Progress and plans for PPM in the

South-East Asia Region

Fifth PPM Subgroup Meeting

3 - 5 June, Cairo

TB incidence rates per capita

25 to 49

50 to 99

100 to 299

< 10

10 to 24

300 or more

No Estimate

per 100 000 population

TB in SE Asia 5 m prevalent cases3 m new cases and 500 000 deaths/ yr

~150,000 new MDR-TB cases/yr

~ 2.5 - 3 million TB-HIV co-infected

Countries with GF support for PPM

All countries in the Region with the exception of Myanmar and DPR Korea benefit from support from the Global Fund for expanding private and public partnerships

Regional Progress

• Bangladesh: >90% of TB services through NGOs; Prisons, medical colleges, railways, garment industries being involved

• India: 262 medical colleges; >17695 PPs; >2946 NGOs; > 150 corporate houses; tea estates, railways, employees state insurance hospitals, Ministries of Shipping, Mines, Petroleum and Oil, Indian Medical Association; District TB Societies

• Indonesia: All lung clinics and 37% of large hospitals; 7 medical schools; Ministry of Defence, Police and Prisons Dept

• Myanmar: Private providers; Railways; Ministries of Defence, Religious affairs; Labour, Education and Home Affairs

• Nepal: Private providers; teaching hospitals, communities through village and district DOTS committees

• Thailand: NHSO, Ministry of Labour; prisons systems; private hospitals association; community based organizations, local and international NGOs; Thai business coalition

Successful approachesSome examples

• Intensified training of private and public hospital and laboratory staff in Indonesia

• Introduction of coordination meetings between community health facilities and hospitals: Yogyakarta, Indonesia; between partners: Myanmar

• Franchising, allowing for ensuring of quality throughout network: PSI Sun Quality Health Network

• Inclusion of private laboratories in diagnostic network & QA systems in, India; SQH and accredited labs in Myanmar

• Establishing of referral networks and better follow up of transfers eg., in Padang, Indonesia, between lung clinic and puskesmas; provision of a list of DOTS centres for referral to teaching institutes in India

• Endorsement of the International Standards of TB Care by professional bodies-- Medical associations in India, Indonesia

Regional Priorities: 2008-2009• Catalyze wider implementation (India, Indonesia, Myanmar, Nepal)

Document on-going initiatives, disseminate best practice examples for wider use

• More actively engage with professional associations, teaching universities for dissemination of the ISTC, and use of recommended guidelines

• Ensure coordination mechanisms/forums for information exchange at all levels in countries

• Expand collaboration with industry, corporate sector (not much progress here– may be an area for the PPM sub-group to focus on)

• Help in developing clear strategies and operational guidelines based on lessons learnt (Bangladesh, Sri Lanka, Thailand) sectors not yet involved

• Support pilots in (Bangladesh, Thailand)

• Organize a regional training for national consultants/focal points on strengthening public-private partnerships (long-standing dream!)

PPM activities in priority countries

Priority countries

National Situation assessment conducted

PPM focal person appointed

PPM Operational guidelines developed

Bangladesh Yes, included in the 5-year NTP plan (2006-2011)

Yes, focal point exists at NTP, Min of H&FW

PPM is mainstreamed into the technical and operational guidelines of the programme. PPM guideline is also available as schemes for collaboration.

India Yes, included in the 5-year NTP plan (2006-2011)

Yes, focal point exists at Central TB Division, Min of H&FW

PPM mainstreamed into technical and operational guidelines of the programme. Separate guidelines also available as schemes for collaboration.

PPM activities in priority countries

Priority countries

National Situation assessment conducted

PPM focal person appointed

PPM Operational guidelines developed

Indonesia Yes-2003 and during the subsequent external MMs, in 2005 and 2007

Yes Yes

Myanmar Yes – during the joint MMs in 2004 and 2007

Yes Yes – under revision

Thailand No No No

Progress: BangladeshProvider group

Involvement Contribution

Professional associations

No There are schemes to involve these associations for ACSM activities

Corporate Sector

Yes. Three corporate sector health care units are involved

Hospitals Yes DOTS Corners functional at 24 medical colleges by end 2007

Informal providers

Yes. Very good involvement

(Shasthyo Sebikas, Village doctors: Contribution is in terms of referral of TB suspects for diagnosis and acting as DOT-providers

Private laboratories

No There are schemes for involvement of private labs as designated microscopy centres for the programme

NGOs and private practitioners

Yes 29 NGOs involved as partner of NTP by the end of 2007 and private practitioners are being oriented and involved

Bangladesh Plans for PPM 2008-2009

• Actively engage professional bodies, BMA,BPMPA, specialists using the International Standards for TB Care

• Enhance coordination and collaboration between different Ministries

• Expand collaboration with industry, corporate sector and pharmacy holders through respective association

• Development and distribution of advocacy materials to private providers

Progress: India

Provider group Involvement Contribution (Measured in terms of numbers of patients only in 14 sentinel sites)

Professional associations

Yes. Involvement of a few associations Establishment of the Indian Medical Professional Association Coalition against TB (IMPACT) in 2007.

GFATM supported project being implemented by the Indian Medical Assoc (IMA) since 2007.

Endorsement of ISTC by members of the IMPACT in their personal capacity: March 2008 (endorsement by member associations in process)

Joint consensus statement on pediatric TB by IAP in place and used

Corporate Sector

Yes. About 150 corporate sector health units involved

Hospitals Very good involvement Over 262 medical colleges involved by end of 2007

Informal providers

Yes. Referral of suspects for diagnosis; act as DOT providers

Private laboratories

Yes. Schemes for involvement of private labs as designated microscopy centres for the programme

NGOs and private practitioners

Yes 2946 NGOs and 17695 private practitioners involved by end of 2007

Intensified urban PPM districts; India (14): Summary of contribution by different health sectors – 3rd qtr 2006 to 2nd qtr 2007)

India Plans for PPM 2008-2009

• Revise PPM guidelines for NGOs and private practitioners

• Work with the IMA to increase the number of private practitioners collaborating with national programme

• Develop guidelines for further involvement of the Employee State Insurance and Railways health facilities in TB control

Progress: Indonesia

Provider group Involvement Contribution

Professional associations Yes Endorsement & roll out of ISTC

Corporate Sector Yes Guidelines on TB in work place introduced on a pilot basis

Hospitals Yes Hospital assessment done in 117 hospitals. HDL guidelines developed. TO placed in large hospitals

Informal providers Limited to pilot studies under FIDELIS etc

Pilot studies done on involvement of PP in Bali & Yogja

Private laboratories Limited to pilot studies Same as above

Prison medical services Yes MOU signed between Min of Justice & MOH. Guidelines developed. Training started for 30 prisons

Achievements A hospital assessment study on the implementation of DOTS strategy conducted Guidelines on Hospital DOTS Linkage (HDL) developed and 15 Technical and Surveillance Officers

for HDL have been placed in 12 clusters of districts Integration of DOTS into medical school curriculum implemented ISTC translated and adapted into Bahasa (Indonesian language), officially endorsed and rolled out to

the professional organizations Ministerial decree issued to support DOTS implementation under different Directorate Generals Directive letter from DG Medical Care on DOTS implementation in hospital issued Guidelines on TB in workplace, prison and army developed, and activities initiated CEA study initiated on PPM approaches

Constraints Varying degree of commitment and

quality of services in DOTS implementation

Plans for 2008-2009 Dissemination of HDL guidelines/ training Strengthening linkages and surveillance in HDL Further expansion of HDL to other public and private hospitals, Institutionalizing of ISTC, incl. certification/accreditationHospital assessment study in outer Java

Progress: Indonesia

Progress: Myanmar

– National PPM DOTS Sub group established– PPM capacity at WHO strengthened

(international MO + national consultant)– PPM capacity at MMA strengthened

(national PPM team + 2 Divisional Coordinators and part-time Township Coordinators/ full time social outreach workers in all townships)

Achievements: PPM DOTS Sub group in Myanmar

• Standardized Training Manual PPM DOTS

• 3Diseases Orientation Package for GPs

•Implementation Guide on PPM DOTS (draft)

• Strategy Paper on PPM DOTS in Myanmar (draft)

Progress: MyanmarProvider group Involvement Contribution

Professional associations

Yes 1. Myanmar Medical Association( MMA )526 General Practitioners involved in 23 townships)- Contributed 20.27% of sputum smear positive cases to National Tuberculosis Programme

Corporate Sector Yes (Railways, Labour)

Hospitals Yes 4 Tertiary Specialist Hospitals Pilot Project, Yangon Division

Informal providers Yes

Private laboratories Yes Through PSI social franchising scheme and through MMA

Other provider groups

Yes Ministry of Defence, Religious affairs, Education and Home affairs

Myanmar Plans for PPM 2008-2009

Public Private Mix DOTS1. Finalize Implementation Guide on PPM DOTS and Strategy paper on PPM DOTS in

Myanmar2. Sustain in implementing townships and scale up public private mix DOTS project

• Myanmar Medical Association( MMA ) 600 General Practitioners involved in 26 townships

• to include private and charity hospitals, religious hospitals• Population Services International (PSI) –to scale up number of Sun Quality Health Care

Doctors• CARE Myanmar to sustain in 10 townships• IOM to sustain 6 townships• JICA under the Major infectious diseases control project, to scale up to 6 townships• Myanmar Red Cross Society and Myanmar Maternal and Child Welfare Association

members act as DOT ProvidersPublic Public Mix DOTS• To consolidate the public public mix demonstration projects in 4 tertiary specialist Hospitals• Develop Interim Guidelines on Public Public Mix DOTS• End 2008: joint workshop on TB control between NTP and Prison Department

ISTC• Workshop with leading medical specialists on Adapting ISTC to Myanmar context, July 2008 • Conduct similar workshop for GP branch of the Myanmar Medical Association• Implement and roll out the ISTC stepwise approach

Progress: Thailand

MOU with National Health Security Office MOU with Ministry of Labour to implement TB control in the

workplace MOU with MSF for TB treatment and care among migrants Coordination with Department of Corrections to continue

TB control in prisons Collaboration with US. CDC for TB surveillance and

research Engagement of Private Hospital Association to provide TB

care according to ISTC ISTC translated into Thai and endorsed by NTP Involvement of NGOs (World Vision, American Refugee

Committee, Thailand Bossiness Coalition of AIDS) to control TB in vulnerable population

Progress: ThailandProvider group Involvement Contribution

Professional associations

No

-

Corporate Sector Yes

TB control in the workplace

Hospitals Yes About 60 Private hospitals implementing TB activities with TB recording and reporting system

Informal providers No

Private laboratories No

Other groups Yes TB control activities with R&R system in 144 prisons

Thailand Plans for PPM 2008-2009

– Establishment of working group to develop a plan, oversee the implementation and coordinate mechanisms at all levels of the programme

– Officially appointment of a focal person for PPM– National situational analysis of PPM– Continuation for PPM collaborative activities with:

• Private Hospitals• Factories• Prisons• NGOs• Health insurance organization

621 625

568

438 431 411

244

340

147108

180 169

253299

244

789

391

8096

197

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100

200

300

400

500

600

700

800

900

1,000

1,100

1,200

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Tuberculosis prevalence rates in SEAR countries

Source : WHO, Global Tuberculosis Control Report 2008