Public Private Mix sub group meeting 23 October, 2011 Scale up PPM in Myanmar Dr. Thandar Lwin Programme Manager National TB Programme, Myanmar
Myanmar INDIA KACHIN BANGLA DESH CHIN RAKHINE SAGAING MAGWE MANDALAY BAGO SHAN KAYAH AYARWADDY YANGON KAYIN MON CHINA LAOS THAILAND Area - 676,578 sq.km Regions/States - 14 Districts - 67 Townships - 330 Sub Townships - 60 Wards - 2,781 Village tracts - 13,714 Villages - 64,910 Population - 57 millions TANINTHARYI Urban - 30% Rural - 70%
Magnitude of TB in Myanmar A major public health problem Estimated incidence all forms (2010) Estimated prevalence of TB (2010) Estimated TB mortality (2010) 384/100,000 pop. 525/100,000 pop. 49/100,000 pop. (Global TB control: a short update to the 2010 report, WHO, Geneva. 2011) MDR-TB among new TB patients 4.2% (2007-08) HIV prevalence among new TB patients 10.4 % (2010, in 20 sentinel sites)
Achievement of NTP in 2010 Total TB patients notified = 137,403 (CNR = 279/100,000 pop.) Total smear positive TB patients notified = 48,783 (CNR = 99/100,000 pop.) New smear positive TB patients notified = 42,318 (CNR = 86/100,000 pop.) CR = 77%, TSR = 85%
Prevalence of TB among aged 15 years and above (2009-2010) Smear Positive Case Bacteriologically confirm Case >15 Yrs No. /100,000 95% CI No. /100,000 95% CI All Participants 123 242.3 (186.1-315.3) 311 612.8 (502.2-747.6) Strata Region 70 191.6 (137.4-267.3) 192 522.8 (420.9 649.1) State 53 369.0 (235.6-577.5) 119 838.0 (560.3 1251.5) Urban/ Rural Urban 38 330.7 (216.2 505.7) 103 903.2 (661.8-1231.5) Rural 85 216.1 (153.6 304.0) 208 526.8 All Age S(+) prevalence 172/100,000 Bac(+) prevalence 434+/100,000
Background for PPM Political commitment - policy on Private- Public Mixed DOT was adopted in 2003. Operational guideline on Public Private Mix was developed by NTP together with PSI, MMA, JICA and WHO and published in 2005. Public-Private Mix-DOTS: PSI and MMA are coordinating with NTP. Lab. using by PPs are under EQA (358 public labs + 62 private labs) Public-Public Mix-DOTS : 4 Public Hospitals started in 2007 Other health related department: Ministry of Labors, Ministry of Home Affairs, Ministry of Defence, Ministry of Railway Involvement of INGOs 11 JATA, UNION, WVI, Pact, AHRN, IOM, Merlin, Malteser, MSF-H, MSF-Switz, MDM Local NGOs MWAF, MMCWA, MMA, MRCS, MHAA
Current approaches 1. Advocacy meeting and Training on TB control 2. Drugs and lab. Supplies distribution from NTP 3. Endorsement and Dissemination of International Standards for Tuberculosis Care (ISTC) among Myanmar National Health Professional Associations 4. Offer of incentives to engage care providers - NTP - No incentive. - PSI - To providers, incentives at regular intervals (transportation, nutrition, money) - MMA in kind to PPs, enablers and incentives to patients 5. Supervision, M&E 6. TB screening at work place in collaboration with Occupational Health 7. OR for involving pharmacies and informal health care providers.
Public Private Mix in Myanmar In Public-Public Mix currently there are two main non-ntp care providers in Myanmar (1) PSI (2) MMA In collaboration with private parishioners, there are currently three schemes available for engagement of private parishioners in TB control: Scheme 1-Health Education and proper referral of TB suspects Scheme II- Health Education, referral and act as a DOT provider Scheme III referral, diagnosis and treatment provision to run an affiliated DOT clinic
PPM with PSI Population Service International (PSI) started the collaboration with NTP in March 2004. PSI organizes the PPs and running the Sun Quality Clinics as DOT units. PSI is implementing Scheme 3. In 2010 - PSI contributed 12.1% of new smear positive pulmonary TB patients notified to NTP and achieved Treatment Success Rate - 85%.
PSI--Area coverage of PPM-DOTS network Year No. of Providers No. of State/Region No. of Township 2004 101 2 24 2005 222 5 48 2006 316 8 70 2007 413 9 100 2008 505 11 120 2009 623 11 145 2010 731 12 168 2011 up to July 855 13 189 108 new providers in 23 new townships in 2011 10
PSI-- Expansion of sputum microscopy centers Year No. of Private Lab No. of NTP Lab Total 2004 6 6 2005 19 4 23 2006 23 27 50 2007 31 53 84 2008 35 71 106 2009 40 87 127 2010 42 126 168 2011 up to July 49 144 193 11
120000 100000 80000 PSI contribution on all type s of B cpatients notified to NTP in project area (2004-2010) 15% 11% 12% 13% 15% 60000 40000 7% 11% PSI NTP 20000 0 2004 2005 2006 2007 2008 2009 2010
40000 35000 30000 PSI contribution on new smear (+) TB patients notified to NTP in project area (2004-2010) 14% 14% 16% 19% 25000 20000 15000 10000 5000 8% 13% 15% PSI NTP 0 2004 2005 2006 2007 2008 2009 2010
PPM with MMA Myanmar Medical Association (MMA) started in 2005 MMA use three schemes: In 2010, 70 townships have been covered and 914 PPs are implementing Scheme 1, 118 PPs are implementing Scheme 3. In 2011, MMA is planning to implement in 101 townships.
MMA (Scheme I) contribution on new smear (+) TB patients notified to NTP in the project area (2007-2010) 14000 12000 16% 12253 10000 8000 6000 7% 5793 23% 6778 17% 8108 NTP MMA S 1 4000 2000 0 1577 1386 2009 410 2007 2008 2009 2010
MMA (Scheme 1) contribution on total smear (+) TB patients notified to NTP in the project area (2007-2010) 16000 14000 15% 14449 12000 10000 8000 6000 6% 6962 22% 7943 16% 9608 NTP MMA S 1 4000 2000 0 1736 1511 2181 425 2007 2008 2009 2010
MMA (Scheme III) contribution on new smear( +) TB patients notified to NTP in project area (2009-2010) (16%) 4500 4000 3500 3000 2500 2000 1500 1000 500 0 (16%) 651 557 3015 3506 2009 2010 MMA S III NTP
17.8% 17.5%
(16%)
Proportion all forms of TB patients contributed by NTP and other reporting units (2010) PSI, 12.1% MMA, 1.6% MDM, 0.2% AHRN (Shan North), 0.2% MSF-H, 2.1% Hospital, 3.0% NTP, 80.8% 22
Treatment outcomes of PSI-PPM DOTS (2004-2010)
Treatment outcome of new smear positive TB pateints 2006 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% NTP PSI AZG MMA Transferred out Defaulted FaiIure Died TSR Cured
Treatment outcome of new smear positive TB pateints 2007 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% NTP PSI AZG MMA Transferred out Defaulted FaiIure Died TSR Cured
Treatment outcome of new smear positive TB pateints 2008 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% NTP PSI AZG MMA Transferred out Defaulted FaiIure Died TSR Cured
Treatment outcome of new smear positive TB pateints 2009 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% NTP PSI AZG MMA Transferred out Defaulted FaiIure Died TSR Cured
Treatment outcome of new smear positive TB pateints 2010 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% NTP PSI AZG MMA Transferred out Defaulted FaiIure Died TSR Cured
Public-Public Mix DOTS Public-Public Mix (between NTP and public hospitals) 9 general hospitals - 2 TB hospitals - Specialist hospitals especially treating HIV patients - 1 Military hospital - Workers hospital (TB) - Central jail, Mandalay
No of NS(+) TB cases Hospital Contribution in NTP of NS(+) TB cases 45000 367 0.9% 468 545 647 612 1.1% 1.3% 1.6% 1.5% 40000 329 0.9% 35000 431 1.4% 30000 25000 20000 15000 30977 36212 39874 42120 40703 40742 41706 10000 5000 0 2004 2005 2006 2007 2008 2009 2010 NTP total cases Hospital total cases Years
No of All S(+) TB cases Hospital Contribution in NTP of All S(+) TB cases 50000 45000 40000 746 2% 579 1.4% 743 1.6% 720 795 908 917 1.5% 1.7% 1.9% 1.9% 35000 30000 25000 20000 15000 10000 5000 36615 41559 45614 48531 46508 46969 47866 0 2004 2005 2006 2007 2008 2009 2010 Years NTP total cases Hospital total cases
No of All type TB cases Hospital Contribution in NTP of All type TB cases 140000 1715 1.4% 2457 3582 1.9% 2.9% 3806 4087 2.9% 3.1% 120000 1932 2% 1307 1.2% 100000 80000 60000 40000 20000 95977 106684 121878 131090 125157 130217 133316 0 2004 2005 2006 2007 2008 2009 2010 Years NTP total cases Hospital total cases
Engage all care providers National Workshop on ISTC (March 4-5, 2009) Dissemination Workshop on ISTC (August 31, 2009) Introduction to Regional level Hospitals : 13 / 17
Major barriers to scaling up engagement Weakness in coordination between Practitioners Conceptual changes among private doctors Limitation in resources Operational barriers at all levels transportation, health seeking behavior of patients, patient support, etc. Requirement of ACSM strategy
Planned actions to scale up / strengthen engagement 1. NTP - To scale up of PPM hospitals up to 21 hospitals by 2015 - To disseminate ISTC up to district / township level - To involve informal health care providers and drug sellers in TB control - PAL to do situation analysis and resources mobilization 2. PSI - To expand 100 SQH clinics, 500 SPH workers, 20-25 townships annually to achieve 15% of national case detection by 2015. - To involve informal health care providers and drug sellers - To initiate TB/HIV prevention and control activities - Financial/ logistic support to MDR cases in close collaboration with NTP
Planned actions to scale up / strengthen engagement 1. MMA-TB - Further scale-up of Scheme III, - To establish more Private Labs and sputum collection centers - To engage all care providers - To intensify community based TB care activities - To strengthen infection control and TB-HIV prevention and control activities - To involve informal health care providers : Pharmacists, Traditional medicine practitioners
Thank you