TB service and Health insurance Extending TB benefit package to help mitigate economic burden of TB patients, Cambodia contex

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TB service and Health insuranceExtending TB
benefit package to help mitigate economic burden
of TB patients, Cambodia contex

• TAG-NTP manager Meeting
• 9-12/ 12/ 2014,WHO,Manila
• Dr Mao Tan Eang
• Director, National Center for TB and Leprosy
  Control (CENAT)
• Ministry of Health, Cambodia

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Outline of the Presentation

• Burden of TB in Cambodia
• TB Control Infrastructure
• NTP achievements
• NTP Challenges
• TB and health insurance

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1. Burden of TB in Cambodia

• Cambodia,15 Million pop with GDPltUSD 1000 per
  capita, is still one of the 22 HBC with TB in the
  world
• Incidence Rate of all forms of TB for 2012 411/
  100,000 pop. ( 61,000 cases/year ) WHO
  Global TB Report 2013
• Prevalence Rate of all forms of TB for 2012 764
  / 100,000 pop.
  
  
  WHO Global TB Report 2013
• NTP has achieved the MDG target for
  this indicator (4 years before schedule)
• Prevalence Rate of Sm for gt 15 y in 2011 272/
  100,000 pop. (Based on the final result of
  Prevalence Survey 2011) -it was 437 /100,000
  pop. in 200 2 first Prevalence Survey.
• reduction of 38 in 9 years---an
  average of 4.2 per year, quoted in WHO 2012 and
  UN MDG report 2013 as a best example
• Death rate 63/100,000 pop WHO Global TB
  Report 2012
• NTP has achieved the MDG target for this
  indicator (4 years before schedule)
• HIV Sero-prevalence among TB Patients 2.5 in
  1995, 12 in 2003, 10 in 2005, 7.8 in 2007 and
  6.3 in 2009
• Estimate of MDR-TB burden in Cambodia (WHO Global
  TB Report 2012)
• Percentage of TB cases with MDR-TB among new
  smear positive 1.4
• Percentage of TB cases with MDR-TB among
  re-treatment cases 10.5

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2. TB Control Infrastructure

• Central level-CENAT
• Hq for the National TB Program with Technical
  Bureau (30 staff)
• Referral TB/Chest Hospital (130 beds)
• National TB Reference Laboratory
• Provincial level (25)
• Provincial TB Supervisors (2 per province)
• Provincial Referral Hospitals with TB services
  24
• Operational District level (82) (OD TB
  Supervisors)
• Referral Hospitals with TB services all
• Health Centres with TB services 1089
• TB Microscopic Centres 215
• HCs with Community DOTS 577 ( down from 816 in
  end 2013)
• Total 1,314 health facilities are providing TB
  services which includes the 5 National Hospitals
  including Referral TB/Chest Hospital under CENAT,
  all in Phnom Penh

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3. NTP Achievements

• DOTS started in 1994, until 1998 DOTS services
  only available at the hospital level HC DOTS
  began in 1999 but massive HC DOTS expansion
  started in late 2001 and by end of 2004, all HCs
  had DOTS services
• Cases notified increased drastically since the
  start of HC DOTS expansion. Currently ,cases
  notified seems to be peaking for TB all forms,
  but declining for sm TB cases.
• 2012
• Smear positive TB cases 14,838
• All Forms of TB 40,258
• 2013
• Smear positive TB cases 14,082
• All Forms of TB 39,055
• Cure rate has been maintained over 90 for the
  last decade
• 10 years 2004-2013cases notified under NTP All
  forms 379,819
• 
  Sm 178 ,538 --------?
• prevalence reduced by 4-5 per year
• MoH has just received award from USAID a
  Champion in Global fight against TB

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TB Case Notification, 1982-2013

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TB Incidence-notification gap, Cambodia
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4. Challenges for NTP

• High prevalence,incidence and death rates
• New and more ambitious goals/targets(2014-2020
  ,2021-2035) in line with global strategies (end
  TB epidemics)
• Case detection gap missing cases 1/3(20,000
  cases undetected) vs UHC goal
• Resources to maintain and expand existing and new
  services
• Majority of NTP budget comes from
  donors/partners( 75 )

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5. TB services Health insurance Existing
health insurance /social protection schemes and
coverage
Schemes/projects coverage comments
Health equity fund (HEF) 58 / 82 districts MoH Donors Social protection schemes run by NGO operators for the poor(40 fund from government,60 donor)
Community based health insurance 3 For non-poor and informal sector, run by NGOs, very small premium
Private health insurance (Forte,..) ? Main clients NGO/IO staff,..,run by private insurance companies
National social security fund(NSSF) Most formal private employees? Ministry of Labor vocational training ,formal sector employees
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TB patient health care social package

• Diagnosis (sputum examination, X-ray,)
• Anti-biotics before TB diagnosis
• Treatment ( anti-TB drugs)
• Care for additional/co-morbidity
• Transport to health facilities(
  diagnosis,treatment)
• Nutritional support (patients/relatives)

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Existing service benefits in public services
Services/benefits NTP Health facility HEF
Sputum examination (direct,culture,DST) X (Free of charge policy)
Antibioticts X/-
Xray Free policy/_
Anti-TB drugs(1st,2nd line) Free policy
Transport X MDR and some children/care takers X for patients/care takers with ID poor only
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NTP Health facility HEF
Food for IPD for TB patient X (all IPD TB patients)
Food for patients and care takers X mainly for IPD
funeral For poorest patients For poorest patients
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TB services in private sector

• PPM-DOTS cover 27 operational districts (total
  ODs82)
• Private providers just refer TB suspects to
  public providers

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Challenges for expanding health insurance
benefits to TB patients

• Knowing the real situation (Who are relevant
  actors?TB Cost lost along the acre pathway
  ,including at private sector ? Benefit package?
  etc..)
• TB free of charge policy VS HEF(e.g those without
  ID poor, not all TB patients have poor ID cards)
  
• Any possible linkage with private health
  insurance or other schemes/projects?
• How to work with the complex interface
  (integratable / harmonizable/workable areas)
  around UHC different components/angles?
• Who do what and who pay?...etc..

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Some thoughts for managing additional benefits
to help mitigate economic burden of TB patients

• Policy direction on comprehensive package /UHC
  for TB patients within overall UHC
• Clear joint inclusive/comprehensive
  implementation plan linked to each partners
  overall plan ,e.g 3 year plan
• Clear roles of each stakeholders
• Private sector providers?
• Practical lead/coordinating department/body for
  coordination,ME etc
• Next step follow up and come up with practical
  plan
•