International workshop, 20-22 Jun 07 Naresuan University ... Sector Reform and Public... ·...
Transcript of International workshop, 20-22 Jun 07 Naresuan University ... Sector Reform and Public... ·...
Successes, scope & limitations of Public-Private
partnerships in Asia. Experiences from TB control
& beyond.International workshop, 20-22 Jun 07
Naresuan University, Phitsanulok, Thailand
Dr Firdosi. R. Mehta Medical Officer TB, WHO Indonesia
Contents
• Global & Regional situation of TB control
• PPM – Chronology & Evolution
• Country experiences
• Conclusions
TB Control-- GoalsAchieve full coverage with DOTS, reach (2005) and then sustain/surpass the 70% case detection and 85% treatment success targets among new cases (WHA 54)
• By 2010:– To halve TB deaths and prevalence (cf 1990 levels)
• By 2015: – “to have halted and begun to reverse the incidence”( MDG’s - Goal 6, Target 8, Indicator 23+24)
• By 2050:– To have eliminated TB ( Incid <1/million pop)
TB incidence rates per capita
25 to 4950 to 99100 to 299
< 1010 to 24
300 or moreNo Estimate
per 100 000 population
TB in SE Asia5 m prevalent cases3 m new cases and 500 000 deaths/ yr
~150,000 new MDR-TB cases/yr
~ 2.5 - 3 million TB-HIV co-infected
The new Stop TB Strategy and the Regional Strategic Plan, 2006-2015
– Sustaining and enhancing DOTS to reach all TB patients, improve case detection and treatment success
– Establishing interventions to address TB/HIV and MDR-TB
– Forging partnerships, including with communities, to ensure equitable access to international standards of TB care for all
– Contributing to strengthening health systems
Global targets: what has been achieved in the SEA Region?
• Full coverage with DOTS– 15 million patients treated over past 10 years– Nearly 2 million TB patients registered for treatment annually
• 64% case detection and 87% treatment success rates in the Region as a whole (2005)
• Emerging evidence in some settings of falling prevalence, deaths due to TB
50%
60%
70%
80%
90%
100%
0% 20% 40% 60% 80% 100%
DOTS detection rate
Trea
tmen
t suc
cess
rate
1997 1998 1999 2000 20012002 2003 2004 2005
Targetzone
Trends in estimated TB incidence rates (all forms, black lines), and the annual change in incidence rates (red lines), for nine sub-regions and the world, 1990–2005
Established Market Economies
0
5
10
15
20
25
30
1990 1992 1994 1996 1998 2000 2002 2004
Inci
denc
e ra
te (p
er 1
00 0
00/y
ear)
-10
-8
-6
-4
-2
0
2
Cha
nge
in in
cide
nce
rate
(% p
er y
ear)
Central Europe
0
20
40
60
1990 1992 1994 1996 1998 2000 2002 2004
Inci
denc
e ra
te (p
er 1
00 0
00/y
ear)
-20
-15
-10
-5
0
5
10
Cha
nge
in in
cide
nce
rate
(% p
er y
ear)
Latin America
0
30
60
90
120
1990 1992 1994 1996 1998 2000 2002 2004
Inci
denc
e ra
te (p
er 1
00 0
00/y
ear)
-8
-6
-4
-2
0
2
4
Cha
nge
in in
cide
nce
rate
(% p
er y
ear)
Eastern Mediterranean
0
30
60
90
120
150
180
1990 1992 1994 1996 1998 2000 2002 2004
Inci
denc
e ra
te (p
er 1
00 0
00/y
ear)
-20
-12
-4
4
12
20
Cha
nge
in in
cide
nce
rate
(% p
er y
ear)
South- East Asia
0
50
100
150
200
250
1990 1992 1994 1996 1998 2000 2002 2004
Inci
denc
e ra
te (p
er 1
00 0
00/y
ear)
-0.5
0
0.5
1
Cha
nge
in in
cide
nce
rate
(% p
er y
ear)
Western Pacific
0
50
100
150
1990 1992 1994 1996 1998 2000 2002 2004
Inci
denc
e ra
te (p
er 1
00 0
00/y
ear)
-4
-2
0
2
Cha
nge
in in
cide
nce
rate
(% p
er y
ear)
Eastern Europe
0
30
60
90
120
1990 1992 1994 1996 1998 2000 2002 2004
Inci
denc
e ra
te (p
er 1
00 0
00/y
ear)
-5
0
5
10
15
20
25
Cha
nge
in in
cide
nce
rate
(% p
er y
ear)
Africa - low HIV
0
50
100
150
200
250
1990 1992 1994 1996 1998 2000 2002 2004
Inci
denc
e ra
te (p
er 1
00 0
00/y
ear)
-10
-5
0
5
10
15
20
25
Cha
nge
in in
cide
nce
rate
(% p
er y
ear)
Africa - high HIV
0
100
200
300
400
500
1990 1992 1994 1996 1998 2000 2002 2004In
cide
nce
rate
(per
100
000
/yea
r)-10
-5
0
5
10
15
20
Cha
nge
in in
cide
nce
rate
(% p
er y
ear)
200
220
240
260
280
300
1990 1995 2000 2005
23
25
27
29
31
33
1990 1995 2000 2005120
125
130
135
140
1990 1995 2000 2005
Estimated global prevalence, mortality and incidence rates, 1990–2005
Prevalence
Mortality Incidence
PPM - Chronology
1999-2000 Global Assessment2000-2001 Informal global consultations & advocacy2001-2002 Documentation of field initiatives2002-2003 Outcomes analysis & Practical tools;
Subgroup established; First meeting held2003-2006 Economic analysis; Regional and
Country strategies; Selective scale-up;Four Subgroup meetings
Evolution
Why?Achieve targets Improve access and equity and
strengthen health systemsWhat?Engage private providers Engage all care providers
Where? Where PPs manage TB All settings
How?Within the DOTS framework Within the Stop TB Strategy
(ISTC; TB/HIV; MDR-TB)
When?When DOTS is working well When there is mutual willingness
Why work with the private sector?
• Outnumber public sector providers in Asia and rapidly growing in Africa
• Manage large proportions of TB suspects and cases, serving even the very poor in many settings
• For-profit, impose enormous financial burden on patients
• No mandatory continuing medical education
• No regulation or monitoring
• No systematic licensing or re-certification
Hospital & BP4Primary Health Care Private PracticionersSUMATRA 44% 43% 12%KTI 31% 53% 16%JAVA 49% 21% 29%
Initiation of treatment
Treatment seeking practices in patients with hx of TB (Indonesia TB Prevalence survey 2004)
Hospital & BP4Primary Health Care Private PracticionersSUMATRA 49% 38% 9%KTI 22% 58% 16%JAVA 47% 25% 27%
Ending of treatment
Treatment seeking practices in patients with hx of TB (Indonesia TB Prevalence survey 2004)
Health-seeking behaviorif having TB symptoms population has intention to go to…
66.1
49.4
41.9
14.310.7 8.9
0
10
20
30
40
50
60
70
80
Puskesmas Priv Pract Gov Hosp Priv Hosp Midwife Self-treatm
SumatraJava-BaliKTINational
Jak/Jogy41%
Jakarta48%
Substantial Provincial differences:
1st and 2nd line TB drug market by country
Ref: Global alliance for TB drug development, May 2007. Pathway to patients: Charting the dynamics of the global TB Drug Market.
PPM - What benefits for TB control?
• Improve quality of TB care
• Increase case detection
• Improve treatment outcomes
• Enhance access and equity
• Reduce financial burden on patients
• Cost-effectiveness
Key references on PPM benefits• Floyd K, Arora VK, Murthy KJR, et al. Cost and cost-effectiveness of public and
private sector collaboration in tuberculosis control: evidence from India. Bulletin of WHO 2006; 84: 437-45.
• Dewan PK, Lal SS, Lönnroth K, et al. Public-Private Mix in India: Improving Tuberculosis Control Through Intersectoral Partnerships. BMJ 2006; 332: 574-8
• Salim MAH, Uplekar M, Declercq E, et al. Turning liabilities into resources: the informal village doctors and TB control in Bangladesh. Bulletin of WHO 2006; 84: 479-84.
• Lönnroth K, Uplekar M, Blanc L. Hard gains through soft contracts - productive engagement of private providers in tuberculosis control. Bulletin of WHO 2006; 84: 876-83.
• Lönnroth K, Tin-Aung, Win-Maung, et al. Social franchising of TB care through private general practitioners in Myanmar - an assessment of access, quality of care, equity, and financial protection Health Policy and Planning 2007; 22: 156-66.
• Engaging all health care providers in TB control - guidance on implementing public-private mix approaches. Geneva: World Health Organization, 2006 (WHO/HTM/TB/2006.360): http://whqlibdoc.who.int/hq/2006/WHO_HTM_TB_2006.360_eng.pdf
A potential role for every providerPossible
Task
Government / NTP Local public or
private institution (DOTS agency)
Individual physician or
hospital
Private laboratory Non-physician / pharmacy
Refer TB suspects
Supervise treatment
Recording
Sputum microscopy
Make a diagnosis
Clin
ical
func
tions
Prescribe treatment
Retrieve defaulters
Training
Epi reporting
Quality control
Drug supply
Publ
ic h
ealth
func
tions
Stewardship: financing and regulation
Expectations from participating providers
• Follow basic DOTS principles and use International Standards
• Undertake the tasks that they can carry out
• Provide quality assured anti-TB drugs free of charge to their patients
• Keep fees for tests and consultations at a minimum
• Accept supervision by and reporting to NTP
Expectations from the public sector
• Provide training adapted to the needs and conditions of the providers
• Provide drugs, equipment and stationary free of charge
• Coordinate, supervise, control quality
• Use intermediaries such as NGO or medical association
Possible "contractual" mechanisms
• Informal agreements
• Memoranda of Understanding
• Contracting
• Certification / accreditation
• Social franchising
• Reimbursement through TB-specific insurance package
• Non-financial incentives are as (if not more) important as financial (most TB initiatives have no direct financial incentives to providers)
Treatment outcomes in PPM projects
0
20
40
60
80
100
Delhi, I
ndiaLali
tpur, N
epal
Hydera
bad, In
dia
Makati
, Philip
pinesKera
la, In
diaNair
obi, Ken
yaMumbai,
India
Yogya
, Indone
sia
Weighted
avera
ge
PP busine
ss as
usual
Public
secto
r DOTS
Com
plet
ed tr
eatm
ent (
%)
New S+All new
Impact on case detection
PPM Site
Baseline Rate
Increase
Evaluation Approach
Hyderabad 50/100,000 23% Compared to neighbouring TU Delhi 60/100,000 36% Change controlled Kannur 25/100,000 15% Change in same TU Lalitpur 54/100,000 61% Change in same area HCMC 100/100,000 18% Change controlled Punalur 25/100,000 50% Change in same TU Thane 50/100,000 14% Change in same TU Mumbai 55/100,000 19% Change in same TU
Average increase30%
Evidence base
Over 20 countries with PPM experienceOver 20,000 patients evaluated Treatment success around 80-90%Improved case detection in all projects
Reaches the poorCost-effective
Reduces burden for patients
0%
20%
40%
60%
80%
2001 2002 2003 2004
Effect on case detection trend in PPM areas
63.7% - NTP
71.7% - NTP+PPM
Philippines
Courtesy: Dr R Vianzon, NTP, Philippines
Indonesia
Courtesy: Dr Jan Voskens, KNCV, Indonesia
0
200
400
600
800
1000
1200
1400
Num
ber o
f new
cas
es
SS+ SS
-EP
SS+ SS
-EP
SS+ SS
-EP
SS+ SS
-EP
SS+ SS
-EP
SS+ SS
-EP
2000 2001 2002 2003 2004 2005
Case Notification Yogyakarta 2000 - 2005ChestClinicsHospitals
Healthcenters
14 intensified urban PPM sites in IndiaSummary of contribution by different health sectors
1st – 4th Quarter of 2005 (12 months)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
TB suspects referred All sm+ cases diagnosed New s+ cases detected No. of patients providedDOT
State Govt. Other Govt. Medical College Corp. Sector Pvt. Practitioners NGOs
N=362330 N=48056 N=25105 N=73202
NGO guidelines
PP training module includes ISTC
RNTCP advocacy kit
India: Tools for PPM-DOTS
PP guidelines
Guidance on PPM TB
1. National situation assessment
2. Creating national resources
3. Implementing PPM
3.1. Developing operational guidelines• Formulating objectives• Defining task mix• Developing practical tools• Training• Certification• Incentives and enablers• Surveillance and monitoring
3.2. Guidance on local implementation• Preparation• Mapping • Selection of providers• Implementation proper• Advocacy and communication
3.3. Scaling up
PPM DOTS : Situation in Member Countries
• National policy and guidelines in place, scaling up
• National policy in place, Widespread involvement of NGOs; pilots involving PPs
• Formative stage
• No anti-TB drugs in private sector
• No private health care
India, Indonesia, Myanmar, Nepal
Bangladesh
Sri Lanka, Thailand, Timor-Leste
Bhutan, Maldives
DPR Korea
Some lessons for policy
• PPM should not mean privatisation:• Requires strengthened public sector capacity to govern/steer private
sector health care provision• Privately provided services should be mainly publicly funded, with free
drugs distributed through national programme as a minimum
• There is a wide spectrum of providers to consider - from university hospitals to traditional healers: all can have a role, and their roles will be different depending on provider capacity and local needs
• Private sector constitutes a largely untapped human resource pool that could be more effectively utilised for public health
• PPM strategy should be based on a patient perspective: involve providers that people utilise, especially those that are utilised by the poor
• Often simple solutions are possible (e.g. informal contracts based on local dialogue), but collaboration modalities depend on local context and type of provider
Patient and attendant costsPatient costs
Consultations (outpatient)HospitalizationInvestigations (laboratory, X-ray, other e.g. MRI)DrugsTime taken to access treatmentWages lost by patientDays lost from work by patientDays lost from studies (e.g. school/college) by patientInterest paid on loansOthers
Attendant costsTransportationTime taken to accompany patientWages lostDays lost from studies (e.g. school/college)Other
Cost effectiveness study - conclusions
1. PPM-DOTS can be affordable and cost-effective
2. Private sector making substantial contribution in both sites
raises question of whether level of contribution (uncompensated by the public sector) is generalisable and/or sustainable)
3. Strong economic case for expansion of PPM projects such as those implemented in Hyderabad and Delhi
4. Economic evaluation of other PPM projects, and of scaling up, would be useful
TB EpidemicDOTS
HIV Epidemic
Number of MDR among new and re-treatment TB cases2005 estimate
< 10001000 – 10 00010 000 – 50 000More than 50 000No estimate
MDR-TB control practises• Few NTPs manage
MDR-TB and have appropriate national guidelines
• Private practitioners and health providers not linked to NTPs treat MDR-TB in many countries
• Widespread (mis)use of second-line drugs could lead to the development and circulation of incurable TB strains
Estimated TB prevalence (a) and death rates (b), by WHO region, for the MDG baseline year 1990, for 2005, and
compared with the MDG target for 2015
0
100
200
300
400
500
600
AFR AMR EMR EUR SEAR WPR World
1990 2005 Target
0
20
40
60
80
100
AFR AMR EMR EUR SEAR WPR World
1990 2005 Target
(a) TB prevalence rate per 100 000 population (b) TB death rate per 100 000 population
MDG Goal 6, Target 8, Indicator 23+24 – On track?
• The Global Plan
• The Regional Plan
• Country Plans
A pessimist sees the difficulty in every opportunity: an optimist sees the opportunity in every difficulty.Sir Winston Churchill