Presentation Transcript

1. Working with the Private Sector to Control TB April Harding World Bank/ IFC April Harding The World Bank Bali Hyatt Hotel, Sanur, Bali 21-25 June 2010
2. Teaching objectives 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
3. Framework applied to TB Strategies Harness private practitioners Grow quality lab services Policy Tools Contracting Training/Info Social franchising Public Sector Actors Private practitioners Village health workersDiagnostic labs Ownership For-profit small business Non-profit charitable Formal and informal Goal Control TB Reach TB patients Proper diagnosis Effective treatment Assessment Stagnant coverage of TB control programs Private sector treats most TB patients Private Sector Source: Harding & Preker, Private Participation in Health Services, 2003.
4. 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.
5. Where are people dying from TB?
6. Asia has the largest TB burden country rankings Viet Nam Kenya Brazil United Republic of Tanzania Uganda Zimbabwe Thailand Mozambique Myanmar Cambodia Afghanistan India China Indonesia Nigeria South Africa Bangladesh Ethiopia Pakistan Philippines Democratic Republic of Congo Russian Federation
7. Programs keep missing sizable numbers of 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.
8. 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”
9. 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
10. Site of Treatment– South Southeast Asia
11. Poor people go private too Note importance of informal private providers, especially for the poor Source: DHS Data (Cambodia 2005; Indonesia 2007; Philippines 2003; Vietnam 2002)
12. Why TB patients go private Patient perceptions & preferences (e.g. convenience, stigma, gender). Inconvenient clinic opening hours & long waiting times Provider attitudes Direct and indirect costs (public treatment) Perceptions of quality of care at government health facilities drive people away from public facilities, even when the prices are very low or free.
13. What is the problem with people “going private”? 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
14. How do they diagnose TB? Tests Patients Urban (%) Rural (%) Sputum alone 0 0 X-ray alone 56 78 X-ray + Sputum 21 10 Information unavailable 23 12
15. Private practitioners do not manage TB patients properly Practice Desirable Actual DiagnosisSputum basedX-ray based TreatmentFixed regimensVaried regimens MonitoringDOT No DOT Sputum examX-ray EvaluationCure rate None
16. STOP TB/ WHO has been working since 1995 to change this Conducted advocacy using “key facts” Use non-performance as a foundation to pressure for change (e.g. data on coverage of private sector; quality problems of private sector). Supported country programs in piloting & assessment, and identified promising engagement strategies. Used their growing evidence base as a foundation. “Evidence-based advocacy” Created STOP TB sub-group. Meet every year to check progress, share experience, and lessons. Pressure and support www.who.int/gtb or contact PPM Subgroup secretariat, WHO, Geneva For more info and related documents:
17. Country level action supported by STOP TB/ WHO Government commitment or strong local enthusiast Mapping: Who are relevant providers? What is their current practice? Select appropriate private sector engagement options Dialogue with all stakeholders: agree on appropriate instruments to connect to private providers (CM!) Make and implementation & evaluation plan Implementation Monitoring and assessment Look familiar?
18. Engagement strategies developed, piloted, & assessed Strategy Harnessing: getting existing private providers to diagnose properly, treat properly & report Relevant private providers formal private practitioners informal “village health workers” a few hospitals Key facts Target private providers are highly fragmented and dispersed Many question whether private practitioners can be motivated to change behaviour in necessary ways
19. Engagement strategies developed, piloted, & assessed Instruments used and evaluated Training, “drugs for performance” contracts & branding (accreditation) Social franchising Key finding intermediary actors critical (e.g. NGO hospital; Damien Foundation, medical association, existing PHC franchise)
20. What makes the instruments work? Direct financial incentives not essential Free drugs (in-kind incentives) Quality focus (practitioners care!) Providing access to training & equipment Professional recognition
21. Demand creation is key for all instruments
22. Demand creation is key for all the instruments Participating practitioners attract more patients..... Information campaigns Branding Leaflets etc
23. Pilots, evaluation, dissemination
24. Positive results: treatment success(New sputum positive cases) Global target: 85% success Informal practitioners! Free drugs Not free drugs
25. Case detection, Delhi - private sector engagement compared to control Engagement starts Source: LRS / RNTCP / WHO / VK Arora / K Lonnroth
26. Impact on case detection Average increase 30%
27. Source: Katherine Floyd, STB Cost-effectiveness
28. Critical success factors Building capacity of control program locally & nationally is critical National policy / guidelines Regular drug supply Supervision capacity Public-private stakeholder dialogue is critical Openness about conflicts of interest
29. Critical success factors Sensitising public sector staff Pragmatism & “evidence-based advocacy” Private sector engagement “network” – supported by STOP TB/ WHO
30. Private sector engagement and TB MDGs "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
31. Huge possibility to improve impact.... But most still in “project mode”. Implementation at scale not yet realized
32. Many pilots in India, but no scale up India accounts for one fifth of the global TB incidence, topping the list of 22 high burden TB countries . TB kills more adults in India than any other infectious disease
33. Insights from TB private sector engagement initiative so far? 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?
34. TB and course framework Experience shows usefulness of framework in moving from problem identification, to strategy development & implementation. Framework was used to explain need for engagement to mid-level policymakers and program managers (goals; relevant private actors, strategy, instruments, M&E)
35. 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.
36. “Food for thought” Usefulness of framework (and focusing on private sector engagement) is powerfully illustrated. Great for teaching! And “evidence-based advocacy” Lack of expansions illustrates how hard, and important our task is.
37. Key sources “Pragmatist-in-chief” MukundUplekar, 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.