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Thailand National Aids Account2000-2003

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

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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

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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

Current H exp. 2000 2001 2002 2003

CHE per Capita (USD) 63 58 70 76

CHE as % GDP 3.2% 3.2% 3.5% 3.5% Sources: NHA 2000-2001, forecast for 2002-03

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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

PWHA1 635,057

New HIV infections in 20021 23,676

New AIDS cases in 20021 51,738

Orphans due to AIDS2(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

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Objectives

• To develop methodological approaches for the construction of NAA.

• T o 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.

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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

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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)

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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

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NAA matrix (FA x HC)

Function of healthcare MOPH et al

CSMBS SSS Household ROW Total Row Percent

I. Current Health Expenditure

Inpatient care, OI treatment

Outpatient care, OI treatment

STI

ART program

PMTCT

Prevention e.g. VCT, Blood safety, Education, Safe sex, IVDU, surveillance,

Program Administration

II. Health Care Related expenditure

Education and training

Research and development

III. Memorandum items (non-Health Expenditure)

Mitigate impact

Social Research

GRAND TOTAL

Column Percent

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ndMethodology

• 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 2nd data is not available

• Estimate based on PQ approach • Unit cost of services • Total services rendered

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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

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Key Findings from NAA in Thailand

2000 - 2003

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Selected indicators on HIV/AIDS expenditure (current year price)

2000 2001 2002 2003Population (million) 61.9 62.3 63.1 63.7No. of PHA 695,000 665,000 635,000 604,000HIV/AIDS expense (million baht) 3,142 3,448 3,781 4,479Exchange rate, Baht per USD 40.2 44.5 43.0 41.5Expenditure on HIV/AIDS Baht per PHA 4,523 5,182 5,954 7,417 USD per PHA 113 117 138 179Expenditure on HIV/AIDS Baht per capita population 50.8 55.3 59.9 70.4 USD per capita population 1.3 1.2 1.4 1.7Current Health Expenditure (CHE), million baht

157,228 161,752 188,099 199,679

CHE Baht per capita population 2,540.9 2,596.0 2,979.0 3,136.8 CHE USD per capita population 63.3 58.4 69.3 75.5HIV/AIDS expense as % CHE 2.00% 2.13% 2.01% 2.24%

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HIV/AIDS expenditure by financing agencies

NAA MOPH et al CSMBS SSS Household ROW Total (%) Million Baht 2000 73.9 2.8 2.4 16.5 4.3 100 3,1422001 59.6 2.5 2.3 25.4 10.2 100 3,4482002 66 3 2.6 15.7 12.7 100 3,7812003 60 2.8 2.3 21.3 13.5 100 4,479

• 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%)

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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

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Major Functions 2000 2001 2002 2003OI treatment (OP and IP) 48.6 45.1 37.8 32.8STI treatment 1.9 1.8 1.6 1.3ART 19.3 23.1 32.8 45.6PMTCT 6.7 9.5 13.3 3.1VCT 0.9 0.8 0.6 0.9Blood Safety 2.7 2.4 2.2 1.9Condom 1.6 1.0 1.8 0.9IDU-Detoxification & Rehab 3.2 1.1 1.6 1.6Surveillance 0.6 0.5 0.4 0.3IE&C 6.0 3.7 0.8 3.2R&D 4.3 6.1 3.3 6.6Mitigating Impact 2.7 2.5 2.2 1.8Program Administration 1.4 2.2 1.2 0.0Total (%) 100.0 100.0 100.0 100.0Total (million baht) 3,141.5 3,447.8 3,781.1 4,479.2Total (million USD) 78.2 77.5 87.9 107.9Exchange rate, Baht per USD 40.2 44.5 43.0 41.5

HIV/AIDS expenditure by healthcare functions

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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.

Financing OI by source, 2000-2003

1,125 1,162

1,396 1,430

365 393

35 37-

400

800

1,200

1,600

2000 2001 2002 2003

mill

ion

Baht

Public, CSMBS, SSSHousehold

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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.

Financing ART program by sources, 2000-2003

525

362

722

920

82

434

517

868

253

0

250

500

750

1000

2000 2001 2002 2003

mill

ion B

aht

PublicHouseholdROW

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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.

CountriesAdult HIV

prevalence %

AIDS spending, per capita population,

USD

% spending on

prevention

Government %

Household %

ROW %

Thailand 1.3 1.7 10 60.0 21.3 13.5

Belize 2 7.0 41 70.0 10.0 17.0

Burkina Faso

6.5 2.0 34 10.0 20.0 70.0

Costa Rica 0.6 2.4 82 45.0 13.0 -

El Salvador 1.0 5.0 39 48.0 19.0 6.0

Ghana 3.0 1.3 n.a. 33.0 7.0 59.0

Panama 1.5 4.4 28 20.1 16.0 3.0Sources, UNAIDS (2004) selected countries

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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

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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

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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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