Public Private Mix sub group meeting

23 October, 2011

Dr. Thandar Lwin

Programme Manager

National TB Programme, Myanmar

Scale up PPM in Myanmar

CHINA

LAOS

THAILAND

INDIA

BANGLA

DESH

KACHIN

SHAN

SAGAING

CHIN

RAKHINE

MANDALAY

MAGWE

BAGO

AYARWADDY

YANGON

KAYIN

KAYAH

MON

TANINTHARYI

Area - 676,578 sq.km

Regions/States - 14

Districts - 67

Townships - 330

Sub Townships - 60

Wards - 2,781

Village tracts - 13,714

Villages - 64,910

Population - 57 millions

Urban - 30%

Rural - 70%

Myanmar

A major public health problem

Estimated incidence all forms (2010) 384/100,000 pop.

Estimated prevalence of TB (2010) 525/100,000 pop.

Estimated TB mortality (2010) 49/100,000 pop.

(Global TB control: a short update to the 2010 report, WHO, Geneva. 2011)

MDR-TB among new TB patients 4.2% (2007-08)

HIV prevalence among new TB patients 10.4 %

(2010, in 20 sentinel sites)

Magnitude of TB in Myanmar

Achievement of NTP in 2010

Total TB patients notified = 137,403 (CNR = 279/100,000 pop.)

Total smear positive TB patients notified = 48,783 (CNR = 99/100,000 pop.)

New smear positive TB patients notified = 42,318 (CNR = 86/100,000 pop.)

CR = 77%, TSR = 85%

Smear Positive Case Bacteriologically confirm Case

>15 Yrs No. /100,000 95% CI No. /100,000 95% CI

All Participants 123 242.3 (186.1 - 315.3) 311 612.8 (502.2 - 747.6)

Strata Region 70 191.6 (137.4 - 267.3) 192 522.8 (420.9 –649.1)

State 53 369.0 (235.6 - 577.5) 119 838.0 (560.3–1251.5)

Urban/

Rural

Urban 38 330.7 (216.2 – 505.7) 103 903.2 (661.8-1231.5)

Rural 85 216.1 (153.6 – 304.0) 208 526.8

All Age S(+) prevalence 172/100,000 Bac(+) prevalence

434+/100,000

Prevalence of TB among aged 15 years and above (2009-2010)

Background for PPM

• Public-Private Mix-DOTS: PSI and MMA are coordinating with NTP.

• Lab. using by PPs are under EQA (358 public labs + 62 private labs)

• Political commitment - policy on Private- Public Mixed DOT was adopted

in 2003.

• Operational guideline on Public Private Mix was developed by NTP

together with PSI, MMA, JICA and WHO and published in 2005.

• Public-Public Mix-DOTS : 4 Public Hospitals started in 2007

• Other health related department: Ministry of Labors, Ministry of Home

Affairs, Ministry of Defence, Ministry of Railway

• Involvement of INGOs – 11

JATA, UNION, WVI, Pact, AHRN, IOM, Merlin, Malteser, MSF-H,

MSF-Switz, MDM

• Local NGOs – MWAF, MMCWA, MMA, MRCS, MHAA

Current approaches

1. Advocacy meeting and Training on TB control

2. Drugs and lab. Supplies distribution from NTP

3. Endorsement and Dissemination of International Standards for

Tuberculosis Care (ISTC) among Myanmar National Health

Professional Associations

4. Offer of incentives to engage care providers

- NTP - No incentive.

- PSI - To providers, incentives at regular intervals

(transportation, nutrition, money)

- MMA – in kind to PPs, enablers and incentives to patients

5. Supervision, M&E

6. TB screening at work place in collaboration with Occupational Health

7. OR – for involving pharmacies and informal health care providers.

Public Private Mix in Myanmar

• In Public-Public Mix currently there are two main non-NTP care

providers in Myanmar

(1) PSI

(2) MMA

• In collaboration with private parishioners, there are currently three

schemes available for engagement of private parishioners in TB

control:

• Scheme 1-Health Education and proper referral of TB suspects

• Scheme II- Health Education, referral and act as a DOT provider

• Scheme III referral, diagnosis and treatment provision to run an

affiliated DOT clinic

PPM with PSI

• Population Service International (PSI) started the collaboration with

NTP in March 2004.

• PSI organizes the PPs and running the “Sun Quality Clinics’’ as

DOT units.

• PSI is implementing Scheme 3.

• In 2010 - PSI contributed 12.1% of new smear positive pulmonary

TB patients notified to NTP and achieved Treatment Success Rate

- 85%.

Year No. of

Providers

No. of

State/Region

No. of

Township

2004 101 2 24

2005 222 5 48

2006 316 8 70

2007 413 9 100

2008 505 11 120

2009 623 11 145

2010 731 12 168

2011 up to

July 855 13 189

PSI--Area coverage of PPM-DOTS network

10

108 new providers in 23 new townships in 2011

Year

No. of

Private

Lab

No. of

NTP Lab Total

2004 6 6

2005 19 4 23

2006 23 27 50

2007 31 53 84

2008 35 71 106

2009 40 87 127

2010 42 126 168

2011 up to

July 49 144 193

PSI-- Expansion of sputum microscopy centers

11

0

20000

40000

60000

80000

100000

120000

2004 2005 2006 2007 2008 2009 2010

PSI contribution on all type s of B cpatients notified to NTP in project area (2004-2010)

PSI

NTP

7%

11%

13%

12%

11%

15%

15%

0

5000

10000

15000

20000

25000

30000

35000

40000

2004 2005 2006 2007 2008 2009 2010

PSI contribution on new smear (+) TB patients notified to NTP in project area (2004-2010)

PSI

NTP

8%

13%

15%

14% 14%

16%

19%

• Myanmar Medical Association (MMA) started in 2005

• MMA use three schemes:

• In 2010, 70 townships have been covered and 914 PPs are

implementing Scheme 1, 118 PPs are implementing Scheme 3.

• In 2011, MMA is planning to implement in 101 townships.

PPM with MMA

0

2000

4000

6000

8000

10000

12000

14000

2007 2008 2009 2010

5793

6778

8108

12253

410

1577 13862009

MMA (Scheme I) contribution on new smear (+) TB patients notified to NTP in the project area (2007-2010)

NTP

MMA S 1

7%23%

17%

16%

0

2000

4000

6000

8000

10000

12000

14000

16000

2007 2008 2009 2010

69627943

9608

14449

425

1736 15112181

MMA (Scheme 1) contribution on total smear (+) TB patients notified to NTP in the project area (2007-2010)

NTP

MMA S 1

6% 22%

16%

15%

0

500

1000

1500

2000

2500

3000

3500

4000

4500

2009 2010

30153506

557

651

MMA (Scheme III) contribution on new smear( +) TB patients notified to NTP in project area (2009-2010)

MMA S III

NTP

(16%)

(16%)

17.8%

17.5%

(16%)

NTP, 80.8%

Hospital, 3.0%

MSF-H, 2.1%

PSI, 12.1%MMA, 1.6%

MDM, 0.2%AHRN (Shan North), 0.2%

Proportion all forms of TB patients contributed by NTP and other reporting units (2010)

22

Treatment outcomes of PSI-PPM DOTS (2004-2010)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

NTP PSI AZG MMA

Treatment outcome of new smear positive TB pateints 2006

Transferred out Defaulted FaiIure Died TSR Cured

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

NTP PSI AZG MMA

Treatment outcome of new smear positive TB pateints 2007

Transferred out Defaulted FaiIure Died TSR Cured

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

NTP PSI AZG MMA

Treatment outcome of new smear positive TB pateints 2008

Transferred out Defaulted FaiIure Died TSR Cured

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

NTP PSI AZG MMA

Treatment outcome of new smear positive TB pateints 2009

Transferred out Defaulted FaiIure Died TSR Cured

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

NTP PSI AZG MMA

Treatment outcome of new smear positive TB pateints 2010

Transferred out Defaulted FaiIure Died TSR Cured

Public-Public Mix – DOTS

• Public-Public Mix (between NTP and public hospitals)

– 9 general hospitals

- 2 TB hospitals

- Specialist hospitals especially treating HIV patients

- 1 Military hospital

- Workers hospital (TB)

- Central jail, Mandalay

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

2004 2005 2006 2007 2008 2009 2010

30977 36212 39874 42120 40703 40742 41706

431

329

367 468 545 647 612

No

of

NS

(+)

TB

ca

se

s

Years

Hospital Contribution in NTP of NS(+) TB cases

NTP total cases

Hospital total cases

1.4%

0.9%

0.9% 1.1% 1.3% 1.6% 1.5%

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

50000

2004 2005 2006 2007 2008 2009 2010

36615 41559 45614 48531 46508 46969 47866

746

579

743 720 795 908 917

No

of

All S

(+)

TB

cases

Years

Hospital Contribution in NTP of All S(+) TB cases

NTP total cases Hospital total cases

2%

1.4%

1.6% 1.5% 1.7% 1.9% 1.9%

0

20000

40000

60000

80000

100000

120000

140000

2004 2005 2006 2007 2008 2009 2010

95977 106684 121878 131090 125157 130217 133316

1932 1307

1715 2457 3582

3806 4087

No

of

All

typ

e T

B c

as

es

Years

Hospital Contribution in NTP of All type TB cases

NTP total cases Hospital total cases

2%

1.2%

1.4%

1.9% 2.9% 2.9% 3.1%

Engage all care providers

National Workshop on ISTC

(March 4-5, 2009)

Dissemination Workshop on ISTC

(August 31, 2009)

Introduction to Regional level Hospitals : 13 / 17

Major barriers to scaling up engagement

• Weakness in coordination between Practitioners

• Conceptual changes among private doctors

• Limitation in resources

• Operational barriers at all levels – transportation, health

seeking behavior of patients, patient support, etc.

• Requirement of ACSM strategy

Planned actions to scale up /

strengthen engagement

1. NTP

- To scale up of PPM hospitals up to 21 hospitals by 2015

- To disseminate ISTC up to district / township level

- To involve informal health care providers and drug sellers in TB control

- PAL – to do situation analysis and resources mobilization

2. PSI

- To expand 100 SQH clinics, 500 SPH workers, 20-25 townships

annually to achieve 15% of national case detection by 2015.

- To involve informal health care providers and drug sellers

- To initiate TB/HIV prevention and control activities

- Financial/ logistic support to MDR cases in close collaboration with NTP

Planned actions to scale up /

strengthen engagement

1. MMA-TB

- Further scale-up of Scheme III,

- To establish more Private Labs and sputum collection centers

- To engage all care providers

- To intensify community based TB care activities

- To strengthen infection control and TB-HIV prevention and control

activities

- To involve informal health care providers : Pharmacists, Traditional

medicine practitioners

Thank you