Zaw Win, Tin Aung, Sun Tun Population Services International/ Myanmar The Role of Sun Quality Health Clinics (SQHC) Network in increasing TB diagnosis and Treatment in Myanmar Role of the PSI SQHC in PPM Zaw Win, Tin Aung, Sun Tun Population Services International/ Myanmar

TB in Myanmar Myanmar: one of the 22 TB high-burden countries (1) Estimated Incidence of all TB cases: 384/100,000 (2) Bacteriologically confirmed TB prevalence:613/ 100,000 (2) Case detection rate (CDR) all forms: 76% (2010) (1) DOTS covered all townships in 2003 (1) (1) Health in Myanmar 2012 (2) Report on National TB Prevalence Survey 2009-2010 There was little concrete evidence on TB prev in Myanmar until recently. A limited survey in 1994 suggested smear +ve prevalence of 104/100,000, but no more recent data was available until NTP and WHO conducted a national prev survey in 2010. This showed unexpectedly high rates, more than double previous estimates, and the NTP responded quickly by shifting priorities to emphasize case finding. This presentation will highlight the role of PPM in these efforts.

PSI Myanmar’s Health Services Technical support Diagnosis and Treatment Product Training IEC & Enablers PSI is an international NGO working in the health sector in 65 countries. PSI has worked in Myanmar since 1996, using a Social Franchising approach. SF: Application of commercial franchising principles to promote social benefit. PSI operates Sun Quality Health, a fractional franchise, which engages existing private medical practitioners to improve quality, accessibility, and affordability of their services. Franchiser (SQH) Franchisee Client Monitoring & Supervision

SQH Coverage townships in Myanmar Sexual and Reproductive health HIV and AIDS Malaria Tuberculosis Pneumonia and Diarrhoeal disease SQH started in 2001, and has proved a highly successful model. PSI now supports 1,500 clinics across Myanmar, as you can see from the green shading on the map. SQH provides integrated services across the 6 health areas listed. With an established channel, the incremental cost of adding new services is low, allowing PSI to respond to the priorities of the MoH and the needs of Myanmar people.

Social Franchising PPM-DOTS Model (2011 onwards) Technical support Drug supply Training Drugs supply Monitoring & Supervision Patient support Diagnosis Treatment Patients support SQH Let me describe how this works in a little more detail. NTP supports technical issues and TB drug supply to PSI. "This program would not be possible without the NTPs commitment and constant support. PSI supports to SQH with training, monitoring and supervision and patients supports as enablers (nutritional support, IEC, transportation fees, etc). For the diagnosis, in addition to the government labs, private labs have also been accredited under the PPM scheme by NTP. With the PSI’s support, SQH gives diagnosis and treatment. Training by NTP Lab material supply Monitoring & Supervision

PSI: 12.1% of Case Registration This graph shows the growth of SQH TB treatment. The green bars show us SQH network established with 102 TB trained providers in 2004 and reached 944 in 2011. SQHC contributed 2.3% of the total estimated TB burden in Myanmar in 2004 and 12.1% of case registration in 2010 while NTP supported TB drugs to PSI. (1) TB situation and response NTP October 2012

providing free services, and ‘incentives and enablers’ to reach poor. Equity providing free services, and ‘incentives and enablers’ to reach poor. Quality Service Medical staffs’ regular monitoring and supervision visit Data collection and timely reporting Training and supports So we are working at scale - but has SQH delivered quality and equity? Evidence in Myanmar suggests that most people visit private providers early in their care seeking pathway. GPs are often the first formally trained providers visited, and the most accessible to poor communities. By working with private GPs, we can get people on treatment earlier than many other providers, and we can reach poor people more effectively. Evidence from the national prevalence survey support this - the graph shows the distribution of urban patients by soci-economic quartile disaggregated by where they receive TB treatment. Poor people are more likely to be treated in SQH than elsewhere. Chi2 p<0.05 (1) Can Subsidized Private TB Care Serve the Poor? Evidence from Myanmar

Challenges of SQH Network Data recording and reporting burden Funding for sustainability Case detection in rural and peri-unban area TB treatment program requires a lot of data collection. This is increasingly burdensome as the network grows, and requires a lot of time and effort. This in turn drives up total costs. We are currently reliant on donor support for funding. The Prevalence survey 2010 result shifted our emphasis to case detection. SQH is a passive mechanism, and PSI began to look for ways to improve case finding and to take a more active roll. 8

Private healthcare providers Health in Rural Area: Sun Primary Health Private healthcare providers To address case detection in rural, PSI established SPH (Volunteer Health Workers) in 2008. The reason is that GPs practices are in towns while the majority 70% population reside in rural areas. There are barriers in their healthcare like (transportation, inadequate health services, low health knowledge and income) etc. Though there are also township hospitals, Rural Health Centers in rural from public healthcare, we still need to fill the gap for the rural area for more case detection in term of private sector. bcc to raise awareness, active case finding, referral of suspects to SQH (with enablers), contact tracing and patient support ? ? ?

TB case registration from SPH SPH is having a significant impact on case finding. Since 2008 we have trained nearly 2,000 SPH, and they now identify more than 10% of our TB patients.

New Approach for More Case Finding in Urban Slum Setting As PSI SQH network covers for urban and SPH for rural area, another area that needs to address for case finding is urban slum area. With the support of WHO, STOP TB partnership, PSI rolled out urban slum case detection activities with two interventions namely Community based communications and screening events with IPC channel and Incentive schemes to promote referrals from local drug sellers to Sun clinics through Pharmacy Channel.

This graph shows the growth of Franchised TB treatment in Myanmar through Sun Quality Health. You can see that the growth in TB cases treated was flattening out in after 2006, but the introduction of SPH from 2009 increased numbers both through direct referrals (in green) and by generating demand through BCC activities. The TB REACH interventions are just rolling out now, but initial results are encouraging and we believe that we will achieve our ambitious targets of finding an addition 4,000 cases over 12 months. These interventions are making a significant contribution to TB control at a national level. Franchising GPs is an approach that can improve quality, equity and access to TB treatment.

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