Upload
shanon-hunter
View
219
Download
0
Tags:
Embed Size (px)
Citation preview
Building Public-Private Partnership
for Health System Strengthening
Working with the Private Sector to Control Tuberculosis
April HardingThe World Bank
Bali Hyatt Hotel, Sanur, Bali21-25 June 2010
S SE Asia Average
Bangladesh 2007
Pakistan 2006/07
India 2005/06
Cambodia 2005
Indonesia 2007
Nepal 2006 Vietnam 2002
Philipines 2003
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
29.2%
54.4%
16.4%
% of Total Treatment in Non-Formal Private% Total Treatment in Formal Private% of Total Treatment in Public Sector
Site of Treatment– South Southeast Asia
Why TB patients go private• 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. India2. China3. Indonesia4. Nigeria5. South Africa6. Bangladesh7. Ethiopia8. Pakistan9. Philippines10.Democratic Republic of C
ongo11. Russian Federation
12.Viet Nam13.Kenya14.Brazil15.United Republic of Ta
nzania16.Uganda17.Zimbabwe18.Thailand19.Mozambique20.Myanmar21.Cambodia22.Afghanistan
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.
S SE Asia Average
Bangladesh 2007
Pakistan 2006/07
India 2005/06
Cambodia 2005
Indonesia 2007
Nepal 2006 Vietnam 2002
Philipines 2003
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
29.2%
54.4%
16.4%
% of Total Treatment in Non-Formal Private% Total Treatment in Formal Private% of Total Treatment in Public Sector
Site of Treatment– South Southeast Asia
TB patients going private
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”
TB case load in the private sector, 2000
Country Retail Sales Cost / Course Estimated (USD Million) (USD) Cases
India 85.3 100 853000
Indonesia 12.3 100 123000
Pakistan 11.7 100 117000
Philippines 16.6 200 83000
Bangladesh 2.3 100 23000
India: 75% to 88% of TB patients' first contact was a private provider
How private practitioners treat TB patients
Year Doctors Regimens
1991 100 80
1994 113 90
1996 105 79
What is the problem with people “going private”?
They diagnose badly
Tests Patients
Urban (%) Rural (%)
Sputum alone 0 0
X-ray alone 56 78
X-ray + Sputum 21 10
Information unavailable 23 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
Private practitioner engagement strategies
Many question whether private practitioners can be motivated to change behaviour in necessary ways
Key fact: Target private providers are highly fragmented and dispersedKey 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
What makes the instruments work?
Information dissemination is key!
Participating practitioners attract more patients.....◦Information campaigns
◦Branding
◦Leaflets etc
Information dissemination (demand creation) is key
Private practitioners CAN treat appropriately..... even informal practitioners(New sputum positive cases)
0
10
20
30
40
50
60
70
80
90
100H
yder
abad
, Ind
ia
Del
hi, I
ndia
Kan
nur,
Indi
a
Mum
bai,
Indi
a
Lalit
pur,
Nep
al
Man
ila, P
hilip
pine
s
Cav
ite, P
hillip
pine
s
Mak
ati,
Phi
lippi
nes
Yog
ya, I
ndon
esia
DF
B B
angl
a
You
ngon
e, B
angl
a
Yan
gon,
Mya
nmar
Seo
ul, K
orea
Nai
robi
, Ken
ya
HC
MC
, Vie
tnam
Tre
atm
ent s
ucce
ss (
%)
Global target: 85% success
Free drugs Not free drugs
Informal practitioners!
PPM Site Baseline Rate Increase Evaluation Approach
Hyderabad 50/100,000 23% Compared to neighbouring TU
Delhi 60/100,000 36% Change controlled
Kannur 25/100,000 15% Change in same TU
Lalitpur 54/100,000 61% Change in same area
HCMC 100/100,000 18% Change controlled
Punalur 25/100,000 50% Change in same TU
Thane 50/100,000 14% Change in same TU
Mumbai 55/100,000 19% Change in same TU
Private sector engagement significantly increases case detection
Average increase
30%
118
154144
344
0
50
100
150
200
250
300
350
400
Hyderabad PPM-DOTS (Mahavir)
HyderabadRNTCP
(Osmania)
Delhi PPM-DOTS Delhi privatenon-DOTS
Ave
rag
e co
st c
ost
per
pat
ien
t su
cces
sfu
lly t
reat
ed (
US
$)
Private practitioners can even treawt more cost effectively than public
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
Critical Success Factors
Sensitising public sector staff
Pragmatism & “evidence-based advocacy”
Private sector engagement “network” – supported by STOP TB/ WHO
Critical Success Factors
"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
Private sector engagement and TB MDGs
Many control programs still implemented only through public sector;
Others, at quite small scale
Huge opportunity for private sector to contribute to TB control....but....mostly missed
Many pilots in India, but no scale up
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?
Insights from TB private sector engagement initiative so far?
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.
Framework applied to TB
Goal
Control TB - Reach TB
patients- Proper
diagnosis - Effective
treatment
Public Sector
Private Sector
Source: Harding & Preker, Private Participation in Health Services, 2003.
Assessment
Stagnant coverage of TB control programs
Private sector treats most TB patients
ActorsPrivate practitioners
Village health workers Diagnostic labs
Ownership For-profit small business
Non-profit charitable
Formal and informal
StrategiesHarness private
practitionersGrow quality lab
services
Policy ToolsContractingTraining/InfoSocial 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
Teaching objectives