Joint International Monitoring Mission, Thailand, August 13-27, th Joint International Monitoring Mission, Thailand, August 13-27, 2013 The Major Findings Dr Paul Nunn

Joint International Monitoring Mission, Thailand, August 13-27, 2013 Terms of Reference - I  Review implementation of recommendations JMM 2007, and 2009  Review progress in TB Control and towards reaching the Millennium Development Goals  Assessment of the adequacy, completeness and quality of monitoring and recording and reporting systems  Identify actions to ensure the sustainability of the programme by the NTP and its partners

Joint International Monitoring Mission, Thailand, August 13-27, 2013 Terms of Reference - II  Key focus areas:  effectiveness of case finding and contact tracing strategies  TB control in Bangkok  childhood TB  treatment and care for non-registered migrants  PMDT  TB-HIV collaborative activities  involvement of health insurance  prisoners  human resource constraints  programme management in the context of a decentralized health system.

Joint International Monitoring Mission, Thailand, August 13-27, 2013 Selected Sites of the 5 th Joint International Monitoring Mission to Review NTP Thailand, August 13-26, 2013 North Team: ODPC 9 th Phitsanulok and Tak Province North-East Team: ODPC 7 th Ubon Ratchathani and Si Sa Ket Province Central Team: ODPC 3 rd Chon Buri and Samut Prakan Province South Team: ODPC 11 th Nakhon Si Thammarat and Phuket Province Bangkok Team ODPC 1 Bangkok Bureau of TB, Cluster of Planning, Monitoring and Evaluation. Updated: Apr 29, 2013 ODPC = Office of Disease Prevention and Control

Joint International Monitoring Mission, Thailand, August 13-27, 2013 Major Achievements - I  Extension of health insurance to 98% of Thai nationals with coverage for TB treatment  Estimated incidence of TB less than half that of Cambodia and Myanmar and has fallen 10% since 1990  Mortality and prevalence also declining and Millennium Development Goals will be met  Improvements in treatment success for new smear positive cases from 76% in 2007 to 85% in 2010 cohort

Joint International Monitoring Mission, Thailand, August 13-27, 2013 Major Achievements - II  Multiple grants from Global Fund  Drug supply reliably assured  4 th drug resistance survey showed no sign of increase in multi-drug resistance  The impact of HIV on TB has been mitigated  TB/HIV services rolled out  Prevalence survey successfully conducted

Joint International Monitoring Mission, Thailand, August 13-27, 2013  4 Major Issues to be Addressed

Joint International Monitoring Mission, Thailand, August 13-27, 2013 Major Issues to be Addressed - I  Low case notification  Only 21 of 97 Bangkok hospitals report all their cases to the Bureau of TB. Private, university, military and MoPH hospitals under-reporting  Extent of under-reporting is unknown, but significant, especially in children, the elderly, those with MDR-TB  Notification law not enforced  Regulatory oversight of TB notification at hospitals in Bangkok not within the Bangkok Metropolitan Administration needs to be urgently established  Private health care sector not effectively engaged in partnership with NTP

Joint International Monitoring Mission, Thailand, August 13-27, 2013 Major Issues to be Addressed - II  Inefficient reporting and surveillance systems  Data on new cases often entered into two separate paper systems and two computer systems  Multiple local spreadsheets used for local reporting and case management  Provinces and central Bureau of TB routinely analysing only aggregated data  Current systems for registering and following cases are inefficient and not exploiting existing opportunities  TBCM and SMART-TB have made progress – and could be further adapted  IT infrastructure excellent in Thailand and synergies could be had through sharing of data with NHSO data collection system

Joint International Monitoring Mission, Thailand, August 13-27, 2013 Major Issues to be Addressed - III  Improvement of treatment outcomes is urgently needed  Nationally, treatment success was 82% in 2012 in new Thai cases, below the international standard of 85%  Private hospitals in Bangkok treatment success was 73%  Cause mostly default, but also high case fatality – HIV, elderly, marginalized, comorbidities etc.  DOT working well in some provinces, but in others neither staff nor patients convinced by DOT, and often fail to supervise patients  A wider range of support approaches is needed for patient- centred care than can be managed by public services alone  Large hospitals have difficulty doing DOT for discharged patients in the community

Joint International Monitoring Mission, Thailand, August 13-27, 2013 Major Issues to be Addressed - IV  Provision of suitable care for all migrants in need  As many as 3.5 million non-Thai migrants in Thailand, many undocumented, most in border areas and Bangkok  Migrants, and their children, often marginalised, reduced access to health care, under-diagnosed (eg for HIV associated TB, MDR- TB), get less DOT, default higher, at risk of drug resistance  Fear of job loss and interactions with Ministry of Labour, police and immigration authorities are not conducive to positive health behaviour (>90,000 deported annually to Cambodia)  ASEAN Economic Community comes into force in January 2015 with free movement of labour which will likely increase immigration  Demand for healthy labour, human rights, and public health all suggest that access to treatment should be facilitated for migrants

Joint International Monitoring Mission, Thailand, August 13-27, 2013 Recommendation 1 To address the gaps in notification with the goal of finding all TB cases  MoPH to commit to TB control as a priority  MoPH to repair and enforce the notification system in order to achieve mandatory reporting of all cases, including incentives for institutions who comply and (enforced) sanctions for non-reporters  MoPH or BMA to (re-) establish clear regulatory control over non-BMA facilities with respect to TB reporting and case management  MoPH to take the lead in strengthening/establishing a Public-Private Mix approach through a high level conference early in 2014 of MoPH staff and leaders of private, military and university hospitals

Joint International Monitoring Mission, Thailand, August 13-27, 2013 Recommendation 2 To implement a single TB electronic recording and reporting system for all cases  The MoPH should commit adequate, dedicated resources to set up by the beginning of 2015 a unified, nationwide, case-based, electronic, web-based, recording and reporting system for all facilities,  based on further development of the "TB Clinical Management" recording & reporting system  able to be linked with the data collection system of NHSO  careful transition from current system  enabling major efficiency gains  Enabling focused attention on vulnerable groups  In line with the decentralization of upcoming health reform, MoPH to train and facilitate to enable local use of data for analysis and corrective action

Joint International Monitoring Mission, Thailand, August 13-27, 2013 Recommendation 3 Ensure maximal chance of treatment success  MoPH should mount a campaign among both patients and health staff to improve treatment outcomes based on direct observation of treatment (DOT) which should include:  Patient-centered care with careful explanation by health staff of what is required of patients  Focusing of DOT resources towards high risk patients (HIV, elderly, uninsured, marginalized etc) with monitoring quality of care  Proper management of co-morbidities,  Enablers to poor patients  Better data flow (with unified electronic data management system)  Adequate financial resources  In Bangkok, the BMA should take responsibility for a monitoring unit and mobile outreach service that follows up cases using DOT providers/peer educators and support service to private practitioners eg as in San Francisco, US  Leading NTP staff should be supported to help achieve pro-DOTS behaviour change in staff as well as patients

Joint International Monitoring Mission, Thailand, August 13-27, 2013 Recommendation 4 Provision of suitable care for all migrants in need  MoPH to promote active TB case finding and migrant sensitive TB health service delivery among non-Thais  MOPH should further explore innovative financing approaches to ensure migrants' universal health coverage and in bordering countries  MoPH to develop innovative measures to identify unregistered non-Thais in unified electronic data management system, perhaps through a unique ID number  MoPH to extend access to care among non-Thai through coordinated approaches with INGO, and local NGOs and CBOs  Expand political commitment and local initiatives to establish cross border referral mechanismse.g. between Mae Sot and Myawaddy  MoPH to prepare a cross-border application for the Global Fund to support a comprehensive multi-national effort to provide access to universal health care in all countries bordering Thailand

Joint International Monitoring Mission, Thailand, August 13-27, 2013 Strategic and cross-cutting issues  The team advises:  Encouragement of a greater role in TB care and support of civil society organizations (CSOs) / NGOs  Development of a technical assistance plan  Preparation of a detailed National Strategic Plan

Joint International Monitoring Mission, Thailand, August 13-27, 2013 Follow Up  A mission within 2-3 months of electronic database experts to advise on how to set up the web-based unified recording and reporting system  Review progress with a small team of international experts in 2015