PPM Public Private Mix Pakistan

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PPM (Public Private Mix)Pakistan

• NTP Managers Meeting
• Tunis, May 2007

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Population160 million 1/3rd below poverty line

• 6th among the HBCs , contributes about 44 of
  tuberculosis burden in EMR
• Estimated 250,000 new TB cases each year.
• Approximately 1.5 million people in Pakistan
  infected with the disease
• . TB is responsible for 5.1 percent of the total
  national disease burden in Pakistan.
• The incidence of sputum positive TB cases is
  80/100,000 per year and for all types it is
  177/100,000
• 100 public sector (PHC) DOTS coverage in the
  country

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PakistanPopulation 161MDCsTCs Public Private
NA Pop 1M DC 11
FATA Pop 3.7M DC 24 TC 224

• Country map and information

AJK Pop 3.7M DC 67
NWFP Pop 21M DC 193 TC 692
Punjab Pop 87M DC 462 TC 2681
Balochistan Pop 8M DC 80
Sindh Pop 37M DC 205
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TB Epidemiology

• M/F ratio 49
• Age trend 15-24 years - highest in numbers

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Why PPM In DOTS

• Programme is in Consolidation phase
• Expanding and sustaining DOTS
• Improving quality of care
• Implementing EQA
• Mobilizing community
• Engaging all health care providers
• Increase Choices and accessibility

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Composition of Non-NTP structure
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PPM rationale and objectives

• 100 NTP DOTS coverage CDR still 50.
• PPM projects elsewhere15 - 50 increase in CDR
• Sizeable non-NTP sector, with high potential
  role.
• Patients preferences non-NTP options.
• New Stop TB Strategy enhanced scope of work.
• Programme is in Consolidation phase
• Engaging all health care providers
• Increase Choices and accessibility
• Objectives
• Enhance DOTS coverage and quality
• Face new challenges (MDR, TB-HIV, Hospitals)

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Utilization of health services
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NTP preparedness-1

• National strategic framework for PPP development
  a part of National strategic plan (2005 - 10)
• PPM model and guidelines development exercise
• PPM implementation incorporated in public budget
• Coverage Nationwide
• Allocation USD 8 M (Federal)
• Approach District-led partnership development
• Strengthening nationwide EQA to support Public
  and Private sector providers.
• DOTS implementation in Public sector
  satisfactory results

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NTP preparedness-2

• Multiple small-scale PPM implementation
  initiatives launched
• Greenstar - franchising (GFATM)
• PATA and AKHSP - network strengthening (GFATM)
• MC and ASD - public sector strengthening through
  PPM (FIDELIS/EC)
• TAF - ACSM in 20 districts (GFATM)
• USAID supported PPM Initiative
• Peshawar model (supported by GTZ)

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Preparedness of non-NTP providers

• Academic society involved
• Pakistan Chest Society and Paediatric Society
• Pakistan Medical Association and Family Physician
  Association and Paediatric association contacted
  
• Encouraging small-scale PPM experiences
• Intervention with private hospitals development
  and implementation in selected districts

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Regulatory environment

• Constraints
• Anti-TB drugs easily purchased from the market.
• TB notification not mandatory.
• Almost no regulations (implemented) on
  establishment of private practice
• Enforcement of the existing regulations weak.

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Example 1 LahoreCase Detection in Lahore
District, Q1-A4 2006
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Example 2 Case Notification by Sector, Karachi
City, 2003-2006
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(No Transcript)
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Example 3 Peshawar modelGTZ support to NWFP

• Implementation thru District TB Officers (DTO).
• Free medicine provided by DTO to the PPs
• PPs permitted to charge the patients for their
  service at specified timing.
• Diagnosis by sputum examination through
  public/private sector labs
• PTP provide TA in identifying and QA of private
  labs.
• DTOs provide TA, training and MS

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Example 3 Peshawar Model
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Contract and Advocacy

• Regulatory framework document for PPP.
• Agreed arrangements/instruments mapping,
  selection, technical support, regulation,
  franchising, contracting, training/supervision
  etc.
• MoUs public and individual private partners.
• Advocacy
• Advocacy package
• Promotion of ISTC (with Pakistan Chest Society
  and Pakistan Medical Association)
• Provider-patient interaction enhancement tool

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Scale up of PPM

• By FY2010/11 (June 2011)
• Ensure all patients in the country get quality TB
  care, as per NTP guidelines
• Expanded in a phased manner
• First 10 districts be initiated in 2007
• Expansion to 30 districts every year

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Thank you
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PPM DOTS

• National TB Control Program Pakistan

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Engaging all health care providers-1

• Situation analysis
• Large but unregulated private sector
• More than 50 of patients (general) in private
  sector
• Private sector accessible to urban and rural
  population
• Operational research
• Capabilities and capacities
• Health seeking behavior
• KAP private providers
• Training and sensitization effect
• PPM pilots
• Development work
• Consultations
• Strategic framework

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Engaging all health care providers-2

• Initiatives TB care delivery
• NGOs not for profit- PATA, AKHSP (GFATM)
• Franchise DOTS- Green star (GFATM)
• Local small scale initiatives
• Strengthening of public sector by NGOs (Fidelis)
• Parastatal institutions (Fidelis)

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TB and Private sector

• 70 of Heath Expenditure Through Private Sector
• - large but unregulated.
• - Wider variation in capacity and quality of
  services.
• A large proportion of TB patients detected by
  private HCP are not notified and treatment
  outcomes not recorded

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NTP PPM

• NTP has established various activity based
  partnerships with NGOs, largely with the
• - support of GFATM and FIDELIS GTZ.
• The Private sector partner contribution is in the
  following four main areas
• Program development
• Public sector service
  strengthening
• NGO service strengthening
• Enabling a network of private
  for-profit

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PPM initiatives -2

• PROGRAM DEVELOPMENT
• Strategic planning
• Program Guidelines and material development
• Human resource development
• Operational research

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PPM initiatives -3

• PUBLIC SECTOR SERVICE STRENGTHENING
• Human resource development, materials,
  supervision, community mobilization and
  operational research, implemented through EC and
  FIDELIS support.
• Partners- ASD, Mercy Corp
• Community mobilization through interactive
  theatre through GFATM-III support.
• Partner The Asia Foundation, BDN

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PPM initiatives - 4

• NGO SERVICE STRENGTHENING (GFATM-II)
• Support for human resource development,
• Materials
• Supervision/monitoring
• Two Nationwide Networks of NGO clinics are
  strengthened
• Pakistan Anti-TB Association (PATA) and
• Aga Khan Health Services (AKHSP)
• ENABLING A NETWORK OF PRIVATE FOR-PROFIT
  PROVIDERS
• (GFATM-III)
• Franchising TB Services piloted in four
  metropolitan cities
• PartnerGreen Star
•  

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Sindh Experience

• New smear positive cases detected by the private
  and public sector in
• Sindh Province, Quarter 2, 2006
• In Sindh province, the involvement of private
  sector in TB DOTS is in ten districts.

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PPM INITIATIVES

• NTP has included public-private partnership (PPP)
  development as a priority strategy in its next
  five year development plan.
• 39 percent of total cost of PC-1 is allocated for
  PPM
• National strategic framework has been formulated

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NTP's proposed strategic framework and possible
means of partnership
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Research

• National TB Control programme conducted two
  research studies to develop a model of
  partnership with the GPs.
• - The first study was a KAP study conducted in
  2003 in two major cities of Pakistan.
• - The second was an intervention study designed
  in the light of findings of the previous study.
  The aim was to develop a viable model for PPP to
  involve the private practitioners in the DOTS
  delivery system.

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Evidence Based Decision making

• Private Public Mix
• Base line study in 2001 General Practitioners
  Does not Follow The National Guidelines for
  Management of TB Patients.
• Intervention study concludes a Practical model
  to involve GPs in DOTS improve management
  Practices and Treatment outcome
• Adaptation of Recommendation for implementation
  of PPM Model through PC1

• Community based DOTS
• Two Intervention study to see the effects of
  community based DOTS
• The Studies Concludes that involvement of LHW as
  treatment supporter improves Case detection, Case
  holding and treatment outcome.
• Adaptation of Study results as LHW CIDA Project
  to train LHW as treatment Supporter in twenty
  Districts.

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PPM Strategy

• PPM models and implementation guidelines
  developed (through TAMA support)
• - A situation analysis has been carried out
  through a participatory process as initial step
  to develop PPP models.
• - PPP models and their implementation and
  monitoring guidelines were developed through
  focus group discussions, key informant interviews
  and consultative workshops.

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Urban and Peri-urban PPP Framework
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Rural PPP Framework
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Monitoring and Supervision mechanism for PPP DOTS
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Flow of National support to Partnership TB DOTS