WHO report 2008
Global tuberculosis control
2.5 Engaging all care providers
2.5.1 Public–public and public–private mix approaches
Considerable progress has been made since the PPM initiative was launched by WHO in 2000. By 2007, 16 of the 22 HBCs had a focal person for PPM in the central NTP, 16 had undertaken a situational analysis for PPM implementation and 14 had developed national operational guidelines for PPM. The number of HBCs scaling up PPM interventions more than tripled between 2005 and 2007, from four to 14 countries.
Almost half of the HBCs have managed to involve all health institutions belonging to public sector health-care networks, such as public hospitals, medical college hospitals, army health facilities and prison health facilities (Figure 2.18 and Figure 2.19). A large number of HBCs have also started to involve private practitioners, private hospitals and NGO health facilities in key activities such as referral of patients with TB symptoms, diagnosis according to programmatic guidelines and treatment with anti-TB drugs provided by the NTP (Figure 2.18 and Figure 2.19). However, in most HBCs, only a small fraction of all eligible providers belonging to these categories has been involved to date.
Of the top five HBCs, three HBCs (Bangladesh, China and India) reported formal PPM activities in place in nearly 100% of their basic management units (BMUs). However, geographical coverage of formal PPM activities does not imply a high level of actual involvement or contribution to referral, diagnosis and treatment by non-NTP providers. To quantify the contribution of different providers to referral, diagnosis and treatment, PPM monitoring that is in line with existing WHO guidelines on recording and reporting for NTPs needs to be implemented. By 2007, only nine of the 22 HBCs had started to systematically record the source of referral and place of treatment of patients.
Among all countries, around 100 or more (depending on the category of provider) reported that all or some of the following types of provider were involved in referral and diagnosis: private practitioners, private hospitals, general public hospitals, medical colleges and prisons. Numbers were lower (mostly around 60 to 80 countries reporting the involvement of some or all providers) for three categories: NGO and mission facilities, health and social insurance services, and the corporate sector. Figures were generally lower again for treatment. Around 70 countries reported that some or all providers in the following categories were involved in treatment: private practitioners, private hospitals, NGO and mission facilities, and health insurance services, although figures were higher for the involvement of medical colleges (100 countries) and general public hospitals (127 countries). Details of these data are not shown in this report, but are available upon request.
2.5.2 International Standards for Tuberculosis Care
The ISTC have been disseminated and used in seven HBCs and endorsed by national professional associations in six HBCs. Several HBCs have promoted and implemented the Standards in some settings: examples include Indonesia, India, Kenya, Thailand and the United Republic of Tanzania. Other HBCs including China, Kenya, Myanmar, Nigeria, Thailand and the United Republic of Tanzania have plans to either launch the ISTC nationally or to use them to target specific groups of care providers. Kenya plans to use the ISTC as a tool of accreditation. The ISTC have been particularly useful for convincing national professional societies and associations, as well as academic institutions, to support implementation of internationally recommended approaches to TB control.