Tuberculosis (TB)

Public-Private Mix (PPM) for TB Care and Control

Country Experiences

India: mainstreaming PPM
India has many successful initiatives aimed at engaging its vast number of public and private health care providers. These initiatives aim to ensure equal access for all patients to good quality treatment, improved treatment results and reduced costs of care.

The Revised National TB Control Programme (RNTCP) has already developed guidelines to institutionalize involvement of NGOs and private practitioners. As of December 2007, the RNTCP was engaging with 2,946 NGOs and 17,695 private practitioners. An important part of mainstreaming PPM in India has been the public and private medical colleges. The RNTCP has constituted five zonal taskforces and seven nodal centers to steer and involve medical colleges across the country. Over 250 medical colleges were involved with the RNTCP as of December 2007 and approximately 10% of sputum positive cases were diagnosed at medical college microscopy centers.

Recognizing the potential of involving the corporate sector, the RNTCP is working with over 150 corporate houses through the Confederation of Indian Industries (CII), Federation of Indian Chamber of Commerce and Industry (FICCI) and the World Economic Forum to provide TB control in the workplace. The RNTCP is also working closely with the Indian Medical Association to engage its broad network of 160,000 medical practitioners, with support from a five year – “Umbrella Model” project under the Global Fund.

The RNTCP’s approach to other public sector institutions is directed at three levels: the central TB unit generates policy directive from the relevant ministries to health facilities under their jurisdiction; state-level RNTCP staff pursues it through; and local-level staff undertake training, implementation, support and monitoring.

The special initiative launched by the Central TB Division in India in 2003, to scale up PPM in 14 large urban areas came to a successful close at the end of 2007. Evaluations show important contributions to increased case detection and improved treatment results. A phased countrywide expansion is ongoing.

The Philippines: Public-Private Coalition Against TB
The first PPM project in the Philippines was set up in 1995 by a private infectious disease specialist based in a university hospital. Since then, several PPM projects have been put in place with support and encouragement from the Department of Health. These include initiatives in diverse settings such as hospitals, corporate health facilities, family practices and the workplace. Evaluations of these projects have convincingly demonstrated the feasibility of effectively engaging different types of health care providers in DOTS implementation. Collectively PPMD projects have shown a sustained impact on case detection and treatment success rates.

DOTS center in the Philippines

The Department of Health has made great strides in scaling up PPM in the country. To facilitate large scale expansion of PPM, the DoH has received drugs from the Global Drug Facility and grants from the Global Fund and other donors. National and regional coordinating committees for PPMD have been created, operational guidelines for PPMD developed, training materials prepared, and over 220 PPMD units established across the country. As of December 2007, around 5000 physicians were trained and 48 206 patients were treated with high success rates at the PPMD units, over 60% of which were accredited by PhilHealth.

The Philippines Coalition Against Tuberculosis (PhilCAT), the ‘TB DOTS outpatient benefit package’ of PhilHealth– the national health insurance organization, and a large private sector project for TB control, PhilTIPS, have also contributed to effectively engaging all stakeholders in TB control.

In addition in April 1999, a DOTS-Plus pilot project was initiated at the Makati Medical Center (MMC) in Manila, Philippines in collaboration with the Tropical Disease Foundation and the Barangay San Lorenzo with financial support provided by the Philippine Charity Sweepstakes. This project: the Makati Medical Center (MMC) DOTS Plus pilot project was aimed at managing MDR-TB through the utilization of individualized treatment regimens based on drug susceptibility testing (DST) and administered by directly observed therapy (DOT).A study conducted to evaluate the project in 2005, concluded that the project demonstrated that treatment of patients with MDR-TB using the DOTS-Plus strategy and individualized drug regimens can be feasible, comparatively effective, and cost-effective in low- and middle-income countries.

Kenya: Engaging private chest specialists
In 2000, a brand new strategy was launched aimed at engaging Nairobi's private chest physicians in TB control. The initiative allowed doctors to receive anti-TB drugs at reduced rates if they agreed to keep records of TB patients and report outcomes to the national TB control programme. Still in its early scale up phase, PPM in Nairobi is showing a positive impact.

In 2005, nine percent of 20,000 cases notified were managed by the private sector and their contribution is expected to rise to 20%. Similar schemes are now under way in four other major cities of Kenya. Altogether, 88 private sector DOTS centres have been established covering a population of about 5 million.The focus of PPM is also broadening to include frontline private care providers - nurses and clinical officers. Training courses, based on the TB national guidelines, are also being offered through professional associations.