9th Meeting of the Subgroup on Public-Private Mix for TB Care and Control

&

Global Workshop on Engaging Large Hospitals

28-30 August 2013, Bangkok, Thailand

PPM in Myanmar Dr Thin Thin Nwe, NTP

Presentation overview

• NTP Myanmar background

• PPM Background

• Engagement of GPs (PSI and MMA)\

• Public-public mix (hospitals)

• Engagement of implementing partners

• PPM results

• Future plans

CHINA

LAOS

THAILAND

INDIA

BANGLA

DESH

KACHIN

SHAN

SAGAING

CHIN

RAKHINE

MANDALAY

MAGWE

BAGO

AYARWADDY

YANGON

KAYIN

KAYAH

MON

TANINTHARYI

Area (km2) - 676,578

Regions/States - 17

Districts - 69

Townships - 330

Sub Townships - 82

Wards - 3,040

Village tracts - 13,267

Villages - 67,285

Population - 59.78 m

Urban - 30%

Rural - 70%

Myanmar

Magnitude of TB in Myanmar • TB is a major public health problem

• Myanmar is one of the 22 HBCs 27 high MDR-TB countries 41 high TB/HIV countries

. Est. Annual Risk of TB Infection (ARTI)

1972 - 1.66%,

1994 - 1.5%

• 2011 disease burden (2012 Global TB Report): – Est. incidence (all forms): 381/100,000/year – Est. prevalence (all forms): 506/100,000 – Est. mortality: 48/100,000

• HIV prevalence in TB (2012 HIV sentinel survey): 9.7%

TB epidemiology, Myanmar (2011)

Mortality

Prevalence

Incidence

6 6

39 43 44

55

66

70 73

83

95

86

89 87 95

76 77

84 82

83 81 82 82 82 81 84

85

85

85 85 85

86 86

0

10

20

30

40

50

60

70

80

90

100

2000 2005 2010

%

Year

Trend in Case Detection Rate & Treatment Success Rate of the Myanmar NTP, 1997-2012

CDR New SS+

TSR

Target reset

Achievements in 2012: Total case notification: 148,149 (or 251/100,000) Smear-positive case notification: 42,910 (or 73/100,000)

PPM in Myanmar: background • Policy on PPM DOTS: 2003 • Operational guidelines for PPM DOTS: 2005 • Engagement of GPs through (2) NGOs [PSI and MMA]

and (3) schemes: – Scheme 1: health education and suspect referral – Scheme 2: health education, suspect referral, DOT – Scheme 3: referral, diagnosis, treatment, DOT

• Engagement of private laboratories: – 79 labs under EQA (plus 386 public labs)

• Engagement of public hospitals: – 4 in 2007 → 23 in 2013

• Other ministries: Labour, Home Affairs, Defence

Partners of NTP 1. Myanmar Women Affairs Federation (MWAF).

2. Myanmar Maternal & Child Welfare Association (MMCWA)

3. Myanmar Medical Association (MMA)

4. Myanmar Red Cross Society (MRCS)

5. Myanmar Health Assistant Association (MHAA)

International NGOs 1. Population Services International (PSI) 2. MSF - Holland 3. Malteser International 4. World Vision Myanmar 5. Japan Anti-TB Association (JATA) 6. International Organization of Migration (IOM) 7. Asia Harm Reduction Network (AHRN) 8. Merlin 9. Pact Myanmar 10. Union 11. Progeto 12. Cesvi 13. MSF – Switzerland 14. MDM 15. FHI 360

Local NGOs

UN Agencies

Bilateral Agencies

1. World Health Organization (WHO)

1. Japan International Cooperation Agency (JICA)

PPM by PSI • Population Services International or PSI is US-based

NGO

• Collaboration with NTP since 2004

• PSI organized GPs through “Sun Quality Clinic” as DOT unit

• Coverage: 189 townships in 13 states/regions

894 GPs in Scheme 3

• Achievements: contributed 16% of national case finding (2012) Treatment success rate 85%

PSI: service delivery for PPM DOTS 2004 2008

Scheme 3 Scheme 1 HE, DOT, contact tracing

PSI: Area coverage of PPM-DOTS (2012)

Channel Townships No. of

providers

SQHC 185 894

SPH 68 1627

TB REACH (IPC) 38 60

TB REACH (Pharmacy)

38 526

No. of private lab

No. of NTP lab

Total

53 152 205 SQH only

SUN (SQH/SPH)

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

50000

2004 2005 2006 2007 2008 2009 2010 2011 2012

PSI contribution on new smear (+) TB patients notified to NTP in project area (2004-2012)

PSI

NTP

8%

13%

15%

14% 14%

16%

19%

PPM by MMA • Myanmar Medical Association or MMA

started PPM activities in 2005 • MMA uses (3) Schemes:

– Scheme 1: health education, suspect referral – Scheme 2: health education, referral, DOT – Scheme 3: referral, diagnosis, treatment, DOT

• Coverage in 2012: – 116 townships in 11 states/regions – Scheme 1 by 1266 GPs – Scheme 2 by 2 GPs – Scheme 3 by 175 GPs

PPM coverage by MMA

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

2009 2010 2011 2012

3015 3506

70068401

557651

797

864

MMA (Scheme III) contribution on new smear( +) TB patients notified to NTP in project area (2009-2012)

MMA S III

NTP+other unit

(16%) (16%)

(10%)

(11 %)

PPM Contribution 2012

Provider group No. of

townships

New smear-

positive

All forms Contribution

of all forms

MMA 24 863 3,086 2%

PSI 189 7,205 23,793 16%

Subtotal GPs 8,068 26,879 18%

MSF-H 14 997 3,678 2.5%

MSF-CH 4 289 565 0.38%

MDM 4 11 112 0.07%

AHRN 5 137 336 0.24%

Subtotal INGOs 1,434 4,691 3.2%

PPM hospitals (17) 630 4,278 2.9%

Total 10,132 35,878 24.21%

NTP 76%

PSI 16%

PPM hospitals 2.9%

MSF-H 2.5%

MMA 2%

MSF-CH 0.38%

AHRN 0.22%

MDM 0.07%

Proportion of all form of TB patients contributed by NTP and other reporting units (2012)

0%

20%

40%

60%

80%

100%

120%

Treatment outcomes of new smear positive TB patients, by PPM partner, 2011 cohort

Transfer

Defaulter

Failure

Died

Completed

Cured

Public-public mix DOTS

Hospital engagement

• Aim: – to strengthen link between public TB centres and public

hospitals within framework of DOTS strategy

• 4 hospitals in 2007 → 23 hospitals in 2013

– General hospitals: 12 – TB hospitals: 3 (including workers hospitals) – HIV hospitals: 2 – Military hospitals: 2 – Prison hospital: 1 (Mandalay) – Children hospitals: 3

Hospital engagement: process

• Advocacy meeting in each hospital

• Two-day training for relevant hospital staff

• Set-up of Hospital DOTS Committee

– Chair: Medical Superintendent

– Members: Heads of clinical departments

• Set-up of Hospital PPM DOTS Unit

– Coordinator: Assistant Medical Superintendent

– Roles identified of laboratory technician, nurses, pharmacist, social worker

Hospital engagement: (4) options

• Option 1: diagnosis, treatment prescription, referral to NTP for DOT, clinical follow-up • Option 2: diagnosis, treatment prescription, referral to NTP for DOT • Option 3: diagnosis, treatment initiation, referral to NTP during treatment • Option 4: diagnosis, full treatment from hospital

• Only Options 3 and 4 are in use

Hospital engagement: functioning

• DOTS corner • Logistics management • Recording and reporting • Monitoring • Supervision • EQA for hospital laboratory

• → improved accessibility and reduced out-of pocket expenditures

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

2004 2005 2006 2007 2008 2009 2010 2011 2012

30977 36212 39874 42120 40703 40742 41706 41762

42402

431

329 367 468 545

647 612 573

597

No

of

NS(

+) T

B c

ase

s

Years

Hospital Contribution in NTP of NS(+) TB cases (2004-2012)

Hospital total cases NTP total cases

0

20

40

60

80

100

2004 2005 2006 2007 2008 2009 2010 2011 2012

98.6 99.1 99.1 98.9 98.7 98.4 98.5 98.6 98.1

1.4 0.9 0.9 1.1 1.3 1.6 1.5 1.4 1.9

(%

)

Years

Hospital Contribution in NTP of NS(+) TB cases by Percentage (2004-2012 )

Hospital

NTP

0

20000

40000

60000

80000

100000

120000

140000

160000

2004 2005 2006 2007 2008 2009 2010 2011 2012

95977 106684 121878 131090 125157 130217 133316 139351

143999

1932

1307

1715

2457 3582 3806 4087

3813

4150

No

of

All

typ

e TB

cas

es

Years

Hospital Contribution in NTP of All type TB cases (2004-2012 )

Hospital total cases NTP total cases

0

20

40

60

80

100

2004 2005 2006 2007 2008 2009 2010 2011 2012

98 98.8 98.6 98.1 97.1 97.1 96.9 97 97

2 1.2 1.4 1.9 2.9 2.9 3.1 3 3

(%)

Years

Hospital Contribution in NTP of All type TB cases by percentage (2004-2012)

Hospital NTP

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

50000

2004 2005 2006 2007 2008 2009 2010 2011 2012

36615 41559 45614 48531 46508 46969 47866 48112 48789

746

579743

720795 908 917 900 870

No

of

All

S(+

) T

B c

ase

s

Years

Hospital Contribution in NTP of All S(+) TB cases (2004-2012)

Hospital total cases NTP total cases

0

20

40

60

80

100

2004 2005 2006 2007 2008 2009 2010 2011 2012

98.0 98.6 98.4 98.5 98.3 98.1 98.1 98.1 98.2

2.0 1.4 1.6 1.5 1.7 1.9 1.9 1.9 1.8

(%

)

Years

Hospital Contribution in NTP of All S(+) TB cases by percentage (2004-2012 )

Hospital NTP

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

%Treatment outcome of new smear positive TB patients from PPM-DOTS

hospitals by percentage (2011 tri quarter cohort)

Transfer out

Defaulter

Failure

Died

completed

Cured

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

%Treatment outcome of new smear positive TB patients from PPM-DOTS

hospitals by percentage (2011 tri quarter cohort)

Transfer out

Defaulter

Failure

Died

completed

Cured

PPM: weaknesses • Human resources: shortage of staff (medical doctors,

laboratory technicians) in public hospitals

• Turnover of medical doctors and staff

• No regular refresher training

• Non adherence to treatment guidelines

• Weakness in coordination

• Weakness in supported supervision

• Problems with recording and reporting

• Fund flow

Future Plan

• Refresher training will be provided for expanded PPM hospitals

• Regular supervision for newly expanded townships

• Strengthen EQA system to ensure laboratory quality

• Strengthen referral system from GPs

• Start MDR-TB management through GPs

Thank you!