Public-Private Mix (PPM) for
TB Control in Global Fund grants
Scope and significance
SS Lal *, Mukund Uplekar#, Itamar Katz*, Knut Lonnroth#, Ryuichi
Komatsu*, Monica Yesudian#, Mohammed A Aziz*, Rifat Atun*
* The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva
# World health organization, Geneva
Background
• TB case detection stagnating a little over 60%
• Efforts to strengthen TB control mainly in public sector
• Providers outside NTPs:
– yet to be fully involved
– TB management practices questionable/cases not notified
• ‘Engaging all care providers’ through PPM approaches :
essential component of Stop TB Strategy
• Stop TB Partnership's PPM sub-group set up specifically
to address this issue
The Global Fund and PPM
• Global Fund (GF) is a major funding source for
NTPs
• Global Fund in itself a public-private partnership
• Country coordination mechanism (CCM) - national
level partnerships of stakeholders
• Global Fund financing enables to set up/scale up
PPM
Methodology
•
Extent and scope of PPM interventions in
approved Global Fund grant proposals

Evolution of Global Fund support to PPM, as reflected in its
official documents/processes

Distribution, trends and characteristics of PPM initiatives
within the Global Fund-supported programs
•
PPM programmes in selected country settings

Six country case studies: Bangladesh, China, India, Kenya,
Pakistan, and the Philippines
PPM in Global Fund documents and
processes
• Proposal guidelines
• Assessment of proposals by Technical Review
Panel
• PPM indicators within the Monitoring and
Evaluation Toolkit
–
–
–
–
Private and Public health providers collaborating with NTP
Proportion of NSP cases referred by health care provider
NSP cases managed/supervised by health care provider
NSP cases successfully treated by a health care provider
Number and percentage countries with
GF funding for PPM
Number of countries with PPM activities within active grants
% of countries with PPM activities within active grants
70
80%
60%
58
60
62%
50
50
59%
58%
29
42
39
57%
40
56%
55%
30
40%
20
20%
Number of countries
% of countries with active TB grants
100%
13
10
0%
0
2003
2004
2005
2006
2007
2008
Trend of the proportion and number of countries which received Global Fund
support for PPM activities N=Number of countries with active TB grants
Percentage of countries with GF
funding for PPM across regions
% of countries with active TB grants
90%
82%
63%
67%
62%
56%
50%
52%
60%
30%
0%
Latin America & the Caribbean
South and East Asia
Sub-Saharan Africa
North Africa & the Middle East
Eastern Europe & Central Asia
0%
2003
2004
2005
2006
2007
2008
Trend of the proportion of countries with Global Fund support for PPM activities, by region
N=Number of countries with active TB grants per region
Number of countries with GF funding for PPM
Number and proportion of countries with GF funding
for PPM that involve different health providers
Prison
30
Private
NGO
Others
28 (48%)
24
25
19
20
17
19
17
15
20 (34%)
18 (31%)
15 (26%)
11
10
13
14
11
8
5
5
4
3
0
2003
2004
2005
2006
2007
2008
Trend of the number of countries with Global Fund support for PPM activities
(proportion of countries with GF funding for PPM), by implementer
Common types of collaboration within countries
with GF funding for PPM across regions
NGOs
Prisons
Private
Sector
East Asia & the Pacific
(8)
38%
38%
25%
38%
0%
Eastern Europe &
Central Asia (11)
36%
91%
18%
27%
9%
Latin America & the
Caribbean (8)
25%
63%
0%
50%
0%
North Africa & the
Middle East (8)
63%
25%
38%
25%
13%
South Asia (6)
50%
17%
67%
17%
50%
East Africa (5)
0%
40%
40%
0%
20%
Southern Africa (4)
25%
0%
0%
50%
50%
West & Central Africa
(8)
25%
63%
25%
38%
13%
All regions (58)
34%
48%
26%
31%
16%
Region (N)
Other
Not
specified
Budgets and expenditures
• 4.4% of TB funding of Global Fund allocated to PPM through
2008
• Median spending of Global Fund grants with PPM component
on PPM was 5% of total TB expenditure
• Top 2 regions with highest share of budget allocated to PPM:
– East Asia and the Pacific: 10.4%
– West & Central Africa: 6.9%
• Largest PPM investments were in
– China: US$ 18.8 million
– Indonesia: US$ 6.1 million
– Ghana: US$ 3.5 million
Country studies: PPM performance
in selected countries
Country
PPM provider
category
Contribution
Bangladesh
Village doctors
Referred over 28,000 TB suspects, contributed to
15% NSP case detection (2006), supervised half
the detected cases, treatment success: 90%
China
Hospitals
Contribution to case notifications rose from
16.3% (2004) to 32.9% (2007), achieved Global
Targets
India
Diverse
providers
14 city scale up: private providers contributed 16%
of the TB cases, treatment success rate: 86%
Kenya
Chest
physicians
10% cases in Nairobi referred/treated by private
chest physicians
Pakistan
Diverse
providers
A fifth of all cases detected (39,635) contributed by
PPM providers, Karachi:50% from PPs
Philippines
Private clinics
18% of NSP cases referred by private
providers in PPM areas. Treatment success: 88%
Limitations
• Underestimation of the PPM within TB grants
supported by the Global Fund:
– Limited data on sub-recipients of Global Fund grants including
activities implemented by NGOs and the private sector
– Categorization of PPM types: No mechanism to identify public
health facilities that are not part of NTP
• The Global Fund is not the only financier and there is
a lack of sufficient information to estimate the
contribution from other funding agencies.
All these limitations require further in-depth case studies.
Summary
• Importance and scope of PPM not reflected at desired
level in TB proposals and budgets
• Over a third of countries with active Global Fund TB grants
do not have PPM as a component
• The current median budget allocation for PPM activities of
5% is probably not sufficient for large-scale PPM initiatives
• Extent and type of PPM with Global Fund financing varies
by region
• PPM contributed 15-20% to the referral and/or treatment
of detected cases
• Improvement in treatment success at private sector
providers
• Untapped potential exists in scaling up PPM across
countries
Acknowledgments
Daniel Low Beer
Donna lee
Aboua Ange-Joel Djoman
Country programs, Global Fund
National TB Control Programs
THANKS