Dedicated HIV budget helps widen access to care in Thai UHC

Thailand’s decision to separate HIV/AIDS funding from its general per-capita health budget has helped widen access to testing, prevention and treatment by allowing government, private and civil society providers to take part in delivering services, according to Prof. Emeritus Dr. Praphan Phanuphak, former director of the Thai Red Cross AIDS Research Centre.

The funding arrangement, introduced in 2006 under the country’s Universal Health Coverage (UHC), has also helped reduce the number of new HIV infections from about 100,000 a year before the reform to an estimated 8,000–10,000 today, he said.

But with new infections still above Thailand’s target of no more than 1,000 a year, Dr. Praphan said the country needs to strengthen proactive outreach rather than change the existing funding model.

“Although the situation has improved considerably compared with the past, the number of new infections remains higher than the target of no more than 1,000 cases per year,” he said.

“At the policy level, there should therefore be greater emphasis on proactive efforts, both to identify people at risk and connect them with prevention services, and to identify people living with HIV and bring them into treatment as quickly as possible.

Dr. Praphan was commenting on the management of HIV/AIDS funding under Thailand’s National Health Security Fund, managed by the National Health Security Office (NHSO. He said keeping HIV/AIDS funding separate from the per-capita budget was necessary and represented an important achievement for the country.

Before 2006, funding for HIV prevention and treatment was included in the per-capita budget. People living with HIV and people with AIDS therefore primarily received services at hospitals designated under their healthcare entitlement.

Hospitals were already dealing with large numbers of patients and heavy workloads, while people living with HIV, people with AIDS and people at risk also faced stigma and discrimination. These factors could discourage people from seeking testing, prevention and treatment, limiting access to services.

The 2006 reform opened the system to a wider range of providers. People could seek HIV testing, diagnosis, prevention and treatment from public hospitals, private facilities and civil society networks, with participating providers receiving reimbursement from the NHSO. People covered by Universal Coverage Scheme, Social Security Scheme and the Civil Servant Medical Benefit Scheme could all access relevant services.

Dr. Praphan said expanding the choice of providers and reducing barriers to care had played an important role in bringing down new infections. He argued that returning HIV/AIDS funding to the general per-capita budget could risk bringing back some of the access problems seen before the reform.

It could also put additional pressure on hospitals, he said, even though external providers are already helping to reach and care for target groups.

Thailand has a clear plan for ending AIDS, and more than 4 billion baht a year is allocated within the health system for HIV/AIDS-related services, Dr. Praphan said. He considered the funding sufficient overall, partly because falling drug prices have reduced treatment costs. The challenge, he said, is ensuring that policies translate into services that people can actually use.

PrEP, or pre-exposure prophylaxis, illustrates the gap. Although Thailand has a policy allowing people to access PrEP to prevent HIV infection before exposure, some people may still be unaware of their entitlement or where they can obtain the medication. Full cooperation from service providers is also needed to ensure that the policy reaches people who need it.

Civil society groups have traditionally played an important role in finding people at risk and connecting them with prevention and treatment services. Much of this work has received support from international donors, but the end of some external funding has left gaps in financing for proactive outreach.

Dr. Praphan proposed an additional 300 million baht a year to support civil society organizations in reaching target groups. He said the funding could increase the country’s chances of achieving its goal of reducing new infections to no more than 1,000 cases a year.

He also cautioned against interpreting increases in the cumulative number of people living with HIV as evidence that new infections are rising sharply. He said the number of new infections each year has remained relatively stable over the past six to eight years.

Children and young people remain groups requiring close attention, he said, but older people should not be overlooked. Some older people may engage in risk behaviors without recognizing that they could be exposed to HIV, while prevention efforts often focus on younger groups.

He called for prevention communication and services to cover people across age groups so that those at risk can access testing, prevention and treatment quickly and support Thailand’s longer-term goal of ending AIDS.