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)

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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%

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150

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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