Ensuring Universal Access: User Fees and Free Care Policies in the
context of HIV Treatment

Meeting sponsored by UNAIDS, WHO and the World Bank

21-22-23 March 2005. Conference Centre of Geneva, Switzerland,

Background and justification

Financing antiretroviral care and treatment from end users was a
major issue at the XV International AIDS conference in Bangkok in
July 2004. During the conference, Thailand announced that it would
provide care--including ARVs--free at points of service delivery. In
doing so, it joined a growing list of countries including Brazil,
Costa Rica, Senegal, and more recently Uganda, Malawi, Botswana, and
Mali.

But the issue is not a new one. The costs and benefits of end-user
cost recovery have been hotly debated in international health
circles since the 1980s, when balance-of-payments crises in the
developing world led to a restructuring of many state health budgets
in order to free up public funds. User fees were widely imposed for
drugs and curative care that had previously been available without
charge; the new pricing structure was implemented throughout Asia
and Latin America, and in nearly every country in sub-Saharan
Africa. However, for many individuals in poor countries,
affordability poses an insurmountable obstacle.

Decisions made by local policy makers on the cost of HIV care and
treatment at the point of service have a profound impact on the
ability of individuals to receive care and treatment for HIV,
affecting program uptake, adherence to treatment, and the emergence
of drug resistance. Meanwhile, the cost of HIV care and treatment is
a significant component of national health budgets. Moreover, all
governments have some type of health financing policy or strategy
and many are in the process of examining or implementing reforms in
this area, so the question of end user cost for ARVs must be
considered in light of its impact on the health system more broadly
and in the context of overall health financing policy.

These concerns cut to the heart of the global development agenda.
The access to HIV treatment is a cornerstone of poverty alleviation,
as well as economic, social and political security, and will be a
significant determinant of progress toward achievement of Millennium
Development Goals.

Purpose
The purpose of the three-day meeting is to analyse the importance
and impact of policy on free access to HIV care and treatment versus
user fees, with the specific intention of identifying enabling
mechanisms and steps to guide countries and partners in their policy
decision-making process.

Objectives
The objectives of the consultation would be:

1. To understand the range of health financing strategies and
policies across countries and review current experiences of and
obstacles to provision of free HIV care and treatment services at
point of delivery versus fees for services, in resource constrained
settings;
2. To discuss the potential consequences of free HIV care and
treatment on health systems and financing mechanisms capable of
sustaining a free access policy at the national and international
levels;
3. To make recommendations on a basic package of HIV care, funding
mix, and process from situation assessment to decision making, for
policy makers in government, donor agencies, and civil society.

The discussion will range from human rights and ethics, to public
health, economics, and political mobilization. Concerns about
sustainability often confronted by decision makers as a barrier will
be addressed.

Expected outcomes
The expected outcomes will include:

1. Agreement on an agenda for incorporation of free care and
treatment into national and international financing strategies
2. Policy guidance for national decision makers and partners,
3. Launch of a transnational network for monitoring the impact of
user fees and free care policies on access to HIV treatment;
4. Publication of a meeting report with a summary of key issues and
discussions.

National experiences and policy analysis will be used for generating
guidance for government policy decision making.

Organizers
UNAIDS Secretariat, WHO/HIV/AIDS with EIP, EDM, ETH Departments and
the World Bank

Participants
National AIDS Programme managers from low and middle income
countries and Ministries of Finance representatives; national NGOs
providing treatment; International NGOs, People Living with HIV,
ICW, researchers, public health experts, medical ethics specialists,
health economists, human rights practitioners, donor agencies.

Meeting Agenda (Provisional)

Chair: Visweswaran Navaratnam, Malaysia
Monday 21 March 2005

16:00-16:10 Chair's Welcome
16:10-16:45 Opening Remarks
WHO, Jim Kim, Director, HIV Department
World Bank, Debrework Zewdie , Global HIV-AIDS Program
UNAIDS Secretariat, Catherine Hankins, SMI

16:45-17:00 Introduction of Participants
17:00-17:30 Overview of Meeting: Background and Objectives
Françoise Renaud-Théry, UNAIDS Secretariat
17:30-18:00 Questions and Clarifications
18:00-20:00 Reception at WHO


Tuesday 22 March 2005
Morning Facilitator: Paulo Teixeira
I. Report on situation and process for policy decision on free
access to treatment and care at point of delivery versus fee for
services

08:30-09:00 UNAIDS and WHO: review of the evidence and policy
position Julian Fleet, UNAIDS Secretariat
Yves Souteyrand, WHO, HIV Department

09:00-09:20 La gratuité du traitement et ses conséquences sur le
système de santé
Dr Alain Yoda, Minister of Health, Burkina Faso

09:20-09:40 Making HIV treatment free and consequences for
health system Mrs Mutale Nalumango, Minister of Information &
Broadcasting Services, Zambia

09:40-10:30 Discussion (30 minutes)

10:30-10:45 Refreshment Break

10:45-11:05 Community response to HIV care and treatment:
lessons learnt on free access by Community-based Organizations
Marie-José Mbuzenakamwe, Director, Association Nationale des
Séropositifs et Sidéens, Burundi (TBC)

11:05-11:25 Equity and Social Justice: Sliding fee scales and
subsidization schemes. Do they ensure equity and social justice? Are
they worth the cost? Alice Desclaux, University of Marseille, France

11:25-12:30 General Discussion
12:30-13:30 Lunch

Afternoon Facilitator: Purnima Mane, Director, SMI

II. Economics and Package of care
13:30-13:50 Estimating the cost: How much would be lost to the
public system by foregoing all user fees in providing HIV
treatments free to patients at the point of delivery?

William McGreevey or John Stover, Futures Group

13:50-14:10 From ARVs to comprehensive HIV care and treatment:
what services would be included in the package provided free at
point of delivery? Representative from Partners in Health, Haiti

14:10-15:10 Discussion (60 minutes)

15:10-15:30 Refreshment Break

III. Enabling financing mechanisms
15:30- 15:50 Configuring health system to minimize the impact of
a free HIV care policy on other primary health services
Anupong Chitwarakorn, Ministry of Health, Thailand

15:50-16:10 Macroeconomic Planning and Access to HIV care and
treatment: the ontribution of International Financial Institutions
Peter Heller, IMF, Washington D.C.

16:10-16:30 Sustainable financing: Mechanisms of risk pooling
to support free treatment at the point of service. David Evans, WHO,
Health System Financing, Expenditure and Resource Allocation (FER)

16:30-17:30 Discussion (60 minutes)

17:30-18:00 Orientation for group work on day 3
Aaron Shakow, WHO, HIV Department

1) PACKAGE OF CARE
2) FROM ASSESSMENT TO DECISION
3) FUNDING MIX

Wednesday 23 March 2005

Morning Facilitator: Jean Paul Moatti, Director, INSERM
08:30-9:00 Review of Principal Points from Prior Day
Chair

IV. Panel for discussion:

09:00-11:00 Mobilizing international resources for supporting
free access and issues for donors

Moderator:
Jean-Paul Moatti, Inserm, Université de la Méditerranée (Aix-
Marseille II), France
Participants:
The World Bank, Debrework Zewdie
GFATM, Vinand Nantulya (TBC)
OGAC, USA, Mark Dybul (TBC)
DFID, UK, Robin Gorna (TBC)
French Minister of Foreign Affairs, Serge Tomasi (TBC)

V. Generating guidance for policy decision making on how countries
and treatment programmes can achieve universal and free access to
care and treatment

11:00-13:00 Group work
1) PACKAGE OF CARE
2) FROM ASSESSMENT TO DECISION
3) FUNDING MIX

13:00-14:00 Lunch

Afternoon Facilitator: Debrework Zewdie
14:00-15:00 Reporting on group work in plenary discussion

15:00-15:20 How can UNAIDS, WHO and World Bank maximize the
impact of their Guidance?
Nasr El Sayed, Ministry of Health and Population, Cairo

15:20-15:40 Piloting financing mechanisms – Country follow-up
Aaron Shakow, WHO, HIV Department

15:40-16:10 Discussion

16:10-16:30 Refreshment Break

16:30-17:30 What indicators will be useful in monitoring the
impact of free access versus fee for services in scaling up?
Paul de Lay, UNAIDS (TBC)

17:30-18:00 Reactions from co-organisers WHO, WB and UNAIDS
Secretariat

18:00-18:15 Summary and Closing Chair