Community clinics left in limbo after new regulations restrict HIV prevention services

Story by Anna Lawattanatrakul and Sicha Rungrojtanakul
Cover illustration by Kittiya On-in

New orders issued by the Ministry of Public Health restricting the HIV prevention budget and requiring community-based clinics to be supervised by a government medical facility have drawn criticism from civil society due to concerns that the new regulations would limit their ability to provide HIV testing and preventative medication to at-risk groups.

Just before the New Year, the National Health Security Office (NHSO) announced its 2023 National Health Security Budget Plan. Due to questions raised by legal advisors for Public Health Minister Anutin Charnvirakul, the plan allows that only budget allocated to health promotion and disease prevention can be used to provide services for those covered by the Universal Care , or “Gold Card,” Scheme.

Meanwhile, another regulation issued by the Department of Health Service Support, Ministry of Public Health, requires sexual health clinics run by civil society organizations to be supervised by a government-run medical facility and to submit blood test results to a doctor so that medication can be prescribed. In the wake of the new regulation, several clinics in Bangkok suspended their HIV prevention service out of the fear that it would be illegal to continue.

These new regulations have drawn criticism from community clinics, who have been providing HIV testing and preventative medication for everyone, regardless of their healthcare scheme, due to concern that their HIV prevention work will be restricted and that it will lead to the shrinking of safe spaces for people seeking counselling about their sexual health without the fear of facing prejudice. They also expressed concern that these restrictions would increase the risk of HIV infection in Thailand due to the reduced access to blood tests and anti-viral medication.

All in the reading of the law

Yupadee Sirisinsuk (Photo from the NHSO)

Yupadee Sirisinsuk, Assistant Secretary-General of the NHSO, said that the budget problem is because the NHSO and the Ministry of Public Health have interpreted legislation differently. In the past, she said, the NHSO has been providing health promotion and disease prevention services for everyone on the principle that they should be available to every citizen, and have been requesting a budget on behalf of the Social Security Fund and the government employee benefit programme.

Questions were recently raised by Anutin’s legal advisor whether the NHSO is allowed to do this, but it is nothing new. Yupadee said that, in 2003, the NHSO sought a ruling from the Office of the Council of State on a similar issue and were told that, because of a section in the National Health Security Act stating that everyone has the right to healthcare that is efficient and up to standard, the NHSO is allowed to use its budget to provide healthcare for everyone. 

Yupadee also cited another section in the Act stating that the NHSO is authorized to perform any duties assigned by the Cabinet, and said that the NHSO has been interpreting that to mean that it is authorized to distribute its budget once it has been allocated the money, which has to be approved by parliament.

However, the Act also requires the NHSO to come up with a mutual agreement with the Social Security Fund or any agency responsible for the government employee benefit programme before it provides any service for people covered by the two other schemes. The agreement must also be published in the Royal Gazette to be valid.

Because no such agreement has been announced, questions was raised whether the NHSO will be breaking the law if it continues to use its health promotion and disease prevention budget for everyone regardless of their healthcare scheme. Yupadee said that after several discussions with the National Health Commission and a long delay in announcing its budget plan, usually declared before the start of the fiscal year on 1 October, the NHSO decided to announce its budget plan covering just patients in the Universal Care scheme while it seeks clarification on what it can do for everyone else.

However, this meant that HIV prevention, previously covered by the health promotion and disease prevention budget along with birth control and abortion, is now covered by the NHSO only for those in the Universal Care scheme. Anyone covered by other schemes must go to the hospital or clinic they are registered at if they want to get tested for HIV or get prescriptions for Pre-Exposure Prophylaxis (PrEP) or Post-Exposure Prophylaxis (PEP), both of which are medications taken to prevent HIV infection either before or after exposure to the virus. Medical facilities will also not be reimbursed for services given to those outside the Universal Care scheme for the time being.

Meanwhile, the regulation issued by the Department of Health Service Support led to the suspension of services at clinics operated by the Service Workers in Group (SWING) Foundation and the Rainbow Association of Thailand. Both organizations announced that they would no longer be prescribing PrEP and PEP as they previously worked in a network with a private clinic and were concerned that it would be illegal for them to continue.

Inthira Suya, Thailand representative for FHI 360’s EpiC programme

“The new Ministry regulation will affect the clinics, especially clinics in Bangkok,” said Inthira Suya.

Inthira is the Thailand representative for FHI 360’s EpiC programme, which works to reduce HIV infection in key populations, including men who have sex with men, transgender women, and sex workers, through providing prevention services, such as through the Key Population-Led Health Services Model in partnership with civil society organizations like the Institute of HIV Research and Innovation (IHRI), SWING Foundation, MPlus Foundation, and Caremat Foundation.

She noted that PrEP is available at private hospitals, but is expensive and can be unaffordable for many people.

She said that if PrEP is not accessible at a price they can afford, people may decide not to take the medication to protect themselves, which can lead to a rise in HIV infections.

Meanwhile, a network of civil society organizations led by TestBKK and APCOM launched a campaign on Change.org calling for the Ministry of Public Health to allow civil society organizations and clinics to continue to provide PrEP and PEP and to provide financial support to ensure access to these services to reduce the risk of HIV and other sexually-transmitted diseases. As of 23 February, the campaign had over 6,660 signatures.

Representatives of civil society organizations working on HIV prevention also filed a petition with the Senate Standing Committee on Public Health on 16 January, stating that requiring people not covered by the Universal Care Scheme to obtain HIV prevention services from their registered hospital makes it harder for them to access the means to protect themselves. Requiring community clinics to work under the supervision of a government agency also will result in several clinics suspending their services, leading to an increased risk of HIV infection. The organizations therefore called on the committee to have the regulations revised to ensure equal access to HIV prevention for everyone.

Yupadee said that the NHSO is now trying to find solutions and will not let services be disrupted. The NHSO has requested the assistance of other government agencies, asking them to step in to provide these services, and promised that it will reimburse every service provider once there is a plan for how it can use its budget for people outside of the Universal Care Scheme.

The NHSO is also pairing community-based clinics with public hospitals and has requested support from the Department of Disease Control to provide the necessary medication.

“Every side sees the importance, and it’s very clear, especially when it comes to PrEP and PEP that civil society organizations are the main service providers, because people can’t access government services, and people who are at risk do not want to go [to a government facility] because they want confidentiality and things like that, so they won’t go,” Yupadee said.

On 24 January, SWING announced that its clinics are now back in operation, while Rainbow Sky’s clinics announced their return on 26 January. They are now working with the Bang Rak Medical Centre and the Department of Disease Control’s AIDS and Sexually Transmitted Diseases Division.

To fix the issue at its cause, Yupadee said the NHSO is now in the process of discussing with the Social Security Fund and the government employee benefit programme and will be announcing a mutual agreement as required by the National Health Security Act. Although she said that there is no predicting when this process will be completed, Yupadee thinks that there should be no obstacle, as every involved agency believes that the people will benefit from it and the budget has already been allocated. She also said that they should have no problem getting clarification from the Cabinet even if the Cabinet’s term ends or if parliament is dissolved.

Left in Limbo

A sign attached to a utility pole in an alleyway pointing the way to the Caremat Clinic

Due to the new regulations, community-based clinics are now facing uncertainty about whether they could continue to provide HIV testing and prevention for anyone regardless of their healthcare scheme, and if or when they would be compensated for the services they gave.

Satayu Sittikarn, Director of the Caremat Foundation, said that the Caremat Clinic has been working with priority populations since 1993. Funded by the United States Agency for International Development (USAID) and the US President's Emergency Plan for AIDS Relief (PEPFAR) via the EpiC Progamme, Caremat operates a clinic in Chiang Mai city providing sexual health counselling, voluntary HIV testing, and medication like PrEP and PEP. They also refer anyone testing positive for HIV to a hospital so they can be prescribed anti-viral medication, follow up on them to make sure they are taking medication continuously and correctly, as well as provide mental support.

Satayu said that some people may not be able to go to a government facility, either because of their working hours or because they do not feel comfortable disclosing details about their sexual lives to an employee in a government facility. He said that the Caremat Clinic welcomes anyone regardless of their healthcare scheme or citizenship status, as the clinic prioritizes the person’s risk level over these factors.

“We don’t know if condoms would always keep them safe. If their sexual life is still risky, we will offer them PrEP. We don’t care what scheme they’re under. We only care about how much risk this individual is facing of contracting HIV,” Satayu said.

Due to the current uncertainty over how the NHSO can use its health promotion and disease prevention budget, clinics like the Caremat Clinic cannot be reimbursed for services given to people covered by healthcare schemes other than the Universal Care scheme, such as the Social Security Scheme or government employee benefits, and now have to carry the cost themselves.

Even though Caremat is part of a network of community clinics supported by a local public hospital, they have been asked to prioritise those covered by the Gold Card Scheme and those who are registered at the hospital under the Social Security Scheme, since the hospital itself also cannot be reimbursed for services given to people outside of these two groups.

Although it has been announced that anyone seeking HIV testing or preventative medication prescription can go to the facility they are registered at, community clinic workers are concerned that at risk groups may not want to go to a public hospital. Satayu said that some people cannot afford testing fees and may not know what services are available to them under their healthcare scheme. Meanwhile, the social stigma regarding HIV means that some may avoid getting tested, and community clinics cannot be sure that they will go to the hospital if they are told to or if hospital personnel would understand the conditions of their lives.

Satayu Sittikarn

Satayu also said that facilities like the Bangkok Metropolitan Authority’s public health centres or social security hospitals may not be prepared to provide these services. For example, they may not be able to prescribe PrEP and may not have the medication in stock. He said that if the NHSO will only cover HIV prevention for people in the Gold Card scheme, it should make preparations so that people outside of the scheme can get their medication elsewhere, since the cost of treatment is higher than that of prevention, and HIV infection rates may rise without access to preventative medication.

“We do this every day because we are doing it for the country. We’re not doing it for ourselves. … We are determined to end the problems of AIDS, but at the same time, our service is facing obstacles like these,” Satayu said, explaining that the clinic is finding solutions for the short term.

Despite the obstacles, it is still business as usual at the Caremat Clinic, and Satayu said that it is still their policy to never turn anyone away.

“Because they come to us with the hope that we can help them, if we refuse them, how would they feel?” Satayu said. “We think that we have to help them. We’re not a government service provider with many conditions and restrictions. We see people as equal.”

Surang Chanyaem at the 10 January press conference

Meanwhile, SWING Foundation’s Director Surang Chanyaem said during a press conference on 10 January that the Ministry of Public Health’s new regulation requiring community clinics to submit blood test results to a government medical facility for a doctor to prescribe medication will limit people’s ability to protect themselves and may put people now using PrEP more at risk of HIV. She also said that it is a violation of the fundamental right to healthcare. 

Surang said that SWING and other civil society organizations working to prevent HIV call on the NHSO to revise its budget plan so that the money can be used to cover the cost of HIV prevention for everyone, and for the Ministry of Public Health to combine the Universal Care scheme, the Social Security Scheme, and government employee benefit into one healthcare scheme to ensure that HIV prevention is accessible to everyone.

They also call for the Ministry of Public Health to revise its regulations to allow civil society volunteers to work under the supervision of medical professionals at both public and private medical facilities, as well as to stock PrEP on their premises. They should also be allowed to operate a Telemedicine service with a medical professional.

Meanwhile, Yupadee said that requiring community clinics to pair up with a government facility is not about working with an institution but about having the input of a medical professional, such as a doctor or a pharmacist. She believes that the new regulation should be expanded to allow clinics to form networks with private medical facilities to increase access to healthcare.

“We want to end AIDS, right? So it’s all the more reason for us to make sure there is service that is easily accessible, especially because a government agency is not available 24 7, right? The issue here is that, if possible, that announcement or regulation should allow civil society to pair up with a private organization that has doctors and pharmacists,” Yupadee said.

A vanishing safe space?

The Caremat Clinic in Chiang Mai

According to information collected by SWING Clinic, around 60% of people who are using PrEP in the country get their medication from community-based clinics.

Not only do community clinics provide blood tests and give out medication, they also function as safe spaces for people to seek advice about their sexual health without stigmatization or prejudice. The civil society is therefore concerned that, if they are no longer able to provide services to those outside the Universal Care scheme, there will be less safe space for people who are uncomfortable going to a government hospital but need advice, lowering access to HIV-related healthcare.

Satayu said that even though a public hospital has a standard of care and employs medical professionals, many people may not go because they feel uncomfortable disclosing details about their sexual lives to a government employee, such as sex workers or those whose sexual activity involves drug use, who may be concerned that they will be prosecuted if they have to disclose this information to a government-run medical facility. LGBTQ+ people may also face stigmatization and prejudice from hospital personnel. For example, a trans woman who is still addressed as “Mr” by hospital employees might feel uncomfortable seeking treatment.

Meanwhile, the opening hours at most public hospitals make it difficult for some people to see a doctor, while community clinics tend to open at more accessible hours. The Caremat Clinic, for example, is open from 13.00 – 19.00 on weekdays and until 17.00 on Saturdays.

“Our clinics do not open according to official hours. They also close late. It’s more convenient to come here and it takes less time,” said Inthira. She noted that community-run clinics are led by members of key population groups, and therefore have a better understanding of the daily lives of their target group and so their space and counselling process are more friendly.

“They feel more comfortable talking and asking for advice about their problems. It’s like if I have to do a pelvic exam. I’d feel more comfortable with a woman doctor too,” Inthira said.

Meanwhile, Satayu said that the opening hours at community clinics make it so that people do not need to take time off work to see a counsellor or get tested, such as during the weekend. He questioned whether people would seek these services if they have to half a day or a full day off work to go to a hospital and have to worry about being stigmatized or treated with prejudice.

He also noted that public hospitals are already seeing so many patients each day, and to reduce the workload, mild cases can be dealt with by community hospitals or clinics run by civil society organizations to give doctors a chance to treat serious cases. The Caremat Clinic, he said, is part of a model where community clinics work with local hospitals to send information to a doctor who will prescribe medication and follow up on how people are taking their medications. For Satayu, this model should be used elsewhere in the Thai healthcare system to reduce the workload of public hospitals.

Satayu said that 82% of people who are on PrEP in Chiang Mai get their medication from Caremat, which shows that the clinic has the capacity to care for everyone regardless of their healthcare scheme. He pointed out that even migrant workers or indigenous people without Thai citizenship will not be turned away if they come to the clinic.

“They are also Thai, but they are not covered by the NHSO, like ethnic people. There are a lot of ethnic minorities in Chiang Mai. They move from their communities and come to work in the city and they are at risk, but we will give them services. We don’t refuse them because they’re covered by a healthcare scheme that don’t have these services, because we think that if we want to end AIDS, the main population should know their blood test result and have access to treatment,” Satayu said.

Chanan Yodhong

Meanwhile, Chanan Yodhong, who oversees the Pheu Thai Party’s gender diversity policy, pointed out that not only is it more convenient to go to a community clinic than a hospital, the confidentiality provided by these clinics also make people more comfortable because discussing sexual health is sensitive and personal.

“The confidential way they store information makes people receiving the services feel more comfortable going to a facility run by civil society. This is a very sensitive issue,” Chanan said.

Towards ending AIDS

30 years ago, AIDS was seen as a death sentence, but with current medical technology, people can live with HIV as long as they take their anti-viral medication and keep their viral load in check. Infection is also preventable with PrEP or PEP.

Satayu said that it has always been the goal for civil society organizations to work proactively to provide treatment and prevention for at-risk groups, which he thinks is something the civil society is better at. For him, people who test positive for HIV will not develop AIDS and will not die from it if they know that they have the virus and have access to anti-viral medication to keep their viral load down.

Inthira also said that having more community clinics is part of how to meet the goal of ending AIDS by 2030. She noted that, in Australia and the UK, PrEP are mostly provided by community clinics, which makes the medication more accessible and reduces the workload in the healthcare system.

“Because HIV is no longer the biggest problem for the Thai healthcare system like in the past. Now, we have medication that both cures and prevents, and especially if we can quickly identify at-risk groups and have them take preventative medication, then we can end AIDS,” Inthira said.

Meanwhile, Chanan said that centralizing the system so that people can get medication only from hospitals will mean that treatment becomes less accessible. To make healthcare more easily accessible, especially sexual health services like PEP, which must be taken within 72 hours of being exposed to HIV and the sooner one can get the medication the better it will be at preventing infection, he said resources should be distributed to communities and to have a common standard for everyone to follow. He believes that resource distribution is not difficult, and centralization would increase the workload for medical professionals.

“You have to do whatever you can to make it easier for people to access medication and distribute resources so they reach more people,” Chanan said.

In the long run, the NHSO is also planning on increasing the number of community clinics that provide PrEP. Yupadee said that the NHSO is planning to register more organizations, a process she said can be difficult as it needs approval from the National Health Commission, but she noted that the number of community-based organizations working on HIV prevention and treatment is now on the rise.

The NHSO is also planning to work with the Network of People Living with HIV/AIDS to found continuum care centres in hospitals to care for HIV-positive people, including follow-up on whether they are taking their anti-viral medication properly and continuously and by working with couples in which one partner is HIV positive and the other is HIV negative to decrease the risk of infection.

Such centres would also work with the communities to raise awareness that AIDS is no different from other chronic health conditions that can be managed with medication, and work to provide treatment for other conditions that often co-exist with HIV, such as Hepatitis C, which Yupadee noted is now curable.

“Right now, the understanding is that HIV is caused partially by stigmatization. The stigma means that people are not open about it. They feel that it’s an illness that’s not okay. If the society stops stigmatizing people, it would be a reason for them to be prepared to enter the system to get tested and get medication,” said Yupadee, who noted that the NHSO also wants to work to end the stigmatization of HIV positive people, and that it may fund civil society organizations using budget from its National Health Security Local Fund to run projects working to prevent illness and decrease the stigma.

“I think, right now, we have to get past this. The community and society have to get past it. They are a member of the society. It’s not like in the past where we stigmatised them or were afraid of infection,” said Yupadee. 

But to ensure that everyone has equal access to healthcare, Thailand may need to combine all of its healthcare schemes into one or facilitate collaboration between the schemes. Chanan said that having several healthcare schemes means there are some overlaps between what is available under the Social Security Scheme, the Universal Care Scheme, and government employee benefits, which is regulated by different legislation and organizations, while they should be collaborating to make healthcare more accessible.

Satayu agrees that there should be one scheme for all, instead of having different systems that can be unequal.

“I think that the Gold Card budget should belong to every Thai person, instead of saying that this is your right and this is my right, that you can’t use my right. No. That’s not how it should be,” Satayu said.

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