1. TB PUBLIC-PRIVATE MIX DOTS Dr. Team Bakkhim Deputy Director CENAT Intercontinental Hotel 7 th November, 2012 NATIONAL FORUM ON PUBLIC-PRIVATE PARTNERSHIP IN HEALTH

2. OUTLINE  Background of TB PPM-DOTS  TB PPM-DOTS : Design and implementation  Lessons learnt from the success  Recommendations TB PUBLIC-PRIVATE MIX DOTS Dr. Team Bakkhim, Deputy Director, CENAT 1of16

3. BACKGROUND OF THE PROJECT (1)  Cambodia is ranked 21 among the 22 TB high burden countries  Approximately two-thirds of all Cambodians are infected with TB, and around 13,000 Cambodians die annually from the disease  National Tuberculosis Program (NTP) focus on reducing morbidity and death rates due to tuberculosis is a key strategy for improving the overall health of the population  The private sector is accessible, with two thirds of Cambodians seeking care outside the public sector for their first visit with TB symptoms  To align with the WHO Global strategy for TB control (Stop TB Strategy 2006 : engage all care providers ) TB PUBLIC-PRIVATE MIX DOTS Dr. Team Bakkhim, Deputy Director, CENAT 2of16

4. BACKGROUND OF THE PROJECT (2)  In 2004 the NTP began to engage private providers in TB control.  The NTP, with support from their partners, developed the Public-Private Mix (PPM) strategy and it was approved by the Ministry of Health.  During Phase I, with USAID/JICA funds, the NTP and partners designed, implemented, and evaluated a referral network in the private sector where symptomatic individuals seek care and public sector DOTS facilities in pilot provinces TB PUBLIC-PRIVATE MIX DOTS Dr. Team Bakkhim, Deputy Director, CENAT 3of16

5. Clients suspected TB Private Clinic / cabinet Private Pharmacy / depot Private Lab. Public Hospital / Health Center Diagnosis, Treatment Recording & Reporting PHASE I REFERRAL STRATEGY = Referral System TB PUBLIC-PRIVATE MIX DOTS Dr. Team Bakkhim, Deputy Director, CENAT 4of16

6. GOAL FOR TB PPM-DOTS  To test and scale–up a public-private mixed DOTS partnership model that aims to strengthen both the public and private sectors in TB case management and increase case detection TB PUBLIC-PRIVATE MIX DOTS Dr. Team Bakkhim, Deputy Director, CENAT 5of16

7. SPECIFIC TB PPM-DOTS OBJECTIVES  Reduce diagnostic delay for people with suspected TB, increase case detection, and decrease the opportunity for multi-drug resistance  Strengthen public-private linkages & partnerships in TB case management and control through a referral system to public DOTS services (Phase I)  Improve access to quality DOTS services for people seeking care at the private sector providers by implementing DOTS services in private clinics and hospitals qualified by NTP (Phase II) TB PUBLIC-PRIVATE MIX DOTS Dr. Team Bakkhim, Deputy Director, CENAT 6of16

8. KEY ACTIVITIES  Develop TB PPM-DOTS strategy  Identify and engage private sector partners (Pharmacists Association of Cambodia (PAC) and Cambodian Medical Association (CMA))  Review and revise national recording and reporting forms  Develop standardized referral tools  Develop IEC and training curriculums  Develop Memorandum of Understanding agreements  Organize a sensitization workshop for public and private-public providers and sign MoU agreements  Build capacity for national, PHD, and OD TB staff on PPM and supervision of private sector  Train private providers and DOTS health center staff  Conduct quarterly Public-Private Partner meetings  Conduct monthly supportive supervision and data collection TB PUBLIC-PRIVATE MIX DOTS Dr. Team Bakkhim, Deputy Director, CENAT 7of16

9. PPM IMPACT INDICATORS  Number of private providers involved in PPMD.  Number of TB suspects referred from the pharmacy to the DOTS health center  Number of TB suspects presenting at DOTS health center with referral from private providers  Number of TB cases identified among TB suspects referred from private providers. TB PUBLIC-PRIVATE MIX DOTS Dr. Team Bakkhim, Deputy Director, CENAT 8of16

10. - 2005 : Piloting in : - 3 ODs (2 provinces) (JICA,USAID/PATH, URC) - 2008 up to now : scaling up : - 37 ODs (10 provinces) (USAID/PATH/TBCARE I /FHI 360/ RHAC, RACHA) TB PPM sites ACHIEVEMENT TB PUBLIC-PRIVATE MIX DOTS Dr. Team Bakkhim, Deputy Director, CENAT 9of16

11. Year 2005 2006 2007 2008 2009 2010 2011 District 3 15 37 37 37 37 37 Private* 287 755 1362 1690 1735 1735 1547 ACHIEVEMENT : PRIVATE PROVIDERS INVOLVED IN TB PPM-DOTS * Pharmacy, Cabinet/clinic, Laboratory, other TB PUBLIC-PRIVATE MIX DOTS Dr. Team Bakkhim, Deputy Director, CENAT 10of16

12. Year 2005 2006 2007 2008 2009 2010 2011 Total Referred 314 1989 5562 4212 9781 7612 5024 34494 Received 242 1154 2763 1882 5540 4280 2920 18781(54%) TB cases 46 224 533 301 769 851 691 3415 ACHIEVEMENT : REFERRED, RECEIVED AND TB CASES 76% 58% 50% 45% 57% 58% There is clear benefit to involving private providers to identify undiagnosed TB cases, to stop selling Anti-TB drugs and prevent MDR-TB TB PUBLIC-PRIVATE MIX DOTS Dr. Team Bakkhim, Deputy Director, CENAT 11of16

13. LESSONS LEARNT(1)  Factors for success:  Strong support from MoH officials and key stakeholders (USAID, JICA…)  Leadership from NTP at all levels (Central, Provincial, OD)  Clear task division (MoU)  Commitment from all partners (PATH, JICA, URC, RACHA, RHAC, CATA…)  Strong support from professional societies in Cambodia (CMA, PAC…)  High commitment/motivation of private providers at all levels (Pharmacist, cabinet/clinic,…) TB PUBLIC-PRIVATE MIX DOTS Dr. Team Bakkhim, Deputy Director, CENAT 12of16

14.  Geographic application :  Usefulness of PPM-DOTS in less-populated geographic areas (rural) : Solution applying difficulties (thinly populated, transportation, time, money…)  Recommendations : should be integrated with other projects  Partnerships :  Need participation of all private providers  Recommendation : Link with other organizations/institutions (Cambodia Medical Council Committee, Cambodia Pharmacist Council Committee, Cambodia nurse/midwife association…) LESSONS LEARNT(2) TB PUBLIC-PRIVATE MIX DOTS Dr. Team Bakkhim, Deputy Director, CENAT 13of16

15.  Supportive supervision:  Supervision : to ensure that they maintain a high commitment to their efforts to achieve the TB PPM-DOTS goals.  Recommendations : need regular conscientious supervision of PHD/OD  Regular meetings :  The meetings between the key players are critical factor in the program success and serve several vital functions (opportunity to learn best and receive feedback and new health information) LESSONS LEARNT(3) TB PUBLIC-PRIVATE MIX DOTS Dr. Team Bakkhim, Deputy Director, CENAT 14of16

16.  Incentives:  Private providers, especially pharmacists in Cambodia participate and support public health programs for reason of merit-offering, professional development and social status.  Recommendations : offering a cash incentive to key players would not threaten program sustainability. LESSONS LEARNT(4 ) TB PUBLIC-PRIVATE MIX DOTS Dr. Team Bakkhim, Deputy Director, CENAT 15of16

17. THANK YOU! TB PUBLIC-PRIVATE MIX DOTS Dr. Team Bakkhim, Deputy Director, CENAT 16of16