1. PPM-DOTS in Cambodia Working with Private Pharmacies DOTS Expansion WG Meeting Paris 15 th October 2008 Dr. Mao Tan Eang Director National Center for TB and Leprosy Control (CENAT) MoH, Cambodia

2. Presentation Outline Background Rationale for PPM-DOTS Goal and Objectives for PPM Main Strategies for PPM-DOTS with Private Sector Achievement (up to June 2008) Key activities with Pharmacies Future plan PPM-DOTS partners

3. I. Background In 2005 the National Tuberculosis Program (NTP) began to engage private providers in TB control. The NTP with support from their partners developed the Public-Private Mix (PPM) strategy (phase I & Phase II) and PPM-DOTS in prisons and Factories. PPM-DOTS in prisons and Factories still at pilot phase. During Phase I, with USAID funds and JICA, NTP and partners designed and implemented a referral network between private health providers and pharmacies where symptomatic individuals seek care and public sector DOTS facilities in pilot provinces.

4. II. Rationale Cambodia is among the 22 TB high burden countries Approximately two-thirds of all Cambodians are infected with TB, and around 13,000 Cambodians die annually from the disease NTP focus on reducing morbidity and death rates due to tuberculosis, a key strategy for improving the overall health of the population To align with the WHO Global strategy for TB control The private sector is accessible with two thirds of Cambodians seeking care outside the public sector for their first visit with TB symptoms

5. III. Goal and Objectives for PPM Goal: To test-out and scale–up a public-private mixed DOTS partnership model that aims to strengthen both, the public and private sectors in TB case management and increase case detection Objectives: Reduce diagnostic delay for people with suspected TB, increase case detection, and decrease the opportunity for multi-drug resistant Strengthen public-private linkages & partnerships in TB case management and control through a referral system to public DOTS services Improve access to quality DOTS services for people seeking care at the private sector providers by implementing DOTS services in private clinics and hospitals qualified by NTP (Phase II)

6. IV. Main Strategies for PPM-DOTS with Private Sector PPM-DOTS Phase I: Private sector only responsible for referring TB suspects to public sector PPM-DOTS Phase II: Private sector (excluding pharmacy and lab) can diagnose and treat TB patients ( not yet implemented)

7. V. Achievements (3 years up to June 2008) Service coverage: - PPM-DOTS available in 11 provinces and 38 Operational Districts (OD) (total provinces : 24, total OD:77 in the country) - Private Clinics : 488 - Private Pharmacies : 896 : Service provision : By clinicsBy pharmaciesTotal TB suspects referred 3130944712577 TB suspects arrived: 206143426403 TB cases identified 5748441418

9. Phase I Strategy Private lab Community Private clinic Public Hospital Health Center Referral System Diagnosis, Treatment, Recording & Reporting Pharmacy /Depot CHVs

10. VI. PPM-DOTS with Pharmacies 1. Key activities Develop PPM strategy Identify and engage private sector partner (Pharmacists Association of Cambodia : PAC) Review and revise national recording and reporting forms Develop standardized referral tools Develop IEC and training curriculums Develop Memorandum of Understanding agreements

11. Organize a sensitization workshop for public and private-public providers and sign MoU agreements Train Province and District TB supervisors to deliver pharmacy staff training Build capacity for national, Province and District TB staff on PPM and supervision of private sector Train pharmacy and DOTS health center staff Conduct quarterly Public-Private Partner meetings Facilitate pharmacy staff field visits to DOTS services Conduct monthly supportive supervision and data collection

12. 2. Main indicators Number of TB suspects referred from the pharmacy to the DOTS health center Number of TB suspects presenting at DOTS health center with referral from pharmacy Number of All types of TB identified among TB suspects referred from pharmacies Number of smear positive TB cases identified among TB suspects referred from pharmacies

13. 3. TB PPM sites (Private Pharmacies) 2005-2008 11 provinces 38 ODs 476 Health centers 30 Referral hospitals 896 pharmacies Kandal Phnom Penh

14. 4. Strengths Strong support from Pharmacist Association (attending meeting/WS and M&E etc ) Referrals from pharmacies in PPM areas are yielding high percentages of smear-positive TB cases out of those being evaluated, so that there is a clear benefit to involving pharmacies in TB case detection During this period 9,447 referrals were made of which 4,509 attended DOTS services and 844 were diagnosed to have TB. This result suggests that the pharmacies are an excellent location to identify undiagnosed cases.

15. 5. Weaknesses  Overall, the proportion of TB suspects referred from the private pharmacies and the actual number who received follow-up at the public TB-DOTS facilities remains at around 50%  Based on the project follow-up results, there are some contributing factors to the lack of follow–up such as inadequate communication and recording system.  Some private pharmacy staff do not provide clear information to the TB suspects in order for them to choose the most convenient location of DOTS facility.  Limited incentives to both service providers  linkage with other NGO network in and outside the PPM target areas is still limited

16. VII. Conclusion & Future Plan PPM-DOTS has contribution to overall TB case detection-contribution goes beyond concrete number of TB cases identified Evaluation after 3 year implementation Introduction of PPM-DOTS phase II (from 2009) Resource mobilization for maintaining and scaling up activities (GFATM,USAID…) Involve more professional associations Expand DOTS in prison and factories

17. VIII. Major Partners for PPM-DOTS USAID PATH ( with Pharmacies) JICA URC RHAC CATA GFATM (from 2009 ) Ministry of national Defense Ministry of Interior Ministry of Labor Pharmacist Association of Cambodia Medical Association of Cambodia Cambodia Medical Council

18. Comments/Questions mao@online.com.kh