Policy Dialogue on Mitigating Vulnerabilities and Promoting Sustainable Growth

1 Nov 2012, South Korea

Clifton Cortez

Practice Leader, HIV, Health & Development UNDP Asia Pacific Regional Centre

HIV-sensitive social protection in Asia

1. Socioeconomic impact study

2. HIV-sensitive social protection

3. Sustainable health financing

Outline

Country Year of Survey # HIV-HHs # NA-HHs

Cambodia 2009-2010 2,623 1,349

China 2008 931 995

India 2004-2005 2,068 6,224

Indonesia 2009 996 996

Viet Nam 2008 452 452

TOTAL HOUSEHOLDS 7,070 10,016

• Surveys conducted from 2004 – 2010 in 5 countries in Asia:

– Over 7000 HIV-affected households; 10,000 non-affected control households, covering 72,000 individuals across 5 countries.

– Multi-county studies based on common, but nationally-adapted methodologies, enabling cross-country analysis

Socio-economic impact of HIV at the individual and household levels in Asia

25% 26%

10%

21% 21%

14%

9% 9% 11%

2%

0%

5%

10%

15%

20%

25%

30%

Cambodia China India Indonesia Viet Nam

Un

em

plo

yme

nt

leve

ls

PLHIV NA-HH

Higher unemployment among HIV-HH

• In India, Indonesia, and Viet Nam, HIV-HHs spent over 3 times as much on

health than those in NA-HHs. • In Cambodia, NA-HHs spent more on health than HIV-HHs.

$60

$158

$113

$21

$70

$44

$29 $8

$-

$20

$40

$60

$80

$100

$120

$140

$160

$180

Cambodia India Indonesia Viet Nam

P.C

. An

nu

al H

eal

th C

on

sum

pti

on

HIV-HH NA-HH

High medical expenditure / positive impact of universal access

Greater school drop out among girls in HIV-HHs in China, India and Indonesia

3.8 4.2

7.7

4.4

2.4 1.6

2.9 3.0 2.9 2.3

13.8

0.9

4.2

1.9

6.1

1.0 0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

HIV-HHs NA-HHs HIV-HHs NA-HHs HIV-HHs NA-HHs HIV-HHs NA-HHs

Cambodia China India Indonesia

% C

hild

ren

Dro

pp

ed

Ou

t o

f Sc

ho

ol

Boys Girls

6.3%

3.6%

1.7% 1.4%

3.5%

0.1%

0.6%

2.4%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

Cambodia China India Viet Nam

Ch

ild L

abo

ur

Leve

ls:

Gir

ls

HIV-HH NA-HH

Higher levels of child labour among girls from HIV-HHs

Girls

“The objective of social protection is broadly to reduce the economic and social vulnerability of all poor and vulnerable groups and to enhance

the social status and rights of marginalised people by providing social transfers, ensuring access, and equitable regulation, which can

take many forms.”

- State of Evidence, UNAIDS SP Working Group

Social Protection

• HIV-sensitive social protection: HIV considerations are integrated into the existing general social protection policies and schemes

• HIV-specific social protection: exclusive social protection schemes designed specifically for PLHIV and/or key affected populations

HIV-sensitive vs. HIV-specific

More : inclusive, sustainable & equitable

Emerging field

• Minimum age requirements of 60

• Not accessible by many widows living with HIV as they tended to be young (20s,30s…)

• Rajasthan waved the min. age requirement

– Today, all widows living with HIV are covered by the scheme regardless of age

– Possible positive impacts on OVCs

HIV-sensitive social protection: Example 1

Widow pension scheme (Rajasthan, India)

• Some states give the ‘conditional’ below poverty line (BPL) status to people living with HIV

• Conditional BPL allows access to certain schemes designed for BPL households

– Inclusion in a health scheme

– Food subsidies

HIV-sensitive social protection: Example 2

Conditional BPL status (India)

• Ordered by the Supreme Court in Nepal and Pakistan

• Now the third gender category in the national ID card

– Necessary for healthcare, legal counselling and voting

• Introduction of the third gender category “X” in the national passport in Australia in Sep 2012.

HIV-sensitive social protection: Example 3

Legal recognition of the third gender

• HIV treatment initially excluded but later included

• Comprehensive HIV services

• Fully funded by the government – critical from sustainability viewpoints

• Thai UHC also covers illnesses other than HIV requiring long-term and often expensive treatments such as cancer and heart diseases

HIV-sensitive social protection: Example 4

Thai Universal Health Coverage Scheme

Accessing affordable medicines through the compulsory license/government use

licence As per WTO rules

Government use licenses (GUL) in Thailand reduced the medicine price significantly

-100%

-90%

-80%

-70%

-60%

-50%

-40%

-30%

-20%

-10%

0%

HIV 1 -66%

HIV 2 -70%

Heart -98%

Cancer 1 -98%

Cancer 2 -96%

Cancer 3 -73%

Extent of price reduction in medicines in Thailand due to government use orders to access generic versions of the same drugs

Source: Thai Ministry of Health (2009) Assessing the implications of Thailand’s government use licenses issued in 2006-2008

Price reduction led to $370 million saving and >80,000 more patients on treatment in 5 yrs

Estimated additional number of patients who were given medicines due to price reduction following the government use licenses in Thailand

Source: Thai Ministry of Health (2009) Assessing the implications of Thailand’s government use licenses issued in 2006-2008

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

Cancer 4

Cancer 3

Cancer 2

Cancer 1

Heart

HIV 2

HIV 1

84,158 additional patients

Thailand was able to kill two birds with one stone (use of the compulsory/government use license)

Compulsory licenses

Financial sustainability

Expansion of benefit and treatment coverage

Access to generic medicines – a key to sustainable health financing

$5,500

$174 $0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

Bayer Netco

97% price reduction

after the compulsory license for the generic

version of the same drug in March 2012

Price of a relatively new cancer drug in India (per person per month)

Non-communicable diseases already account for >50% of all deaths in most countries in Asia

52% 53%

46%

83%

77%

53%

64%

72%

67%

79%

72%

51% 50%

46%

61%

71%

75%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Source: WHO (2011) “Non-communicable Disease Country Profile 2011”

% of NCD in total deaths

Access to affordable medicines is one critical element for successful UHC

Universal health

coverage

Poverty reduction

Improved productivity

National development

Financial sustai-nability

Coverage

Affordable medicines

Effective-ness

Where are we heading HIV-sensitive social protection

Equity

SOCIAL PROTECTION

Unique needs

Where are we heading

Persons with disability-sensitive SP

Ethnic/religious minority-sensitive SP

Slum dweller-sensitive SP

HIV-sensitive

social protection

HIV-sensitive social protection may open the door for other marginalised populations

• Prioritize the most vulnerable and marginalized persons in social protection agenda

• Make existing SP schemes sensitive to their unique needs, rather than creating exclusive schemes, whenever possible

• Protect the right to affordable medicines for sustainable health financing, as a strategic policy option to pursue health equity, poverty reduction, social justice and financial sustainability.

Policy recommendations

Thank you

UHC in Thailand reduced impoverishment due to catastrophic health expenditure among poor

Source: “Thailand’s universal coverage scheme: An independent assessment of the first 10 years “

UHC