Tuberculosis Care and Support through the Private Sector in India
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1 Tuberculosis Care and Support through the Private Sector in India Market-based and the Way Forward Oommen George, Technical Specialist Abt Associates (India) June, 2012
2 Outline USAID India initiative to enable participation of private healthcare providers in the Revised National Tuberculosis Control Program (RNTCP) in India Presentation Outline Market-based (MBPH; TB Initiative) o o o o Background and MBPH coverage MBPH: TB model MBPH: Program results MBPH: Lessons learned Opportunities for TB care and support in India Illustrations: Ananth Shankar Photographs: Oommen George June 2012 Private Sector Participation in TB Control (India) 2
3 Background & Coverage June 2012 Private Sector Participation in TB Control (India) 3
4 Need for Engagement of Private Sector in RNTCP Private practitioners are preferred by most 1st time health consumers This sector cannot, & must not, be ignored Most TB patients shop with several healthcare providers Delay in effective treatment & increased risk of drug resistance Very few private healthcare providers follow national or international standards of TB care Increased cost, morbidity, mortality & risk of drug resistance June 2012 Private Sector Participation in TB Control (India) 4
5 Geographical Coverage: 2 States UP & Karnataka June 2012 Private Sector Participation in TB Control (India) 5
6 Target Groups Consumer: Urban slum populations Provider: Private providers catering to urban slum populations June 2012 Private Sector Participation in TB Control (India) 6
7 The MBPH-TB Model June 2012 Private Sector Participation in TB Control (India) 7
8 The (Demonstration) Model Capacity Building ACSM Public-Private Interface Care & Support Provider-Patient Interface 1. Increased & early case finding 2. improved treatment compliance June 2012 Private Sector Participation in TB Control (India) 8
9 National Support for Local Implementation Model design, program planning, strategy development Research baseline consumer and provider, delay study MIS web-based, client-specific (first time in India for TB) Capacity building tools & methodology Technical assistance, supervision and monitoring Program evaluation (by USAID) June 2012 Private Sector Participation in TB Control (India) 9
10 Program Results: Uttar Pradesh Public-private relationships could not be built Only outputs (outcomes reported could not be validated without public sector support) June 2012 Private Sector Participation in TB Control (India) 10
11 Program Results (Karnataka State) June 2012 Private Sector Participation in TB Control (India) 11
12 Target Groups Reached (April-11 to Feb-12) A networked homeopath in Karnataka, who is also a DOT provider # Not counted in total Providers Engaged No. Allopaths Sensitized 616 (Allopaths Trained) # (333) ISMH Sensitized 258 LTFQ Sensitized 57 Chemist Sensitized 560 Total Sensitized/Trained 1,491 Allopaths networked 291 ISMH networked 170 LTFQ networked 28 Chemists networked 0 Total Networked 489 Communication: Total Person Contacts 538,599 Interpersonal communication (above) & a community awareness meeting (below) in Karnataka June 2012 Private Sector Participation in TB Control (India) 12
13 Key Consumer End-line (EL) over Base-line (BL) Findings 100% CS who went to a provider * 88.1 % 100% 80% Type of provider first visited by CS Baseline Endline 80% 60% * 51% 60% 40% 56.4 % 40% 20% 0% 26% * 35% 31% 0% 1% 0% 0% 0% 1% 0% 1% 24% * 10% 20% * 2% 20% 0% BL EL * Significantly (p=<0.05) different from BL: N = 681 (BL: N = 1515) CS Chest Symptomatic June 2012 Private Sector Participation in TB Control (India) 13
14 Consumer Awareness of RNTCP Logo (at EL over BL) 100% Significant increase (at EL) in proportion of CS who identified logo with TB program/hospital 80% 60% 40% * 37.3% 77.3% * 62.3% *Significantly (p=<0.05) different from BL N: EL = 681; BL = 1515) 20% 0% 5.2% TB program/hospital 17.6% 0.0% Heard, do not know what it stands for Not aware of DOTS logo June 2012 Private Sector Participation in TB Control (India) 14
15 Summary of Consumer EL Findings over BL June 2012 Private Sector Participation in TB Control (India) 15
16 End-line Provider Survey Findings N: CS (BL: 1515, EL: 681); Allopaths (BL: 255, EL:144); ISMH (BL= 193, EL= 127); LTFQ (BL:70, EL:25) CS: Chest Symptomatics BL: Baseline, EL: Endline * Significantly (p 0.05) different from baseline June 2012 Private Sector Participation in TB Control (India) 16
17 Sputum Microscopy Trends (Jan-10 to Dec-11) 9000 Trend showing numbers of CS tested each month at DMCs from Jan-2010 to Dec-2011: Data source: RNTCP Lab registers of all 75 DMC engaged by MBPH Total no. of CS tested at DMCs No. of CS from MBPH slums tested 2000 MBPH Intervention Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec June 2012 Private Sector Participation in TB Control (India) 17
18 Impact of MBPH on Sputum Microscopy Change 13% Apr-Dec: 2010 Apr-Dec: 2011 Comparison of numbers of CS tested at DMCs total & from MBPH slums during Apr-Dec 2010 & 2011 Data source: RNTCP Lab Registers of all 75 DMC engaged by MBPH Change 72% 0 Total no. of CS tested No. of CS from MBPH slums tested June 2012 Private Sector Participation in TB Control (India) 18
19 542 1,087 1,316 1,588 2,530 4,288 Market-based Contribution to TB Detection from Intervention Slums June 2012 Private Sector Participation in TB Control (India) 19
20 Impact of MBPH on case Detection Change 8% Comparison of numbers of all type of TB patients detected total & from MBPH slums during Apr- 10 to Feb-11 & Apr-11 to Feb-12 Data source: RNTCP TB Registers of all MBPH TUs (56) Change 2% Comparison of numbers of NSP TB patients detected total & from MBPH slums during Apr-10 to Feb-11 & Apr-11 to Feb-12 Data source: RNTCP TB Registers of all MBPH TUs (56) Apr-10 to Feb-11 Apr-10 to Feb-11 Apr-11 to Feb-12 Apr-11 to Feb Change 38% 2000 Change 65% 0 All TB Cases Detected at TU All TB Cases Belonging to MBPH Slums Detected June 2012 Private Sector Participation in TB Control (India) 20 0 NSP Cases Detected at TU NSP Cases Belonging to MBPH Slums Detected
21 Case Detection Trend Before & After Intervention No. of TB cases (of all type) detected each month from MBPH slums Trend of monthly case detection from intervention slums prior to MBPH Trend of monthly case detection from intervention slums during MBPH June 2012 Private Sector Participation in TB Control (India) 21
22 ? Lessons Learned June 2012 Private Sector Participation in TB Control (India) 22
23 Lessons from Uttar Pradesh A public-private partnership model cannot work when public sector involvement is weak, absent or counterproductive A private-private partnership may be considered in such states. However, this is likely to require: o Outsourcing of all services to private sector players o Re-creation of infrastructure, HR, MIS, supply & logistics o Long-tern government or donor support at national level o Higher cost of procurement of private services June 2012 Private Sector Participation in TB Control (India) 23
24 Factors Contributing to Results in Karnataka (1) Integration with the national program Avoids confusion among consumers Enhances national efforts Public sector commitment & support Synergy ( = 3 ) The model was robust & comprehensive Meaningful for TB patients/families June 2012 Private Sector Participation in TB Control (India) 24
25 Factors Contributing to Results in Karnataka (2) Inclusion of health consumer & provider communities, rather than of individual; reasonable scale Fewer transactions, greater efficiency Inclusion of all type of private providers (allopaths, ISMH, LTFQ & chemists) using innovative tools to build capacity High contribution/referral from non-allopath providers Interface (public-private & provider-patient) Enables bridging of serious gaps in healthcare access and service delivery June 2012 Private Sector Participation in TB Control (India) 25
26 Next Steps? June 2012 Private Sector Participation in TB Control (India) 26
27 Context: RNTCP National Strategic Plan ( ) Goal: Universal Access to quality TB diagnosis and treatment for all TB patients in the community Priorities: Ensure early and improved diagnosis of all TB patients Improve patient-friendly access to high-quality treatment for all diagnosed cases of TB Re-engineer and optimize programme systems Enhancing supervision, monitoring, surveillance and programme operations June 2012 Private Sector Participation in TB Control (India) 27
28 Taking MBPH Conclusions Forward Continue demonstration with improvements o Making care & support worthwhile for private providers o Progressive reductions in cost/client Advocate for NGO interface for TB-PPM Advocate for comprehensive services June 2012 Private Sector Participation in TB Control (India) 28
29 The next generation may receive the highest standards of care & support from healthcare providers of their choice with our assistance June 2012 Private Sector Participation in TB Control (India) 29
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