1. Engaging All Care Providers in S.E Asia Region A pproach to Health Systems Strengthening Jan Voskens. IUATLD Paris, 31 October 2006

2. Summary 1.Why is ‘engaging all care providers’ a component of the Stop TB Strategy? 2.PPM status, results and evidence of success 3.Tools and guidelines to address barriers for scale up 4.Lessons for health systems strengthening 5.Plans and Next steps

3. Treatment seeking behavior TB patients (Prevalence survey 2004)

4. 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)

5. Task Mix (generic) Source: draft GUIDE ON ENGAGING DIVERSE HEALTH CARE PROVIDERS IN TB CONTROL, StopTB

6. Components of Stop TB Strategy: PPP Focus

7. HBCs with PPM DOTS initiatives, 2006 High burden countries with PPM initiatives High burden countries without PPM pilots High burden countries scaling up PPM

8. 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 sectorBhutan, Maldives No private health care DRR Korea

9. Public health impact of PPM Improves quality of care: success rate above the target of 85% (vs. <50% 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)

11. 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

12. Funding sources Government / Ministries GFATM Fidelis TB CAP Bilateral donors (USAID; CIDA, etc) National and international NGOs Corporate sector

13. 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

14. Different views & perspectives Public Health workers Clinicians In Private sector

15. Barriers to PPP expansion identified in 3 rd 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)

16. Tools and guidelines responding to the barriers identified

17. 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 Netherlands Martien W. Borgdorff, MD, PhD, MSc Borgdorffm@kncvtbc.nl Tel.: +31 70-4167222 Fax: + 31 70-3584004  Documents from WHO PPM projects and PPP Subgroup reports

18. Lessons for Health System Strengthening (1) ‘’Generic’’ constraints in health systems : 1.HR crisis: how to involve human resources available in other sectors? 2.Weak governance / stewardship of MoH, especially vis-à-vis private sector providers 3.Many providers alienated from public health programmes and disease surveillance 4.Patients waste large part of their limited resources (out-of-pocket) on poor quality health care

19. Lessons for Health System Strengthening (2) PPM experiences provide valuable lessons for HIV, malaria & other programs: 1.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

20. Lessons for Health System Strengthening (3) 2.Sensitisation of private and other providers to take on public health tasks including surveillance (standardised recording and reporting) 3.Improved linking and referral systems 4.Standardised quality care services at low cost across the health system

21. Plans & next steps

22. Planned activities to assist scaling up of PPM(1): 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

23. Planned activities to assist scaling up of PPM(2): 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

24. Planned activities to assist scaling up of PPM(3): 3.International Standard for TB Care (ISTC) –Dissemination of ISTC –Inclusion of ISTC in pre- and in-service training –Developing ‘’implementation guide’’ for ISTC

25. 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

26. 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

27. Thank you for your kind attention