Building Public-Private Partnership for Health System Strengthening Working with the Private Sector to Control Tuberculosis April Harding The World Bank Bali Hyatt Hotel, Sanur, Bali June 2010

Patient perceptions & preferences (e.g. convenience, stigma, gender). Inconvenient opening hours & long waiting times Provider attitudes Direct & indirect costs (public treatment) Perceptions of quality of care public facilities drive people away, even when prices are very low or free.

TB – key facts 13,700,000 cases of TB worldwide (2007) 1,770,000 (estimated) TB deaths (2007) The poor & marginalized are the worst affected 95% of cases & 98% of deaths from TB occur in developing & “transition” countries.

Where are people dying from TB?

Asia has the largest TB burden country rankings 1.IndiaIndia 2.ChinaChina 3.IndonesiaIndonesia 4.NigeriaNigeria 5.South AfricaSouth Africa 6.BangladeshBangladesh 7.EthiopiaEthiopia 8.PakistanPakistan 9.PhilippinesPhilippines 10.Democratic Republic of CongoDemocratic Republic of Congo 11.Russian FederationRussian Federation 12.Viet NamViet Nam 13.KenyaKenya 14.BrazilBrazil 15.United Republic of TanzaniaUnited Republic of Tanzania 16.UgandaUganda 17.ZimbabweZimbabwe 18.ThailandThailand 19.MozambiqueMozambique 20.MyanmarMyanmar 21.CambodiaCambodia 22.AfghanistanAfghanistan

TB...a public health program missing many sick people Program success requires:  Catching 70% or more of people sick with TB  Doing accurate diagnosis  Treating properly at least 85% of these people What is being achieved:  of the people control program are reaching, 82% of them are getting correct treatment with DOTs  BUT, globally less than half the people with TB are reached by programs. Progress in TB control has stagnated. Guess why.

No direct data, but several pointers: Health services utilization by TB patients Retail sale of TB drugs Size of the growing private sector Health care expenditure in private sector Low case notification despite program “coverage”

Country Retail Sales Cost / Course Estimated (USD Million) (USD) Cases India Indonesia Pakistan Philippines Bangladesh

India: 75% to 88% of TB patients' first contact was a private provider How private practitioners treat TB patients YearDoctors Regimens What is the problem with people “going private”?

They diagnose badly Tests Patients Urban (%)Rural (%) Sputum alone 0 0 X-ray alone56 78 X-ray + Sputum21 10 Information unavailable23 12

They often manage TB badly Practice Desirable Actual Diagnosis Sputum based X-ray based Treatment Fixed regimens Varied regimens Monitoring DOT No DOT Sputum exam X-ray Evaluation Cure rate None

Many question whether private practitioners can be motivated to change behaviour in necessary ways

Key fact: Target private providers are highly fragmented and dispersed Key finding: Intermediary actors critical (e.g. NGO hospital; Damien Foundation, medical association, existing PHC franchise) Who are the private actors formal private practitioners informal “village health workers” a few hospitals Strategy: harnessing existing private practitioners getting existing private providers to diagnose properly, treat properly & report

 Direct financial incentives not essential  Free drugs (in-kind incentives)  Quality focus (practitioners care!)  Providing access to training & equipment  Professional recognition

Information dissemination is key!

Participating practitioners attract more patients..... ◦ Information campaigns ◦ Branding ◦ Leaflets etc

Global target: 85% success Free drugs Not free drugs Informal practitioners!

Average increase 30%

Source: Katherine Floyd, STB

 Building capacity of control program locally & nationally is critical ◦ National policy / guidelines ◦ Regular drug supply ◦ Supervision capacity  Public-private stakeholder dialogue is critical

 Sensitising public sector staff  Pragmatism & “evidence-based advocacy”  Private sector engagement “network” – supported by STOP TB/ WHO

 "by 2015, to have halted and begun to reverse the incidence of malaria and other major diseases"  Potential contribution of private sector engagement: ◦ Improve treatment success ◦ Increase case-detection under DOTS ◦ Reduce diagnostic delay

Many control programs still implemented only through public sector; Others, at quite small scale

Total expenditure is $70M per year. The amount spent last year working with the private practitioners is $588k. That is, less than 1% of overall program expenditure.

Just because it works, and you have evidence, doesn’t mean it will be scaled up and applied in other countries. The power of? Inertia? Ideology ?

TB and Course Framework Experience shows usefulness of framework in moving from problem identification, to strategy development & implementation. In implementation we learned that key actors are not just private sector but also representative bodies and mid- level policymakers and program managers.

TB Insights Private sector engagement strategy was identified and instruments successfully used to harness a range of private actors – suited to program specifics and local context. Lack of expansion illustrates the significant barriers to private sector engagement....even when program success is impossible without it.

Goal Control TB - Reach TB patients - Proper diagnosis - Effective treatment Public Sector Private Sector Source: Harding & Preker, Private Participation in Health Services, Assessment Stagnant coverage of TB control programs Private sector treats most TB patients Actors Private practitioners Village health workers Diagnostic labs Ownership For-profit small business Non-profit charitable Formal and informal Strategies Harness private practitioners Grow quality lab services Policy Tools Contracting Training/Info Social franchising

Key Sources “Pragmatist-in-chief” Mukund Uplekar, Head of the STOP TB/ WHO initiative to engage the private sector in TB control. Uplekar, M and A Harding, Chapter 4, in “Private Patients: Why health aid fails to reach so many, and what we can do about it” by A. Harding, forthcoming from Brookings/ Center for Global Development Press, Washington DC.

To see the course framework in application to a program & specific goal (e.g. reduction of TB morbidity & deaths) To explore the linkage between private sector omission and program performance To understand the policy instruments used to engage the private sector for TB control To understand how engagement happened in a very public-sector focused global program