1. 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

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

3. 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

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

5. • 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.AnnualHealthConsumption
HIV-HH NA-HH
High medical expenditure / positive impact of universal access

6. 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 3.02.9
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
%ChildrenDroppedOutofSchool
Boys Girls

7. 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
ChildLabourLevels:Girls
HIV-HH NA-HH
Higher levels of child labour among girls from HIV-HHs
Girls

8. “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

9. • 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

10. • 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)

11. • 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)

12. • 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

13. • 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

14. 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

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
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

16. 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

17. 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)

18. 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

19. 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

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

21. 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

22. • 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

23. Thank you

24. 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