1. 1 TB service and Health insurance Extending TB benefit package to help mitigate economic burden of TB patients, Cambodia contex TAG-NTP manager Meeting 9-12/ 12/ 2014,WHO,Manila Dr Mao Tan Eang Director, National Center for TB and Leprosy Control (CENAT) Ministry of Health, Cambodia

2. 2 Outline of the Presentation –Burden of TB in Cambodia –TB Control Infrastructure –NTP achievements –NTP Challenges –TB and health insurance

3. 3 1. Burden of TB in Cambodia Cambodia,15 Million pop with GDP:<USD 1000 per capita, is still one of the 22 HBC with TB in the world Incidence Rate* of all forms of TB for 2012: 411/ 100,000 pop. (~ 61,000 cases/year ) * WHO Global TB Report 2013 Prevalence Rate of all forms* of TB for 2012: 764 / 100,000 pop. * WHO Global TB Report 2013 NTP has achieved the MDG target for this indicator (4 years before schedule) Prevalence Rate of Sm+* for > 15 y in 2011: 272/ 100,000 pop. (*Based on the final result of Prevalence Survey 2011); -it was 437 /100,000 pop. in 200 2: first Prevalence Survey. reduction of 38% in 9 years---an average of 4.2 % per year, quoted in WHO 2012 and UN MDG report 2013 as a best example Death rate*: 63/100,000 pop * WHO Global TB Report 2012 NTP has achieved the MDG target for this indicator (4 years before schedule) HIV Sero-prevalence among TB Patients : 2.5% in 1995, 12% in 2003, 10% in 2005, 7.8% in 2007 and 6.3% in 2009 Estimate of MDR-TB burden in Cambodia (WHO Global TB Report 2012) –Percentage of TB cases with MDR-TB among new smear positive= 1.4% –Percentage of TB cases with MDR-TB among re-treatment cases= 10.5%

4. 4 2. TB Control Infrastructure Central level-CENAT –Hq for the National TB Program with Technical Bureau (30 staff) –Referral TB/Chest Hospital* (130 beds) –National TB Reference Laboratory Provincial level (25) –Provincial TB Supervisors (2 per province) –Provincial Referral Hospitals with TB services= 24 Operational District level (82) (OD TB Supervisors) –Referral Hospitals with TB services : all –Health Centres with TB services= 1089 –TB Microscopic Centres= 215 –HCs with Community DOTS= 577 ( down from 816 in end 2013) Total =1,314 health facilities are providing TB services which includes the 5 National Hospitals including Referral TB/Chest Hospital under CENAT, all in Phnom Penh

5. 5 3. NTP Achievements –DOTS started in 1994, until 1998 DOTS services only available at the hospital level; HC DOTS began in 1999; but massive HC DOTS expansion started in late 2001 and by end of 2004, all HCs had DOTS services –Cases notified increased drastically since the start of HC DOTS expansion. Currently,cases notified seems to be peaking for TB all forms, but declining for sm+ TB cases. 2012 –Smear positive TB cases : 14,838 –All Forms of TB 40,258 2013 –Smear positive TB cases : 14,082 –All Forms of TB 39,055 Cure rate has been maintained over 90% for the last decade 10 years 2004-2013:cases notified under NTP : All forms; 379,819 Sm+ : 178,538 --------  prevalence reduced by 4-5% per year MoH has just received award from USAID: a “Champion in Global fight against TB”

6. 6 TB Case Notification, 1982-2013

7. 7 7 TB Incidence-notification gap, Cambodia

8. 8 4. Challenges for NTP High prevalence,incidence and death rates New and more ambitious goals/targets(2014-2020,2021-2035) in line with global strategies (end TB epidemics) Case detection gap: missing cases~ 1/3(~20,000 cases undetected) vs UHC goal Resources to maintain and expand existing and new services Majority of NTP budget comes from donors/partners( ~75 %)

9. 9 5. TB services & Health insurance: Existing health insurance /social protection schemes and coverage Schemes/projects coveragecomments Health equity fund (HEF) 58 / 82 districts MoH & Donors : Social protection schemes run by NGO operators for the poor(40% fund from government,60% donor) Community based health insurance ~ 3 % For non-poor and informal sector, run by NGOs, very small premium Private health insurance (Forte,..) ? Main clients: NGO/IO staff,..,run by private insurance companies National social security fund(NSSF) Most formal private employees? Ministry of Labor & vocational training,formal sector employees

10. 10 TB patient health care & social package Diagnosis (sputum examination, X-ray,…) Anti-biotics before TB diagnosis Treatment ( anti-TB drugs) Care for additional/co-morbidity Transport to health facilities( diagnosis,treatment…) Nutritional support (patients/relatives) ……

11. 11 Existing service benefits in public services Services/benefitsNTPHealth facility HEF Sputum examination (direct,culture,DST) X (Free of charge policy) Antibioticts X:+/- Xray Free policy+/_ Anti-TB drugs (1 st,2 nd line) Free policy Transport X: MDR and some children/care takers X: for patients/care takers with ID poor only

12. 12 NTP Health facility HEF Food for IPD for TB patient X (all IPD TB patients) Food for patients and care takers X mainly for IPD funeral For poorest patients

13. 13 TB services in private sector PPM-DOTS cover 27 operational districts (total ODs=82) Private providers just refer TB suspects to public providers

14. 14 Challenges for expanding health insurance benefits to TB patients Knowing the real situation ( Who are relevant actors?TB Cost lost along the acre pathway,including at private sector ? Benefit package? etc..) TB free of charge policy VS HEF (e.g those without ID poor, not all TB patients have poor ID cards) Any possible linkage with private health insurance or other schemes/projects? How to work with the complex interface (integratable / harmonizable/workable areas) around UHC different components/angles? Who do what and who pay?...etc..

15. 15 Some thoughts for managing additional benefits to help mitigate economic burden of TB patients Policy direction on comprehensive package /UHC for TB patients within overall UHC Clear joint inclusive/comprehensive implementation plan linked to each partner’s overall plan,e.g 3 year plan Clear roles of each stakeholders Private sector providers? Practical lead/coordinating department/body for coordination,M&E etc Next step: follow up and come up with practical plan ********