tuberculosis care and support through the private sector ... · sector in india market-based...

Market-based

Partnerships for Health

Tuberculosis Care

and Support

through the Private

Sector in India

Market-based


and the Way Forward

Oommen George, Technical Specialist

Abt Associates (India)

June, 2012

Market-based


Outline

June 2012 Private Sector Participation in TB Control (India) 2

USAID|India initiative to enable participation of private

healthcare providers in the Revised National Tuberculosis

Control Program (RNTCP) in India

Presentation Outline

• Market-based Partnerships for Health (MBPH; TB Initiative)

o Background and MBPH coverage

o MBPH: TB model

o MBPH: Program results

o MBPH: Lessons learned

• Opportunities for TB care and support in India Illustrations: Ananth Shankar

Photographs: Oommen George

Market-based



Background &

Coverage

Market-based


Need for Engagement of Private Sector in RNTCP

• Private practitioners are preferred by most 1st

time health consumers This sector cannot, & must not, be ignored

• Most TB patients „shop‟ with several healthcare

providers Delay in effective treatment & increased risk of drug resistance

• Very few private healthcare providers follow

national or international standards of TB care Increased cost, morbidity, mortality & risk of drug resistance


Market-based


Geographical Coverage: 2 States – UP & Karnataka


Market-based


Target Groups


Provider:

Private providers catering to

urban slum populations

Consumer:

Urban slum populations

Market-based



The MBPH-TB

Model

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The (Demonstration) Model

Care & Support

Capacity Building

ACSM

1. Increased & early case finding

2. improved treatment compliance

Provider-Patient

Interface

Public-Private

Interface


Market-based


National Support for Local Implementation

• Model design, program planning, strategy development

• Research – baseline consumer and provider, „delay‟ study

• MIS – web-based, client-specific (first time in India for TB)

• Capacity building tools & methodology

• Technical assistance, supervision and monitoring

• Program evaluation (by USAID)


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Program Results: Uttar Pradesh

• Public-private

relationships could

not be built

• Only outputs

(outcomes reported could not

be validated without public

sector support)


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Program Results

(Karnataka

State)

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Target Groups Reached (April-11 to Feb-12)


Providers Engaged No.

Allopaths Sensitized 616

(Allopaths Trained) #(333)

ISMH Sensitized 258

LTFQ Sensitized 57

Chemist Sensitized 560

Total

Sensitized/Trained 1,491

Allopaths networked 291

ISMH networked 170

LTFQ networked 28

Chemists networked 0

Total Networked 489

Communication: Total

Person Contacts 538,599

A networked homeopath

in Karnataka, who is also

a DOT provider

Interpersonal communication

(above) & a community

awareness meeting (below) in

Karnataka

# Not counted in total

Market-based


Key Consumer End-line (EL) over Base-line (BL) Findings


56.4%

88.1%

0%

20%

40%

60%

80%

100%

BL EL

CS who went to a provider

26% 31%

0% 0% 0% 0%

24% 20%

35%

51%

1% 0% 1% 1%

10%

2%

0%

20%

40%

60%

80%

100%

Baseline Endline

*

*

* *

* Significantly (p=<0.05) different from BL: N = 681 (BL: N = 1515)

CS – Chest Symptomatic

*

Type of provider first

visited by CS

Market-based


Consumer Awareness of RNTCP Logo (at EL over BL)


Significant increase (at EL) in

proportion of CS who

identified logo with TB

program/hospital

*Significantly (p=<0.05)

different from BL

N: EL = 681; BL = 1515)

5.2%

17.6%

77.3%

37.3%

0.0%

62.3%

0%

20%

40%

60%

80%

100%

TB program/hospital Heard, do not knowwhat it stands for

Not aware of DOTSlogo

*

*

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Summary of Consumer EL Findings over BL


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End-line Provider Survey Findings


N: CS (BL: 1515, EL: 681);

Allopaths (BL: 255,

EL:144);

ISMH (BL= 193, EL= 127);

LTFQ (BL:70, EL:25)

CS: Chest Symptomatics

BL: Baseline, EL: Endline

* Significantly (p≤0.05)

different from baseline

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Sputum Microscopy Trends (Jan-10 to Dec-11)


0

1000

2000

3000

4000

5000

6000

7000

8000

9000

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Total no. of CS tested at DMCs

No. of CS from MBPH slums tested

MBPH

Intervention

Trend showing numbers of CS tested each month at DMCs from Jan-2010

to Dec-2011: Data source: RNTCP Lab registers of all 75 DMC engaged by MBPH

Market-based


Impact of MBPH on Sputum Microscopy


Comparison of numbers of

CS tested at DMCs – total &

from MBPH slums – during

Apr-Dec 2010 & 2011

Data source: RNTCP Lab Registers of

all 75 DMC engaged by MBPH

0

10000

20000

30000

40000

50000

60000

70000

80000

Total no. of CS tested No. of CS from MBPH slumstested

Apr-Dec: 2010

Apr-Dec: 2011

Change

13%

Change

72%

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Contribution to TB Detection from Intervention Slums


1,5

88

4,2

88

2,5

30

1,3

16

542 1,0

87

Market-based


Impact of MBPH on case Detection


0

5000

10000

15000

20000

25000

All TB Cases Detected atTU

All TB Cases Belonging toMBPH Slums Detected

Apr-10 to Feb-11

Apr-11 to Feb-12

Change

8%

Change

38%


all type of TB patients

detected – total & from

MBPH slums – during Apr-

10 to Feb-11 & Apr-11 to

Feb-12 Data source: RNTCP TB

Registers of all MBPH TUs (56)

0

2000

4000

6000

8000

10000

NSP Cases Detected at TU NSP Cases Belonging toMBPH Slums Detected

Apr-10 to Feb-11

Apr-11 to Feb-12

Change

2%

Change

65%


NSP TB patients detected –

total & from MBPH slums –

during Apr-10 to Feb-11 &

Apr-11 to Feb-12 Data source: RNTCP TB

Registers of all MBPH TUs (56)

Market-based


Case Detection Trend – Before & After Intervention


0

50

100

150

200

250

300

350

Trend of monthly case detection from intervention slums prior to MBPH

Trend of monthly case detection from intervention slums during MBPH

No. of TB cases (of all type) detected each month from MBPH slums 150

140

130

120

110

100

90

80

70

60

50

40

30

20

10

0

Market-based



? Lessons

Learned

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Lessons from Uttar Pradesh

• A public-private partnership model cannot work when

public sector involvement is weak, absent or counter-

productive

• A private-private partnership may be considered in such

states. However, this is likely to require:

o Outsourcing of all services to private sector players

o Re-creation of infrastructure, HR, MIS, supply & logistics

o Long-tern government or donor support at national level

o Higher cost of procurement of private services


Market-based


Factors Contributing to Results in Karnataka (1)

• Integration with the national program

Avoids confusion among consumers

Enhances national efforts

• Public sector commitment & support

Synergy (“1 + 1 = 3”)

• The model was robust & comprehensive

Meaningful for TB patients/families


Market-based


Factors Contributing to Results in Karnataka (2)

• Inclusion of health consumer & provider communities,

rather than of individual; reasonable scale

Fewer transactions, greater efficiency

• Inclusion of all type of private providers (allopaths, ISMH,

LTFQ & chemists) using innovative tools to build capacity

High contribution/referral from non-allopath providers

• ‘Interface’ (public-private & provider-patient)

Enables bridging of serious gaps in healthcare access and

service delivery


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Next

Steps?

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Context: RNTCP National Strategic Plan (2012-17)

Goal: Universal Access to quality TB diagnosis and

treatment for all TB patients in the community

Priorities:

• Ensure early and improved diagnosis of all TB patients

• Improve patient-friendly access to high-quality treatment

for all diagnosed cases of TB

• Re-engineer and optimize programme systems

• Enhancing supervision, monitoring, surveillance and

programme operations


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Taking MBPH Conclusions Forward

• Continue demonstration – with improvements

o Making care & support worthwhile for private providers

o Progressive reductions in cost/client

• Advocate for NGO interface for TB-PPM

• Advocate for comprehensive services


Market-based



The next generation

may receive the

highest standards

of care & support

from healthcare

providers of their

choice … with our assistance

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