Involving informal providers in TB
control
1|
TITLE from VIEW and SLIDE MASTER | July 24, 2016
Working definition
 Individuals working independently (not accountable to any
institution or organization), providing health related
services in a context not formally structured or clearly
regulated (e.g. practitioners of traditional medicine in
African countries); or practitioners not fully qualified to
provide the type of services that they are providing (e.g.
non-qualified providers, village doctors, drug sellers,
village injectionists in African villages etc.).
 “Informal” is not necessarily illegal.
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TITLE from VIEW and SLIDE MASTER | July 24, 2016
PPM: formal vs. informal providers
PPM
approaches
Informal providers
Public
hospitals
Corporate
clin../hosp
Military/P
olice/
Prisons
NGOs &
Faithbased
Private
GPs,
Pharm
acies
Traditio
nal
healers
Drugs
shops,
drugs
peddlers
- Herbalists
- Traditional Birth Attendants
- Spiritualists/faith healers
- Diviners
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TITLE from VIEW and SLIDE MASTER | July 24, 2016
Unqualified.
village
injectionist
s or village
doctors
Why involve informal providers?
They see important proportions of patients, incl.
TB suspects:
- 80% to THs for basic health needs;
- 64% of malaria cases managed by informal drug
sellers (Senegal),
- 66% of deliveries outside health facilities in rural
Uganda…
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TITLE from VIEW and SLIDE MASTER | July 24, 2016
What IPs are doing currently in TB…
 TB patients going to informal providers: a review indicated
that that 10 to 58 % of TB patients using IPs for TB-related symptoms
before diagnosis (Wilkinson, Gcabashe et al. 1999; Brouwer, Boeree et al. 1998;
Pronyk, Makhubele et al. 2001; Barker, Millard et al. 2006; Banerjee, Harries et al. 2000)
 Referral of TB suspects: e.g. village doctors in Bangladesh
referred 11% of ss+ TB cases (2002-2003) (Hamid Salim et al. 2006);
grocers in Malawi etc.
 TB treatment supervision: - as DOT supervisors, THs were as
good as conventional treatment supervisors with satisfactory treatment
completion, cure and clients satisfaction rates (Colvin, Gumede et al. 2003);
DOT supervision by village doctors in Bangladesh with about 90%
success rate (Hamid Salim et al. 2006)
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TITLE from VIEW and SLIDE MASTER | July 24, 2016
…
• IPs
and vulnerable groups: women with TB are more
likely to seek care from THs than men (35% vs. 18) and
experience significantly longer delays (3 months vs. 1.5)
according to a study from South Africa (Pronyk, Makhubele
et al. 2001) and from Vietnam (Thorson, Hoa et al. 2000)
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TITLE from VIEW and SLIDE MASTER | July 24, 2016
Aim with involving IPs in TB control
 Increase case detection
 Reduce diagnostic delays
 Improve equity in access to TB care
 Contribute to community TB care
 Support patients to enhance treatment adherence
 Prevent parallel use of anti-TB drugs and other (e.g. traditional
herbal) therapies
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TITLE from VIEW and SLIDE MASTER | July 24, 2016
Different ways to deal with informal
providers
 Outlawing and repression: e.g. traditional healers in colonial
times, until Alma Ata Conference
 Total indifference: increasingly rare in countries
 Training only: recognition and training - assuming that the
rest will automatically follow (most countries do this).
 More or less systematic involvement: including mapping,
task assignment, training, equipment, supervision, evaluation
and/sometimes provision of incentives (rare, most small scale
pilots…) – unique e.g. village doctors in Bangladesh
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TITLE from VIEW and SLIDE MASTER | July 24, 2016
Village doctors in Bangladesh – a unique example
30000
25000
20000
15000
10000
5000
0
20%
15%
10%
5%
Suspects
Contribution to
projects
0%
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
Absolute number
Suspects refered by village doctors and
contribution to the projects
Year
During the year 2006; suspects referral increased by 70% and case detection
by 27% compared to the year 2005
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TITLE from VIEW and SLIDE MASTER | July 24, 2016
Approach to involvement of THs in TB
control in Burkina
 Elementary task assigned to THs: to refer TB suspects
screening centres. No involvement in treatment supervision
 Organizational strategy: small THs organizations, known
to be effective and reliable and selected with the help of the
health district offices
 Financial performance-based incentives are provided to
THs through their organizations: 1000 FCFA (2,5 USD)
given for each TB suspect referred and screened.
10 |
TITLE from VIEW and SLIDE MASTER | July 24, 2016
The Burkina Model of engaging THs
Selection of TH associations
Active referral
| TITLE from
VIEW
SLIDE MASTER
11 suspect
TB
left
at and
clinic
Training/orientation
TB suspects visit TH
Referral and feedback
form
| July 24, 2016
Feedback forms collected by TH
TH explains TB and
treatment procedures
A few figures on contribution to case
detection – in absolute numbers
400
374
350
300
284
300
231
250
256
199
2006 :225 THs
200
150
2007 :133 THs
100
58
21
50
0
Referred
suspects
12 |
Feedback
from CDT
TITLE from VIEW and SLIDE MASTER | July 24, 2016
Screened
suspects
Cases
detected
Satisfactory SS+ positivity ratio
 Positivity ratio at 23%
in 2006 and 9% in 2007,
meaning THs are
performing good prescreening assessment
Pertes et précision dans les références
100%
85% 86%
80%
60%
40%
2006
2007
23%
20% 19%
20%
9%
0%
Lost referrals
13 |
% confirmed
suspects
TITLE from VIEW and SLIDE MASTER | July 24, 2016
% positive cases
 Important losses of
suspects between THs and
clinics
 Lower detection in
2007
Contribution of THs to case detection
Contributions à la détection au plan national 2006
2%
8% 2%
Labos privés lucratifs
Confessionnels
Tradipraticiens
Public et associatif
88%
14 |
TITLE from VIEW and SLIDE MASTER | July 24, 2016
Critical issues in involving informal
providers …
 Securing good relationship
between health districts and IPs
(knowing each other etc.)
 Assigning appropriate tasks to IPs
with regards to the context and
comparative advantages (do not
hesitate to go beyond the "training
fallacy")
15 |
TITLE from VIEW and SLIDE MASTER | July 24, 2016
 Strengthening IPs organisations
16 |
TITLE from VIEW and SLIDE MASTER | July 24, 2016
…
 Securing collaboration between NTP and other
programmes (HIV and Malaria)
 IPs and information system (recording and reporting data,
standardised or special forms?)- it is best not to overburden
existing systems from the beginning
17 |
TITLE from VIEW and SLIDE MASTER | July 24, 2016
What the PPM team is doing?
 Evidence-gathering (documentation of recent and current
experiences) and evidence-generation (in assisting NTPs to set up
pilot or learning projects)
 Providing technical assistance to countries developing PPM
guidelines, including IPs related issues
 Collaborating with partners in various issues on involvement of IPs,
e.g. development of training material for informal providers on TB, etc.
 Plan: to develop implementation guidance for NTPs on
how to bring onboard IPs in TB control
18 |
TITLE from VIEW and SLIDE MASTER | July 24, 2016
19 |
TITLE from VIEW and SLIDE MASTER | July 24, 2016