Engaging All Care Providers in S.E Asia Region Approach to Health Systems Strengthening

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Engaging All Care Providersin S.E Asia
RegionApproach to Health Systems Strengthening

• Jan Voskens.
• IUATLD Paris, 31 October 2006

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Summary

• Why is engaging all care providers a component
  of the Stop TB Strategy?
• PPM status, results and evidence of success
• Tools and guidelines to address barriers for
  scale up
• Lessons for health systems strengthening
• Plans and Next steps

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Treatment seeking behavior TB patients (Prevalence
survey 2004)
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Private and Public Partners

• Hospitals China, Indonesia
• Private Practitioners India, Indonesia,
  Bangladesh, Philippines, Myanmar etc
• Medical colleges India, Indonesia
• NGO facilities and Community Based Organizations
• Corporate sector (workplaces) all countries
• Public sector providers other then MoH other
  Ministries, prisons Health Insurance facilities
  etc. (India, Indonesia, Bangladesh, Philippines)

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Task Mix (generic)
Source draft GUIDE ON ENGAGING DIVERSE HEALTH
CARE PROVIDERS IN TB CONTROL, StopTB
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Components of Stop TB Strategy PPP Focus
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HBCs with PPM DOTS initiatives, 2006
High burden countries without PPM pilots
High burden countries with PPM initiatives
High burden countries scaling up PPM
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PPM Situation in Member Countries in SEAR
National policy and guidelines in place, scaling up India, Indonesia, Myanmar, Nepal
National policy in place, Widespread involvement of NGOs pilots involving PPs Bangladesh
Formative stage Sri Lanka, Thailand, Timor-Leste
No anti-TB drugs in private sector Bhutan, Maldives
No private health care DRR Korea
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Public health impact of PPM

• Improves quality of care success rate above the
  target of 85 (vs. lt50 in non-DOTS)
• Increases case detection 10-50 increase !
• Reaches the poor
• Bangalore study 50 of patients were from the
  lowest socioeconomic strata (of 3 SES groups)
• Myanmar study 67 of patients treated by private
  GPs were from the two lowest socioeconomic groups
  (of 5 )
• Financial protection 50-100 US reduction for
  patients in India (compared to private non-DOTS)
• (over 30 evaluated initiatives in more than 20
  countries)

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Is PPM cost effective?

• Cost effectiveness of PPM has clearly been
  demonstrated in studies from India, Philippines
  and South Africa .
• PPM-DOTS can be affordable and cost-effective
  compared to treatment provided through NTP
• similar or lower cost per patient treated
• similar or better cost-effectiveness

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Funding sources

• Government / Ministries
• GFATM
• Fidelis
• TB CAP
• Bilateral donors (USAID CIDA, etc)
• National and international NGOs
• Corporate sector

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Challenges

• Building trust
• Combining approaches Public Health
  Clinical
• Scaling up successful pilots
• Investments in HRD
• All hands on deck !!
• expanding Quality DOTS in other sectors
• to curb MDR

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Different views perspectives
Public Health workers
Clinicians In Private sector
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Barriers to PPP expansion identified in 3rd
Subgroup Meeting 2005

• Lack of commitment of NTP and MoH
• Limited capacity of NTP (staff numbers, time,
  motivation, skills)
• Lack of tools
• Guidelines
• Training materials and tools
• Advocacy tools
• Limited technical support (regional, global)

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Tools and guidelines

• responding
• to the barriers identified

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1. PPM guidelines and documents

• Technical Application
• Tuberculosis Control Assistance Program
• (TB CAP)
• RFA Solicitation Number M-OAA-GH-HSR-05-1015
• Submitted To
• United States Agency for International
  Development
• Ronald Reagan Building, 7.09-064
• 1300 Pennsylvania Avenue, N.W.
• Washington, D.C. 20523
• Submitted By
• KNVC Tuberculosis Foundation
• Riouwstraat 7, The Hague

• Documents from WHO PPM projects
• and PPP Subgroup reports

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Lessons for Health System Strengthening (1)

• Generic constraints in health systems
• HR crisis how to involve human resources
  available in other sectors?
• Weak governance / stewardship of MoH, especially
  vis-à-vis private sector providers
• Many providers alienated from public health
  programmes and disease surveillance
• Patients waste large part of their limited
  resources (out-of-pocket) on poor quality health
  care

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Lessons for Health System Strengthening (2)

• PPM experiences provide valuable lessons for
  HIV, malaria other programs
• Building capacity in public sector to engage
  other care providers (private-, hospitals,
  prisons, army etc.)
• Practical approaches to map out and work with
  other providers,
• Management framework to involve other sectors
  (steps)
• Proper compensation / incentive schemes for
  various providers, etc

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Lessons for Health System Strengthening (3)

• Sensitisation of private and other providers to
  take on public health tasks including
  surveillance (standardised recording and
  reporting)
• Improved linking and referral systems
• Standardised quality care services at low cost
  across the health system

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Plans next steps
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Planned activities to assist scaling up of
PPM(1)

• Technical assistance for PPM Country planning
• Development of generic PPM strategies
  operational guidelines
• (based on Stop TB Strategy, Global and Regional
  plans, "PPM Guidance Document", ISTC, the
  "Planning and budgeting tool", situational
  analysis tool, etc
• Development of national PPM strategies and
  guidelines,
• PPM planning workshops in regions
• Advocacy for PPM to catalyze wider implementation

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Planned activities to assist scaling up of
PPM(2)

• HRD
• More staff needed (focal points/ external TA)
• Regional training for focal points and national
  PPM consultants
• PPM consultant course April 2007, Sondalo
  (11-18)
• Training of NTP staff on interacting with
  partners at operational level

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Planned activities to assist scaling up of
PPM(3)

• International Standard for TB Care (ISTC)
• Dissemination of ISTC
• Inclusion of ISTC in pre- and in-service training
• Developing implementation guide for ISTC

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Planned activities to assist scaling up of PPM
(4)

• 4. Hospital linkage, public-public mix
• Postgraduate course on hospital-linkage, (IUATLD
  06)
• Development of operational guidelines for
  hospital-linkage, including workshop in Asia 2007

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Planned activities to assist scaling up of PPM
(5)

• 5. Monitoring and Evaluation
• Include assessment of PPM in every program review
• Encourage use of PPM indicators
• OR on selected issues (e.g. cost-effectiveness,
  TB-HIV, DOTS plus etc)
• Document new and on-going PPM initiatives

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Thank you for your kind attention