ART Program Managementunder

Universal Health Coverage

Sorakij Bhakeecheep, MD.National Health Security Office,

THAILAND.

National Health Security Office

Outline

• Overview of Thailand’s HIV/AIDS situation• Financial aspect of ART program• ARV supply chain management• Key success factors• Challenges

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• HIV/AIDS strategy• HIV prevention program implementation• Care and treatment related technical

guideline• Service delivery (by hospitals)

Ministry of Public Health

(Regulator and Provider)

National AIDS Control Program

National Health Security Office

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Royal Thai GovernmentNational AIDS Committee

National Health Security Office (NHSO)

(Purchaser and System manager)

Program implementation on:• HIV counseling & testing

(HCT)• HIV/AIDS care and ART• Positive prevention

Other Ministries/ governmental org

CBO & private sectors

SSSCSMBSPWHA networks

(Social security scheme) (Civil servant medical benefit scheme )

National Health Security Office

Thailand’s ART Situation

Demands Supplies

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ART centers 1,086CD4 Lab 44Viral load Lab 14Genotype Lab 16

Estimated all PWHA 475,000• # registration 363,000

Estimated ART needs 342,000

• # receiving ART 239,090 (70%)

• # UHC only 162,455

Average newly registration per year 33,000Average newly ART registration per year 20,000

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) 5

National Health Security Office

ART program budget under UHC ran steadily around 100 mUSD for years.

ART Program Budget

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ART Program Budget under UHC(2007-2013)

•58% ARV cost•27% LAB cost

•99% Domestic fund (government)•1% International fund (GF-ATM)

Unit Cost Analysis

National Health Security Office

• Cost of ARV falls to nearly 50% during past five years

• Cost for 2nd line is 4 times of the 1st line

• Central procurement and compulsory licensing play significantly role to make ARV prices more affordable

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Unit cost-USD 1st line Protocol 2nd line Protocol RemarksARV drugs 286.6 1,103 Average cost of ARV consumption

LAB 85.2 79.3 2 CD4 + 1 VL + 2 Blood chem. + DR (allocate total DR cost to all pt) + specimen handling

Capacity building 8.5 8.5 Personnel training, Strenghten quality of care, M&E (allocate total cost to all pt)

Others 11.3 11.3 Peer group activities and facility workload (allocate total cost to all pt)

391.6 1,202.4 Average unit cost for all patients 481.7 USD

Budget Allocation under UHC

National Health Security Office

ARV Drugs

HIV/AIDS Budget

GO, NGO, CBO

LAB + HCT Capacity building

Pay for performance

Hospitals8

GO – Governmental organizationNGO – non Governmental organizationCBO – Community based organization

National ART

GuidelineTaskforce

National Committee

on Essential Drugs List

National ARV

Drugs ListApprove for:-Clinical criteria-Clinical efficacy

Approve for:- Cost effectiveness

-Long term affordability

Academic issue Financial issue

Establishing National ARV Drugs List

9National Health Security OfficeManagement issue

-Planning-Budgeting

National Health Security Office

National ARV Drugs ListFirst 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 domestically by GPO• Drugs indicated in red color are original

drugs• All ARV drugs are managed by GPO,

including procurement, quality control, stock management and logistic.

Original

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Abbrev:ARV Anti-retroviralUCS Universal Health Coverage SchemeSSS Social Security SchemeGPO Government Pharmaceutical

Organization

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

Drugs supply to hospitals

Hospitals

11GPO – Government Pharmaceutical OrganizationNHSO – National Health Security Office

-Data verification-Data calculation

Real

time

data

tran

sfer

Key Success Factors1. Clear policy commitment from government2. Strong existing health system infrastructure 3. Implementation of Universal health coverage4. Effective price regulation mechanism to ensure

ART program sustainability– Centralized program management– Central procurement vs. central negotiation– Domestic manufacturing of generic ARV

5. Good collaboration among key stakeholders6. Effective HIV/AIDS information system

National Health Security Office 12

National Health Security Office 13

Challenge #1

To prevent more deaths through early diagnosis and early treatment

Finding:• > 78% of PWHA has CD4 level < 350 at first diagnosis and registration

•More than half of PWHA has CD4 level < 100 at first time of ART initiation

Challenges # 2

National Health Security Office

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To maintain quality/effectiveness despite of increasing workload

Finding:• Registered PWHA is increasing overtime (+10% each year)• Death & lost follow-up are still high, especially in non-ART group (pre-ART stage)• Increase workload could lead to poor services and poor adherence, thus aggravate

drug resistance and mortality

Challenges # 3

National Health Security Office

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To control ART program budget and ARV cost to ensure affordable financing and supply system

Finding:• 11% PWHA receiving ART are taking 2nd line protocol, and still increasing• A number of PWHA need higher than 2nd line protocol• Cost of 2nd line is 4 times higher than 1st line, but 3rd line is much higher

CL

VL

MPP

National Health Security Office

Thank you for your attention

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