1 sustainable financing hiv/aids and art program viroj tangcharoensathien md. ph.d. international...
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Sustainable Financing Sustainable Financing HIV/AIDS and ART Program 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
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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
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Objectives
1. Background 2. Financing HIV/AIDS program 2000-20033. ART and financing ART in 2004-20204. Cost effectiveness analysis and financial
forecast ART program, 2004-20205. Summary
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Enormous current benefits of prior Enormous current benefits of prior prevention effortsprevention efforts
0.7
7.1
0
2
4
6
8
10
1985 1990 1995 2000 2005 2010
Cu
rren
t HIV
Infe
ctio
ns
in m
illio
ns
Baseline No Intervention
Red line represents what might have been if behaviors had not changed
Infectionsprevented
7
907
680
277
292174
136
461
803915
1208
10611145
1250
0
200
400
600
800
1000
1200
1400
1984-1990
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Outcome of PMTCT 2000Outcome of PMTCT 2000Infection rate 6-8% if AZP+NVP infection rate would be 2%Infection rate 6-8% if AZP+NVP infection rate would be 2%
Paediatric AIDS cases 1984 – 2003Paediatric AIDS cases 1984 – 2003
MOPH Thailand, Epidemiology Division, May 2003
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2. Financing HIV/AIDS program 2000-03
SourceTeokul et al 2004 National AIDS Account 2000-2003
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Selected indicators, NAA, Thailand 2000-2003
Source: Teokul et al 2004
Selected indicators 2000 2001 2002 2003
Population (1,000) 61,879
62,309
63,142
63,656
No. of PHA (1,000) 695 665 635 604
Current Health Expenditure USD per capita 63.3 58.4 69.3 75.5
Expenditure on HIV/AIDS USD per capita 1.3 1.2 1.4 1.7
Expenditure on HIV/AIDS USD per PHA 113 117 138 179
HIV/AIDS expense as % HE 2.0% 2.1% 2.0% 2.2%
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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)
2000 2001 2002 2003
Total current expenditure on HIV/AIDS, million USD, nominal term 78.2 77.5 87.9 107.9
% distribution
prevention 20.4 19.7 20.7 11.6
curative OIART
67.948.619.3
68.245.123.1
70.637.832.8
78.432.845.6
Rehabilitation 5.9 3.6 3.8 3.4
R&D 4.3 6.1 3.3 6.6
Program administration 1.4 2.2 1.2 0
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Financing sources for HIV/AIDS, Thailand 2000-2003
Source: adjusted from Teokul et al 2004
58
13
7
46
20
12
58
14 16
65
2320
0
10
20
30
40
50
60
70m
illi
on
s U
SD
2000 2001 2002 2003
Year
public
household
ROW
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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
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3. ART program and financing ART in 2004-2020
Source • Tantivess and Tangcharoensathien 2004 • Teokul et al 2004 National AIDS Account 2000-03
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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 (D4 T 3+ TC + Nevirapine): 1 , 200 Baht or 30
USD/month D4 T, 3TC, Efavirenz: 3 , 000 Baht or 75USD/month) D4 T, 3TC, Boosted PI (Indinavir +Ritonavir): 4 , 500 Bah or 113USD/month
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Financing sources of ART, Thailand 2000-2003
Source: Teokul et al 2004
12
21
8
10
0.5
16
12
1
21 21
7
-
5
10
15
20
25
mil
lio
ns U
SD
2000 2001 2002 2003
Year
public
household
ROW
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Generic ARV–main driver: Generic ARV–main driver: GPO products GPO products 1995-20041995-2004
1. AZT capsule 100, 300 mg, syrup May 1995
2. Didanosine (ddI) powder 115, 170, 230, 280 mg May 2000
3. Stavudine (d4T) capsule 15, 20, 30, 40 mg, syrup June 2000
4. Lamivudine (3TC) tablet 150 mg, syrup July 2001
5. AZT 300mg + 3TC 150 mg tablet November 2001
6. Nevirapine tablet 200 mg , syrup April 2002
7. GPO-VIR S30, S40 (d4T+3TC+NVP) April 2002
8. Nelfinavir tablet 250 mg November 2003
9. ddI tablet 125, 200 mg October 2004
10. GPO-VIR Z 250 October 2004
o Lamivudine tab. (300 mg) o Indinavir cap. (200, 400 mg) o Saquinavir tab (200, 400, 500 mg) o Ritonavir oral solution o GPO-Vir S7 (chewable tablet) (NVP 50 mg + 3TC 30 mg + d4T 7 mg) o ddI 25 mg (chewable tablet)
2005 pipe-line products
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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
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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
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Outcome of NAPHA--deaths are postponedSource Over et al 2005
Annual Death
0
10,000
20,000
30,000
40,000
50,000
60,000
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
20
15
20
16
20
17
20
18
20
19
20
20
20
21
20
22
20
23
20
24
20
25
Years
Scenario A Scenario D1
Scenario A: Baseline Scenario D1: NAPHA Policy
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And more life years saved
Source: Lertiendumrong et al 2004
Life year with and without ART for 2004-2020 cohorts
24,466
7,884
70,311
85,897
92,270
86,442
78,658
70,050
61,417
53,268
45,891
39,377
33,713
28,838
24,67421,130
9,201
10,75312,58114,721
17,21220,086
23,34926,937
30,69834,357
37,46839,578
35,189
40,39539,399
42,735
94,917
93,223
-
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
100,000
2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 2022
year
life
ye
ar
no ART
with ART
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And orphan years averted
Source: Lertiendumrong et al 2004
Years w ith parents w ith and without ART for 2004-2020 cohorts
71,075
86,042
90,521
84,364
76,432
67,802
59,245
51,241
44,047
37,732
32,267
27,58123,588
20,195
25,067
37,29034,096
30,39026,609
23,02319,776
16,92814,467
12,35810,559
7,740
43,784
93,65092,664
9,034
39,51040,488
39,677
35,667
-
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
100,000
2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 2022
year
life
year
no ART
with ART
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And cost savings from OI treatment averted
Source: Lertiendumrong et al 2004
39
344
61
728498
114132
151172192
223 210227221201
163
105
111129
151
177207
242283
329379
432483
527557
568554
495
-
100
200
300
400
500
600
year
mil
lio
n B
ah
t
with ART
no ART
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ART program cost and cost savings from OI
Source: Lertiendumrong et al 2004
908
305
1,387
1,606
1,682 1,6711,597
1,321
1,472
1,163
1,010
870
746
638545
466398
341
390 391 367
336
300
261222
187
157
131
110
93
7967 58 49
-
200
400
600
800
1,000
1,200
1,400
1,600
1,800
year
mil
lio
n B
ah
t
sum cost
OI saving
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Cost effectiveness analysis, ART programCohort analysis, 2004-2020, Adherence 0.8, not allow for 2nd line ARV
USD Total ART program cost (million) 455 Total potential OI saving (million) 87 Cost per life year saved 592 Cost per year of orphan-hood prevented 614 Total life years saved (year) 620,486 Year of orphan avoided (year) 598,757
Source: Lertiendumrong et al 2004Source: Lertiendumrong et al 2004
Cost per life year saved is 0.3 of GNI per capita Cost per life year saved is 0.3 of GNI per capita
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After 2010, most costs are 2nd line drugs
Total Cost of Public ART (NAPHA)
$0
$50
$100
$150
$200
$250
$300
$350
$400
$450
$500
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
20
15
20
16
20
17
20
18
20
19
20
20
20
21
20
22
20
23
20
24
20
25
Millions
Cost of Public ART_1 line_asy Cost of Public ART_1 line_sym
Cost of Public ART_2 line_asy Cost of Public ART_2 line_sym
Source: MOPH WB joint study 2004
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5. Summary
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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
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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
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Sex behaviourSex behaviour: impact of ART : impact of ART programprogram
Asymp. Sympt. <6m ART
Avg. monthly sex acts 6.4 3.8 3.4
spouse 52% 79% 86%
Boyfriend/girlfriend 12% 10% 6%
Friend 6% 2% 3%
Direct sex worker 15% 4% 4%
Indirect sex worker 7% 2% 0%
Casual sex 7% 3% 1%
Percent use condom every sex act
spouse 9% 56% 78%
Boyfriend/girlfriend 10% 54% 93%
Friend 14% 50% 83%
Direct sex worker 27% 64% 100%
Indirect sex worker 18% na 100%
Casual sex 26% 25% 50%
N 562 in N 562 in 4 PH 13 DH in 4 PH 13 DH in 4 provinces, 2004 Source: Lertiendumrong et al 20044 provinces, 2004 Source: Lertiendumrong et al 2004
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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
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Thank you for your attention