Tanahashi Round-5

Md. Akramul Islam, Associate Director, Health Nutrition and Population Program, BRAC, made a presentation on ‘PPP for Effective Coverage of TB’.

PPP for Effective Coverage of TB

28 May, 2013

Secretariat Center of Excellence for Universal Health Coverage (CoE-UHC) project, James P Grant School of Public Health (JPGSPH) Level-6, icddr,b, Mohakhali Dhaka, Bangladesh

The Center of Excellence for Universal Health Coverage (COE-UHC) at the James P Grant School of Public Health and UNICEF jointly organized the 5th Tanahashi Rounds on 28th May, 2013. The 5th rounds focused on the Public Private Partnerships for Effective Coverage of Tuberculosis program – What can the Tanahashi framework contribute? Two presenters introduced the topic for discussion: Dr. Mirza Nizam Uddin, Deputy Program Manager, National TB Control Program, DGHS and Md. Akramul Islam, Associate Director, Health Nutrition and Population Program, BRAC. The discussion was moderated by Professor Dr. Timothy G. Evans, Dean of the JPGSPH and Dr. Pascal Villeneuve, UNICEF Representative.

Dr. Mirza Nizam Uddin Deputy Program Manager, National TB Control Program DGHS Dr. Nizam Uddin provided an overview of the epidemiology of TB and the National TB control program (NTP) in Bangladesh. According to WHO estimates, Bangladesh is the country with the 6th highest number of cases of Tuberculosis with an estimated prevalence of 411 persons with TB per100,000 population or about 650,000 persons living with TB. The estimated case fatality of TB is 45/100,000 equivalent to about 70,000 deaths due to TB per year. While the majority of cases are pulmonary TB diagnosed as sputum smear positive, the epidemiological picture is complicated by the so-called “hidden cases”: pulmonary TB that is smear negative; non-pulmonary TB, problems with under-diagnosis in children,

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Functional Structure of NTP, Bangladesh

Tanahashi Round-5

and detection of multi-drug resistant TB a major cause of TB relapse. Dr. Uddin’s presentation depicted three distinct periods in the evolution of the NTP: the pre-DOTS (directly observed treatment – short course) era up to 1993; the DOTS era from 1993-2006; and the Stop TB strategy since 2006. In the pre-DOTS era the program was a vertical government run program through clinics and hospitals focussing on individualized treatment regimens. With DOTS in 1993, an integrated approach was introduced in which the Government of Bangladesh joined with BRAC and 43 NGOs in a Public Private Mechanism (PPM). This PPM has remained the foundation of the further evolved STOP TB strategy in 2006 that has 100 per cent administrative coverage of the country. The

NTP draws on a detailed division of labour between Government and NGO partners, that extend from the central level to the grass roots and specifies division of labours with clear responsibilities for each tier of partner. The Government roles focus particularly on ensuring that diagnostic laboratories are observing standards and on procurement of equipment and drugs. The NGO roles support service delivery and community mobilization. Together the partnership includes participatory planning and joint review, resource mobilization, health systems strengthening and advocacy and communication. An indication of the strength of the NTP structure is evident in the way in which it has received support from the Global Fund for AIDS, TB and Malaria:

since 2004 the GFATM has provided “dual track funding” to two principal recipients amounting to about $US 130 million to the Government and $US 150 million to BRAC on behalf of the consortium of NGOs. This support has helped to strengthen the PPM approach, the achievement of NTP targets and the strengthening of community and health systems. Mr Uddin, highlighted the importance of having infrastructure for TB control program that includes availability of well-equipped laboratory facilities for quality diagnosis of new cases and adequate human resources. Bangladesh has been offering free services for detection of new cases as well as laboratory tests for those who have already developed TB.

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Tanahashi Round-5

National case notification Absolute number: 2001-2012

Md. Akramul Islam, Associate Director, Health Nutrition and Population Program, BRAC Dr Islam began by noting the milestones achieved by the NTP not only with the successful expansion and implementation of DOTS program, but also by building community trust. He focused on trends in national case notification in the last 11 years noting a large increase in detection of smear positive TB (more than a doubling) as well as a large rise in case detection of non-pulmonary TB. Despite this increase, the case notification rates is only thought to be about 70% of total cases at present suggesting that the first step in TB coverage – diagnosis - remains a significant barrier to effective coverage (see slide National Case notification). In contrast, of those

diagnosed with TB, the treatment success rate has improved from 80% to 92% over the last two decades. This improvement in treatment success is equally reflected in the decrease in MDR TB that has declined from 3.6% of new TB cases in 2006 to 1.4% in 2011. Drawing on the Tanahashi model, Dr. Islam highlighted that the NTP through its country-wide PPM structure provides very high (100%) availability coverage. Despite this high availability of the program, the low case detection rates suggest that there may be significant bottlenecks related to accessibility and utlization. It was noted for example, that many patients are not aware that they have TB and hence are unlikely to seek diagnosis. Similarly, in certain contexts such as urban slums, many TB patients are failing to register with the NTP. For once in the TB

program, however, the treatment completion rates are very high suggesting that accessibility, acceptability and utilization coverage are very strong as reflected in the 92% treatment completion rates of diagnosed cases. Dr. Islam highlighted four challenges for improving effective coverage of the NTP: i) increasing the level of private sector involvement in the NTP especially amongst informal providers and private diagnostic clinics; ii) overcoming the delay in initiating treatment following diagnosis; iii) addressing the problem of MDR and TB-HIV co-infection cases and iv) strengthening the health care system to respond more quickly to “hidden cases” including smear-negative TB, extra-pulmonary TB and children with TB.

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Tanahashi Round-5

The discussion was interactive at Tanahashi round 5.

At the end of his presentation, Dr Islam shared some of the lessons learnt through the PPM approach of the NTP: • Strong government leadership is essential and has no substitute for its leadership roles; • Partnerships between/among private, public and NGOs sectors require effective and efficient management and institutionalization • Partners must actively develop their own capacity • All infrastructure requires ongoing support and supervision; • Effective TB control requires continuous updating and change informed by good research on effectiveness. Discussion Participants acknowledged the significant accomplishments of the NTP and its global recognition as one of the best TB control programs in the world drawing on its unique public-private structure. A number of points related to the Tanahashi analysis of the NTP were raised. First was the recognition of the need for multiple levels of Tanahashi analysis: that the national program is perhaps too large in aggregate to generate meaningful insights into the availability, accessibility, acceptability and utilization bottlenecks that are

limiting effective coverage. But rather, a focus on different sub-national levels such as Districts or Upazilas with low or high coverage levels as well as focusing on urban slums will expose the coverage gaps and constraining factors to effective coverage of the NTP. This higher resolution analysis of constraints may inform adjustments to the national program in those specific contexts and help to improve overall effective coverage. Linked to effective coverage of the NTP is the recognition that while the national TB program is a publicprivate partnership, there is a need to further understand how the publicprivate interface can inform delivery in difficult settings. For example the first level of care sought by many persons with TB are either informal providers or private diagnostic clinics who are economically driven and may be reluctant to integrated into the NTP that offer free service. In addition, these providers despite opportunities for training and guidelines for referring patients, may not be sufficiently integrated into the NTP. Arising from the analysis was the impression that “timing” in the delivery of the NTP is critical i.e. the time between case detection and initiation of treatment was revealed to be as much as 12 weeks in some cases. Lack of timeliness, or delays,

in getting patients diagnosed and started on appropriate treatment appears to be an inhibiting factor to effective coverage. It was recommended that research be undertaken on the causes of the delays and efforts to improve timeliness such as demand creation through community mobilization or strengthening “community penetration of the NTP. More so, an element of time was also recommended as one of the factors to be considered in the definition of effective coverage to challenge current norm. It was remarked that while the treatment completion rates for the NTP are very high (over 90%), the case detection rates appear quite low (about 70%). There are a multitude of possible reasons for lower than expected case detection rates including for example urban diagnostic centres that may be under-reporting, certain disadvantage populations that remain beyond the reach of the NTP i.e. urban slum dwellers and migrant workers, low detection of “hidden” cases, and even problems with the estimated denominator perhaps being too high. Some of icddr,b’s research on risk factors as well as further research on the possible reasons for low case detection as well as assessments on the yield of more “active” case detection strategies will be important in addressing this issue.

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to analyze TB Services

Coverage determinants applied

Tanahashi Round-5

Central to Tanahashi analysis is having good data on the population in question both in terms of the numerators i.e. those that are diagnosed and get treatment but also in terms of the deonominators i.e. the total population with TB. Unfortunately, most of the denominators in Bangladesh are based on WHO estimates and not on nationally representative studies. This shortfall will be remedied in the coming year with the conduct of a national prevalence survey for TB supported by the GFATM. While responding to critical queries of the respondents, Dr. Akram appreciated the participants for their enthusiastic participation and thoughtful analysis of the program which made the session for them a real learning one. He admitted that these queries created the opportunity for more analysis and looking at potential strategies to effectively bridge coverage gaps. He committed to returning with more advanced analysis on some of the points raised by the participants in a future Tanahashi round. In response to adoption and regulation of new technology for case detection of TB and NTP’s action to address these challenges, Dr. Akram was a bit disappointed while sharing the gaps

Adapted from Tanahashi T. Bulletin of the World Health Organization, 1978, 56 (2)

of TB care in-terms of point of care and unavailability of new technology. He talked about necessity of more modern drugs, diagnosis tool and accessible point of care. Regarding partnership among different NGOs and government and treatment guideline to be followed, Dr. Uddin talked about the MOU and pattern of this PPP and pointed that every partner organization has to follow the NTP guideline to avoid variation of treatment. In wrapping up the discussion, Dr. Villeneuve congratulated the colleagues for their presentation, particularly focusing on the PPP in the context of TB. He noted the complexity of the NTP program with multiple players with specific responsibilities. He also recognized that public-private collaboration extends beyond national boundariessuch as the GFATM and other international PPPs aimed at improving new drugs, vaccines and diagnostics for TB. He remarked that TB case management is a good case for Tanahashi analysis. The performance of the partnership can be visualized through the analysis pointing to underlying problems and directing attention to areas for improvement such as

avoiding delays between TB diagnosis and initiation of treatment. He stressed the importance of getting real denominators to get a precise estimate of how many people are actually diagnosed and received effective coverage. Dr. Evans started his closing remarks with an example from the Commission on Social Determinants of Health (WHO, 2008) that posed a cascade of provocative questions with respect to TB and poverty inspired by the Tanahashi framework: ‘why are poor people two times more likely to have TB, three times less likely to be diagnosed, four times less likely to have treatment and five times more likely to be impoverished in paying for their treatment?’. He remarked that the NTP with its public-private structure is one of the best performing TB program in the world and observed that its whole-ofsociety approach is an important model that should be considered in addressing other health problems. Ironically, and importantly it appears from the Tanahashi analysis that further extension and strengthening of the PPP structure of the NTP is likely to be the best approach to achieving even higher levels of effective coverage.

REPORT Tanahashi Round-5

Tim Evans of JPGSPH and Pascal Villeneuve of UNICEF moderated the session.

Tanahashi organizing team: IT support: Tapan Biswas Rouf Sarker

Overall Supervision: Dr. Timothy G Evans Overall coordination and Report preparation: Nadia Ishrat Alamgir Lal B. Rawal

Logistics: Sohel Rana Khorshed Alam Support: Mansura Akter Shah Ali

Invitation and Reception: Md. Rashidul Alam Mahumud Design/Communications: Kazi Shamsul Amin

Contact Nadia Ishrat Alamgir Sr. Research Associate Center of Excellence for Universal Health Coverage (CoE-UHC) project JPGSPH, Level-6, icddr,b, Mohakhali Email: [email protected]