1. HIV-sensitive social protection in Asia
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

2. Outline
1. Socioeconomic impact study
2. HIV-sensitive social protection
3. Sustainable health financing

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

4. Higher unemployment among HIV-HH
30%
PLHIV NA-HH
26%
25%
25%
21%
21%
Unemployment levels
20%
15% 14%
11%
10%
10% 9% 9%
5%
2%
0%
Cambodia China India Indonesia Viet Nam

5. High medical expenditure / positive impact of universal access
• 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.
$180
HIV-HH NA-HH
$160
P.C. Annual Health Consumption
$158
$140
$120
$100 $113
$80
$60 $70
$60
$40
$44
$20 $29
$21 $8
$-
Cambodia India Indonesia Viet Nam

6. Greater school drop out among girls in HIV-HHs
in China, India and Indonesia
14.0
13.8
% Children Dropped Out of School
12.0
Boys Girls
10.0
8.0
7.7
6.0
6.1
4.0 4.4
4.2 4.2
3.8
2.0 2.9 2.9 3.0
2.3 2.4
0.9 1.6 1.9 1.0
0.0
HIV-HHs NA-HHs HIV-HHs NA-HHs HIV-HHs NA-HHs HIV-HHs NA-HHs
Cambodia China India Indonesia

7. Higher levels of child labour among girls from HIV-HHs
7.0%
6.3% HIV-HH NA-HH
6.0%
Girls
5.0%
Child Labour Levels: Girls
4.0%
3.5% 3.6%
3.0%
2.4%
2.0% 1.7%
1.4%
1.0%
0.6%
0.1%
0.0%
Cambodia China India Viet Nam

8. Social Protection
“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

9. HIV-sensitive vs. HIV-specific
• HIV-sensitive social protection: HIV
considerations are integrated into the existing
More : inclusive,
general social protection policies andfield
sustainable & equitable
Emerging schemes
• HIV-specific social protection: exclusive social
protection schemes designed specifically for
PLHIV and/or key affected populations

10. HIV-sensitive social protection: Example 1
Widow pension scheme (Rajasthan, India)
• 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

11. HIV-sensitive social protection: Example 2
Conditional BPL status (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

12. HIV-sensitive social protection: Example 3
Legal recognition of the third gender
• 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.

13. HIV-sensitive social protection: Example 4
Thai Universal Health Coverage Scheme
• HIV treatment initially excluded but later
included
• Comprehensive HIV services through
Accessing affordable medicines
the compulsory license/government use
• Fully funded by the government – critical from
licence
As per
WTO
sustainability viewpoints rules
• Thai UHC also covers illnesses other than HIV
requiring long-term and often expensive
treatments such as cancer and heart diseases

14. Government use licenses (GUL) in Thailand
reduced the medicine price significantly
Extent of price reduction in medicines in Thailand due to government use orders
to access generic versions of the same drugs
0%
-10%
-20%
-30%
-40%
-50%
-60%
-70%
HIV 1 HIV 2
-80% -66% -70% Cancer 3
-73%
-90%
-100%
Heart Cancer 1 Cancer 2
-98% -98% -96%
Source: Thai Ministry of Health (2009) Assessing the implications of Thailand’s government use licenses issued in 2006-2008

15. 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
90,000
84,158
80,000
additional
patients
70,000
60,000 Cancer 4
Cancer 3
50,000 Cancer 2
Cancer 1
Heart
40,000
HIV 2
HIV 1
30,000
20,000
10,000
0
Source: Thai Ministry of Health (2009) Assessing the implications of Thailand’s government use licenses issued in 2006-2008

16. Thailand was able to kill two birds with one stone (use
of the compulsory/government use license)
Financial sustainability
Compulsory
licenses
Expansion of benefit and
treatment coverage

17. Access to generic medicines – a key to sustainable
health financing
Price of a relatively new cancer drug in India (per person per month)
$6,000
$5,500
$5,000
97% price reduction
after the compulsory
$4,000
license for the generic
version of the same
$3,000 drug in March 2012
$2,000
$1,000
$174
$0
Bayer Netco

18. Non-communicable diseases already account for
>50% of all deaths in most countries in Asia
90%
83%
79%
% of NCD in total deaths
80% 77%
75%
72% 72% 71%
70% 67%
64%
61%
60%
52% 53% 53%
51% 50%
50% 46% 46%
40%
30%
20%
10%
0%
Source: WHO (2011) “Non-communicable Disease Country Profile 2011”

19. Access to affordable medicines is one critical
element for successful UHC
Poverty reduction
Universal
health Improved productivity
coverage
National development
Financial
Effective-
sustai- Coverage ness
nability
Affordable medicines

20. Where are we heading
HIV-sensitive social protection
Unique
Equity
needs
SOCIAL PROTECTION

21. HIV-sensitive social protection may open the
Where are we heading
door for other marginalised populations
Slum dweller-sensitive SP
Ethnic/religious minority-sensitive SP
Persons with disability-sensitive SP
HIV-
sensitive
social
protection

22. Policy recommendations
• 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.

23. Thank you

24. UHC in Thailand reduced impoverishment due
to catastrophic health expenditure among poor
UHC
Source: “Thailand’s universal coverage scheme: An independent assessment of the first 10 years “