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

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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