TB PUBLIC-PRIVATE MIX DOTS
Dr. Team Bakkhim
Deputy Director
CENAT
NATIONAL FORUM ON PUBLIC-PRIVATE PARTNERSHIP IN
Intercontinental Hotel
HEALTH
7th November, 2012
OUTLINE
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Background of TB PPM-DOTS
TB PPM-DOTS : Design and implementation
Lessons learnt from the success
Recommendations
TB PUBLIC-PRIVATE MIX DOTS
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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 )
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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
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PHASE I REFERRAL STRATEGY
Public Hospital / Health Center
=
Diagnosis, Treatment
Recording & Reporting
Referral System
Private Clinic / cabinet
Private Pharmacy / depot
Private Lab.
Clients suspected TB
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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
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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)
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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
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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.
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ACHIEVEMENT
TB PPM
sites
- 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)
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ACHIEVEMENT : PRIVATE PROVIDERS INVOLVED IN TB PPM-DOTS
1800
1600
1400
1200
1000
District
Private
800
600
400
200
0
2005 2006 2007 2008 2009 2010 2011
Year
2005
2006
2007
2008
District
3
15
37
37
Private*
287
755
1362
1690
2009
2010
2011
37
37
37
1735
1735
1547
* Pharmacy, Cabinet/clinic, Laboratory, other
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ACHIEVEMENT : REFERRED, RECEIVED AND TB CASES
10000
9000
8000
7000
6000
5000
4000
3000
2000
1000
0
57%
57%
58%
50%
45%
Referred
Received
TB cases
58%
76%
2005
Year
2005
2007
2009
2011
2006 2007 2008 2009 2010 2011
Referred
314
1989
5562
Received
242
1154
2763 1882
TB cases
46
224
533
4212
301
Total
7612
5024
34494
5540
4280
2920
18781(54%)
769
851
691
9781
3415
There is clear benefit to involving private providers to identify undiagnosed
TB cases, to stop selling Anti-TB drugs and prevent MDR-TB
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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,…)
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LESSONS LEARNT(2)
 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…)
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LESSONS LEARNT(3)
 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)
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LESSONS LEARNT(4 )
 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.
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THANK YOU!
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