Engaging

All Care Providersin S.E Asia Region

Approach to Health Systems Strengthening

Jan Voskens. IUATLD Paris, 31 October 2006

Summary

1. Why is ‘engaging all care providers’ a component of the Stop TB Strategy?

2. PPM status, results and evidence of success

3. Tools and guidelines to address barriers for scale up

4. Lessons for health systems strengthening

5. Plans and Next steps

Treatment seeking behavior TB patients

(Prevalence survey 2004)Initiation of TB Treatment in Indonesia

0%

10%

20%

30%

40%

50%

60%

SumatraEastern IslandsJava

Sumatra 44% 43% 12%

Eastern Islands 31% 53% 16%

Java 49% 21% 29%

Start treatment: Hospitals

Start treatment: Health Centers

Start treatment Private

Practitioners

Private and Public Partners

• Hospitals: China, Indonesia

• Private Practitioners: India, Indonesia, Bangladesh, Philippines, Myanmar etc

• Medical colleges: India, Indonesia

• NGO facilities and Community Based Organizations

• Corporate sector (workplaces): all countries

• Public sector providers other then MoH: other Ministries, prisons Health Insurance facilities etc. (India, Indonesia, Bangladesh, Philippines)

Possible

Task

Government / NTP Public or private

PPM DOTS agency Individual private physician, public hospital or clinic

Private or public laboratory

Non-physician / pharmacy

Refer TB suspects

Recording

Supervise treatment

Sputum microscopy

Make a diagnosis

Clin

ical

func

tions

Prescribe treatment

Retrieve defaulters

Training and Supervision

Reporting

Quality assurance

Drug supply

Pub

lic h

ealth

func

tions

Stewardship: financing and regulation

Task Mix (generic)

Source: draft GUIDE ON ENGAGING DIVERSE HEALTH CARE PROVIDERS IN TB CONTROL, StopTB

Components of Stop TB Strategy: PPP Focus

HBCs with PPM DOTS initiatives, 2006

High burden countries with PPM initiativesHigh burden countries with PPM initiatives

High burden countries without PPM pilotsHigh burden countries without PPM pilots

High burden countries scaling up PPM High burden countries scaling up PPM

PPM Situation in Member Countries in SEAR

National policy and guidelines in place, scaling up

India, Indonesia,

Myanmar, Nepal

National policy in place, Widespread involvement of NGOs; pilots involving PPs

Bangladesh

Formative stage Sri Lanka, Thailand,

Timor-Leste

No anti-TB drugs in private sector Bhutan, Maldives

No private health care DRR Korea

Public health impact of PPM

• Improves quality of care: success rate above the target of 85% (vs. <50% in non-DOTS)

• Increases case detection: 10-50% increase !• Reaches the poor:

– Bangalore study: 50% of patients were from the lowest socioeconomic strata (of 3 SES groups)

– Myanmar study: 67% of patients treated by private GPs were from the two lowest socioeconomic groups (of 5 )

• Financial protection: 50-100 US $ reduction for patients in India (compared to private non-DOTS)

(over 30 evaluated initiatives in more than 20 countries)

Is PPM cost effective?

• Cost effectiveness of PPM has clearly been demonstrated in studies from India, Philippines and South Africa .

• PPM-DOTS can be affordable and cost-effective compared to treatment provided through NTP similar or lower cost per patient treated similar or better cost-effectiveness

Funding sources

• Government / Ministries

• GFATM

• Fidelis

• TB CAP

• Bilateral donors (USAID; CIDA, etc)

• National and international NGOs

• Corporate sector

Challenges:

• Building trust• Combining approaches:

“Public Health’’ – ‘’Clinical’’ • Scaling up successful pilots• Investments in HRD

All hands on deck !!All hands on deck !!expanding Quality DOTS in other sectors expanding Quality DOTS in other sectors

to curb MDRto curb MDR

Different views & perspectives

Public Health workers

Clinicians In Private sector

Barriers to PPP expansion identified in 3rd Subgroup Meeting 2005

• Lack of commitment of NTP and MoH• Limited capacity of NTP (staff numbers,

time, motivation, skills)• Lack of tools:

– Guidelines– Training materials and tools– Advocacy tools

• Limited technical support (regional, global)

Tools and guidelines

responding

to the barriers identified

1. PPM guidelines and documents

Technical Application

Tuberculosis Control Assistance Program

(TB CAP)

RFA Solicitation Number: M-OAA-GH-HSR-05-1015

Submitted To:

United States Agency for International Development

Ronald Reagan Building, 7.09-064

1300 Pennsylvania Avenue, N.W.

Washington, D.C. 20523

Submitted By:

KNVC Tuberculosis Foundation

Riouwstraat 7, The Hague

Netherlands

Martien W. Borgdorff, MD, PhD, MSc

Borgdorffm@kncvtbc.nl

Tel.: +31 70-4167222

Fax: + 31 70-3584004

Documents from WHO PPM projects and PPP Subgroup reports

Lessons for Health System Strengthening (1)

‘’Generic’’ constraints in health systems :1. HR crisis: how to involve human resources

available in other sectors?

2. Weak governance / stewardship of MoH, especially vis-à-vis private sector providers

3. Many providers alienated from public health programmes and disease surveillance

4. Patients waste large part of their limited resources (out-of-pocket) on poor quality health care

Lessons for Health System Strengthening (2)

PPM experiences provide valuable lessons for HIV, malaria & other programs:

1.Building capacity in public sector to engage other care providers (private-, hospitals, prisons, army etc.)– Practical approaches to map out and work with other

providers, – Management framework to involve other sectors (steps)– Proper compensation / incentive schemes for various

providers, etc

Lessons for Health System Strengthening (3)

2. Sensitisation of private and other providers to take on public health tasks including surveillance (standardised recording and reporting)

3. Improved linking and referral systems

4. Standardised quality care services at low cost across the health system

Plans & next steps

Planned activities to assist scaling up of PPM(1):

1. Technical assistance for PPM Country planning:– Development of ‘’generic’’ PPM strategies &

operational guidelines(based on Stop TB Strategy, Global and Regional plans, "PPM Guidance Document", ISTC, the "Planning and budgeting tool", situational analysis tool, etc

– Development of national PPM strategies and guidelines,

– PPM planning workshops in regions– Advocacy for PPM to catalyze wider

implementation

Planned activities to assist scaling up of PPM(2):

2. HRD:– More staff needed (focal points/ external TA)– Regional training for focal points and

national PPM consultants – PPM consultant course: April 2007, Sondalo

(11-18) – Training of NTP staff on interacting with

partners at operational level

Planned activities to assist scaling up of PPM(3):

3. International Standard for TB Care (ISTC)– Dissemination of ISTC– Inclusion of ISTC in pre- and in-service

training– Developing ‘’implementation guide’’ for ISTC

Planned activities to assist scaling up of PPM (4):

4. Hospital linkage, public-public mix

– Postgraduate course on hospital-linkage, (IUATLD ’06)

– Development of operational guidelines for hospital-linkage, including workshop in Asia 2007

Planned activities to assist scaling up of PPM (5):

5. Monitoring and Evaluation – Include assessment of PPM in every program

review– Encourage use of PPM indicators– OR on selected issues (e.g. cost-

effectiveness, TB-HIV, DOTS plus etc)– Document new and on-going PPM initiatives

Thank you for your kind attention