The Endless Concerted Efforts for Universal Access: Accessibility, Quality, Equity, Sustainability

1. The Endless Concerted Efforts for Universal Access:Accessibility, Quality, Equity, Sustainability Taweesap Siraprapasiri MD, MPH Office of the Global Fund Grants Administration Department of Disease Control Ministry of Public Health The Royal Thai Government

2. Universal Access to HIV Prevention and Care • There is no doubt on the benefits of prevention and care efforts at a national scale • This can save million of lives if we are able to implement in a timely manner

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

4. Number of annual death in Baseline VSNational access to ART for PLWHA program (NAPHA)Scenario, Thailand ART roll out

5. Universal Access for ART • What we have learned from the 3by5 Strategy on antiretroviral treatment (ART)? • Globally, ART access has increased from 400,000 on 12/2003 to 1,300,000 on 12/2005 • Thailand is able to include ART to universal health care coverage on Oct 1 2005 • Can we achieve the goal of universal access to treatment by 2010?

6. Universal Access for ART Yes, we can BUT We need concerted efforts with a sustained manner

7. Key issues for scaling up ART program • ARV and lab reagent (CD4) affordability and accessibility • Human and infrastructure capacities • Multi-sector and level collaboration • Resource mobilization and sustainable financing

8. Programmatic Challenges • At what level of ART coverage (accessibility) is feasible for limited resource countries • Phasing to Universal Access • What approach and strategy should be used to achieve • appropriate quality • ensure equity • long term sustainability

9. Scaling up ART to Universal Access;Thailand experience Universal Access GF major contribution NAPHA launched Local generic drug productionon 4/2002 All District hospitals are able to provide ART Provincial hospitals are able to provide ART

10. ARV affordability • Triple combination of ARVs before 2001 was 220 USD /month in Thailand • April 2002, Government Pharmaceutical Organization launched D4T+3TC+NVP in a fixed dose combination at 30 USD/month • During 2004-2005, GF has supported about 30% ARVs providing to patients in Thailand using the standard 3-regimen of first line therapy ( Average cost is 40 USD/month) • D4T+3TC+NVP (FDC local production) 30 USD/month (80%) • D4T(local), 3TC (local), EFV (original) 64.5 USD/month (15%) • D4T, 3TC, Boosted PI (original) 87.5 USD/month (5%)

11. Challenging issues for ARV affordability • Can Thailand afford second line treatment? • ABC+ddI+Boosted PI 561.5 USD/month • Currently, Thailand can not use the Global Fund budget to purchase GPO’s generic products due to the policy restriction of WHO- GMP prequalification • The price of first line ARVs from original companies are 3 to 10 time even they have been marketed more than 15 years • There is no practical mechanism for lower middle income countries to get the Global Access Price • Does Thailand compromise the quality of care?

12. GF contributing in laboratory monitoring networks • Before 2002 • 25USD / CD4 test • 18 units of flow cytometry located in 14 provinces are used for 3,000 patients • Currently in 2006 • 6 USD/ CD4test • 90 units (64 units from the GF) in 70 provinces are used for more than 100,000 cases

13. Multi-sector and level collaboration GF budget supports and strengthens PLWHA networks so that their members have necessary knowledge, skills and resources to participate as equal partners • “Within 2 years, 160 holistic centers are ran by PLWHA in concordance with 160 hospitals, which follow around 20,000 PHA on ART. • 300 centers with 39000 PLWHA are expected to reach in 2008.

14. 4 religions including Buddhism, Muslim, Protestant, and Catholic have jointly created an interfaith network for providing care 4500 PLWHAs are expected to benefit from the work of this interfaith network in 3 years GF support faith based organizations to provide community and home based care

15. Resource mobilization and sustainability • Government budget on ARVs has increased from USD 6.2 M in 2002 to USD 70 M in and integrated into Universal Health Coverage (cover 48 millions) in 2006 • Social Security Scheme (cover 8 million workers in private sector) has covered ARV in the health benefit package since 2004 • GF has provided additional resources about 40% of budget for ARV care in 2004 and phasing to 15% in 2006

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

17. Universal Access to HIV Prevention and Care Can we achieve the goal of universal access to treatment by 2010 Ensure equity At appropriate quality And be sustained Together We Can

18. Acknowledgements • Health personnel from different levels and sectors • Thai NGOs coalition on AIDS • PLWHA network • Academic persons and institutions • International organization • Political support from Ministers, Permanent Secretary, Director Generals. • Funding agencies