%)

1992

1994

1996

1998

2000

2002

2004

2006

2008

Source: Analysis from household socio-economic surveys (SES) in various years 1992-2008, NSO

Reduce household out-of-pocket as % household income

Reducing the incidence of catastrophic health spending

Source: Analysis of Socio-economic Survey (SES)

Protect financial risk of individual and family Reduce incidence of catastrophic health spending

The ASEAN Plus Three UHC Network (13 Countries)

-Brunei Darussalam -Cambodia -Indonesia -Lao PDR -Malaysia -Myanmar

-Philippines -Singapore -Thailand -Viet Nam -China -Japan -Rep of Korea

7

An establishment of the ASEAN Plus Three UHC Network

• 5th ASEAN Plus Three Health Ministers Meeting in Phuket, Thailand, 6 July 2012 – Roundtable discussion on UHC – The Joint Statement Paragraph 3 “We recognize the significant and concrete roles played by the

Universal Health Coverage (UHC) on poverty reduction and universal access to essential health services

…. We commit to collectively accelerate the progress towards UHC in all countries by tasking the ASEAN Plus Three SOMHD (Senior Officials’ Meeting on Health Development) to discuss the formation of an ASEAN Plus Three network on UHC.

… We concur and will collectively move the issue of UHC to be discussed and committed at the highest regional and global development forum, including ASEAN Plus Three Summit, and the United Nations General Assembly.”

8

An establishment of the ASEAN Plus Three UHC Network

• APT SOMHD in Singapore, 29 Aug 2013 – TOR of the Network was discussed and finalized

• Goal and objective: – To support and accelerate progress towards UHC and

– To advance the regional and global UHC agenda

• Guiding principle: an equal partnership among APT MSs

• Governance: – Steering Committee

– Secretariat

– Network members

9

The First Steering Committee Meeting, Thailand, 21-22 April 2014

• “A trust-based network”

• Steering Committee members and alternates of APT MSs – Chair: Dr Winai Sawasdivorn, the

Secretary General of National Health Security Office, Thailand

– Secretariat: CapUHC [Capacity Building for UHC], Thailand

http://www.aseanplus3uhc.net

Thailand’s ART Program

National Health Security Office

National Health Security Act NAP system

Fund management of HIV/AIDS and TB National Health Security Office

The History of ART in Thailand

1984 - First AIDS case was reported

1997-98

- ART was under research settings

2000 - PMTCT national program was implemented

2001 - Pilot study on National Access to ART

2003 - National Health Security Act

(Still, ART was not included in this benefits)

2006 - Universal Access for ART

11

3 years after UHC

National Health Security Office

Thailand’s ART Situation 2013

Demands Supplies

13

ART centers 1,086

CD4 Lab 119

Viral load Lab 44

Genotype Lab 14

PCR Lab 16

Estimated all PWHA 475,000

• # registration 363,000

Estimated ART needs 342,000

• # receiving ART 239,090

(74%)

• # UHC only 176,926

Average newly registration per year 33,000

Average newly ART registration per year 20,000

National Health Security Office

Laboratory services

Asymptomatic HIV

No ARV

Symptomatic HIV

With ARV

- CD4 1-2 /yr - CD4 1-2 /yr - Bl. chem. 1-2 /yr - Viral load 1-2 /yr - Drug resistance 1-2 /yr and if VL>2,000 cp/ml. HIV

Screening

Anti-HIV

testing

Counseling

DNA PCR in

babies

HIV Service Package for PWHA under UHC

Drugs

ARV

OI Prophylaxis

Lipid lowering agents

1.Simvastatin

2.Gemfibrosil

3.Fenofibrate

4.Atorvastatin

1. ARV Treatment

2. PMTCT (Mother-

to-child

transmission)

3. PEP (Post-

exposure

prophylaxis)

Fund management of HIV/AIDS and TB National Health Security Office

Benefits provided for UHC members: Classified by population

Medication Lab services

Asymptomatic PWHA

•No ART

•Personal health

promotion and prevention

•CD4 every 6-12 mo.

Symptomatic PWHA

(CD4 < 350)

•ART

•First line

•Second line •Third line

•Blood chemistry, CD4,

Viral load every 6-12 mo.

•Drug resistant testing as indicated (1/yr)

HIV positive mother •HAART for HIV prevention (PMTCT)

•CD4 every 6-12 mo.

Baby born from HIV

positive mother

•ARV for HIV prevention (PMTCT) •Infant formula supplement (first year)

•DNA PCR for diagnosis of HIV infection

All Thai citizen •HIV Counseling&Testing 15

Care

& T

reatm

ent

Pre

vention &

Scre

enin

g

Fund management of HIV/AIDS and TB National Health Security Office

National ART Protocol

First line:

• NRTI

– Zidovudine (AZT)

– Stavudine (d4T)

– Lamivudine (3TC)

– Didanosine (ddI)

– Tenofovir (TDF)

• NNRTI

– Nelvirapine (NVP)

– Efavirenz (EFV)

Third line:

• PI

– Darunavir (DRV)

Second line:

• PI

– Lopinavir (LPV) – Ritonavir (RTV) – Atazanavir (ATV)

Remark:

• Drugs indicated in blue color can be produced

locally.

• Drugs indicated in red color are original drugs.

• Drugs indicated in green color are imported

according to the compulsory licensing.

• Drugs in second and third line category need authorization before use.

Need authorization

Need authorization

ARV Starting Criteria • Symptomatic AIDS

• Asymptomatic with CD4 < 350

• 2NRTIs + 1NNRTI

National Health Security Office

NAP Database

NHSO

Government Pharmaceutical Organization

VMI Database

Ministry of Interior

MOI Database

Local Database

Data to NHSO contains PID.

Data from NHSO

contains no PID.

NAP number is used instead.

HIVQual Database

EWI Database

Ministry of Public Health

MoPH Database

For M&E

Internet connection

• National AIDS Program (NAP)

Database

• Web application with centralized

database at NHSO

• Keep clinical record of each visit

individually and confidentially

• Link to external data sources

such as MOI, MoPH, GPO

• Used for ARV supply,

reimbursement and program

monitoring

HIV/AIDS Management Information System

Drugs Supply Framework

National Health Security Office

Daily data transfer

-ID -Demography -Clinical -LAB -Prescription -etc

-Safety stock -ARV consumption -ARV On-hand -Amount delivered

Individual data input

Hospitals

19

GPO – Government Pharmaceutical Organization NHSO – National Health Security Office

-Data verification -Data calculation

National Health Security Office

Reimbursement System

Providers

Providers

AIDS Fund

National Health Security Office

•ARV, •Lipid lowering agents

Anti-HIV Antibody, CD4, VL, Drug resistance, PCR

GPO

Separate Procurement

HIV/AIDS Budget

Central Procurement

GPO

• Two models of reimbursement – Central procurement

– Separate procurement with central negotiation

• NHSO takes central procurement in all drug items

• Logistic and inventory management are accountable by the Government Pharmaceutical Organization

• For other LAB reagents, NHSO prefers money payment with separate procurement

• In separate procurement, price can be controlled by central negotiation

•Condom

National Health Security Office

•Thailand’s AIDS expenditure 330

million USD in 2011

•2.4% of total health expenditure (THE)

•0.09% of GDP

Thailand’s AIDS Expenditure

•73% Treatment & Care

•14% Prevention

•13% Others (social protection,

program management, research, etc) 21

0.08 0.08 0.08 0.09

National Health Security Office

ART program budget under UHC ran

steadily around 100 mUSD for years.

ART Program Budget

22

ART Program Budget under UHC

(2007-2013)

•58% ARV cost

•27% LAB cost

•99% Domestic governmental fund

•1% Global Fund

Domestic

Funding 99%

128.5

146.1

99.5 92.4

99.9 98.0 109.2

30

80

130

180

230

2007 2008 2009 2010 2011 2012 2013

National Health Security Office 23

ART Program Budget under UHC (2007 – 2013)

64,422

94,842

116,075

176,926

131,353

153,214 164,975 Million USD

Number of patients

Program budgets

Average ART budget remains stable for years at 100 mUSD

Unit Cost of ARV Drugs

Item Unit cost $/pt/yr

No. of pt $ per yr

1st line ARV 226 162,600 36.8 mUSD

2nd line ARV 893 14,300 12.8 mUSD

Average cost 280 176,900 49.6 mUSD

Fund management of HIV/AIDS and TB National Health Security Office

Central procurement and compulsory licensing play an important role in price regulation

S. Bhakeecheep, MD

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

24-Jun-14 25 Less than 1$ /pt/day

S. Bhakeecheep, MD

Key Success Factors

for Thailand’s ART Management

• Political commitment

• Multi-stakeholders participation

• Strong network of PLHA

• Centralized HIV budget and inventory

management

• Strong public health system

• Advanced information system for program

management and improvement

S. Bhakeecheep, MD

Challenge #1

How to achieve “Zero new deaths”

• Dead rate of non-ART patients is 7 times higher than

ART patients

• Retention rate of non-ART patients is much lower than

ART patients

• Nearly half of naive HIV patients had very low CD4 level

at first time of diagnosis

• To improve quality of services focusing on pre-ART

patients and counseling services

• To encourage early diagnosis by promoting HIV testing

• To normalize HIV testing among general population

S. Bhakeecheep, MD

• Estimated 500,000 PLHIV across the country

• 300,000 has been registered

• Another 200,000 still hiding under the ground

• Services overload has already been reported in

some service area

• Sustainability of ART program depends on not

only budget controlling but also workload burden

which may affected quality of services

Challenge #2

How to make program “Sustained”

National Health Security Office

Thank you for your attention