joint international monitoring mission, thailand, august 13-27, 2013 5 th joint international...

Joint International Monitoring Mission, Thailand, August 13-27, 2013

5th Joint International Monitoring Mission, Thailand,

August 13-27, 2013

The Major Findings

Dr Paul Nunn


Terms of Reference - I Review implementation of recommendations

JMM 2007, and 2009 Review progress in TB Control and towards

reaching the Millennium Development Goals Assessment of the adequacy, completeness and

quality of monitoring and recording and reporting systems

Identify actions to ensure the sustainability of the programme by the NTP and its partners


Terms of Reference - II Key focus areas:

effectiveness of case finding and contact tracing strategies TB control in Bangkok childhood TB treatment and care for non-registered migrants PMDT TB-HIV collaborative activities involvement of health insurance prisoners human resource constraints programme management in the context of a decentralized

health system.


Selected Sites of the 5th Joint International Monitoring

Mission to Review NTP Thailand, August 13-26, 2013

North Team: ODPC 9th Phitsanulok and Tak Province

North-East Team: ODPC 7th Ubon Ratchathani and Si Sa Ket Province

Central Team: ODPC 3rd Chon Buri and Samut Prakan Province

South Team: ODPC 11th Nakhon Si Thammarat and Phuket Province

Bangkok Team ODPC 1 Bangkok

Bureau of TB, Cluster of Planning, Monitoring and Evaluation. Updated: Apr 29, 2013

ODPC = Office of Disease Prevention and Control


Major Achievements - I Extension of health insurance to 98% of Thai

nationals with coverage for TB treatment Estimated incidence of TB less than half that of

Cambodia and Myanmar and has fallen 10% since 1990

Mortality and prevalence also declining and Millennium Development Goals will be met

Improvements in treatment success for new smear positive cases from 76% in 2007 to 85% in 2010 cohort


Major Achievements - II

Multiple grants from Global Fund Drug supply reliably assured 4th drug resistance survey showed no sign of

increase in multi-drug resistance The impact of HIV on TB has been mitigated TB/HIV services rolled out Prevalence survey successfully conducted


4 Major Issues to be Addressed


Major Issues to be Addressed - I Low case notification

Only 21 of 97 Bangkok hospitals report all their cases to the Bureau of TB. Private, university, military and MoPH hospitals under-reporting

Extent of under-reporting is unknown, but significant, especially in children, the elderly, those with MDR-TB

Notification law not enforced Regulatory oversight of TB notification at hospitals in Bangkok

not within the Bangkok Metropolitan Administration needs to be urgently established

Private health care sector not effectively engaged in partnership with NTP


Major Issues to be Addressed - II Inefficient reporting and surveillance systems

Data on new cases often entered into two separate paper systems and two computer systems

Multiple local spreadsheets used for local reporting and case management

Provinces and central Bureau of TB routinely analysing only aggregated data

Current systems for registering and following cases are inefficient and not exploiting existing opportunities

TBCM and SMART-TB have made progress – and could be further adapted

IT infrastructure excellent in Thailand and synergies could be had through sharing of data with NHSO data collection system


Major Issues to be Addressed - III Improvement of treatment outcomes is urgently

needed Nationally, treatment success was 82% in 2012 in new Thai

cases, below the international standard of 85% Private hospitals in Bangkok treatment success was 73% Cause mostly default, but also high case fatality – HIV, elderly,

marginalized, comorbidities etc. DOT working well in some provinces, but in others neither staff

nor patients convinced by DOT, and often fail to supervise patients

A wider range of support approaches is needed for patient-centred care than can be managed by public services alone

Large hospitals have difficulty doing DOT for discharged patients in the community


Major Issues to be Addressed - IV Provision of suitable care for all migrants in need

As many as 3.5 million non-Thai migrants in Thailand, many undocumented, most in border areas and Bangkok

Migrants, and their children, often marginalised, reduced access to health care, under-diagnosed (eg for HIV associated TB, MDR-TB), get less DOT, default higher, at risk of drug resistance

Fear of job loss and interactions with Ministry of Labour, police and immigration authorities are not conducive to positive health behaviour (>90,000 deported annually to Cambodia)

ASEAN Economic Community comes into force in January 2015 with free movement of labour which will likely increase immigration

Demand for healthy labour, human rights, and public health all suggest that access to treatment should be facilitated for migrants


Recommendation 1To address the gaps in notification with the goal of finding all TB cases

MoPH to commit to TB control as a priority MoPH to repair and enforce the notification system in

order to achieve mandatory reporting of all cases, including incentives for institutions who comply and (enforced) sanctions for non-reporters

MoPH or BMA to (re-) establish clear regulatory control over non-BMA facilities with respect to TB reporting and case management

MoPH to take the lead in strengthening/establishing a Public-Private Mix approach through a high level conference early in 2014 of MoPH staff and leaders of private, military and university hospitals


Recommendation 2To implement a single TB electronic recording and reporting system for all cases

The MoPH should commit adequate, dedicated resources to set up by

the beginning of 2015 a unified, nationwide, case-based, electronic,

web-based, recording and reporting system for all facilities, based on further development of the "TB Clinical Management" recording

& reporting system

able to be linked with the data collection system of NHSO

careful transition from current system

enabling major efficiency gains

Enabling focused attention on vulnerable groups

In line with the decentralization of upcoming health reform, MoPH to

train and facilitate to enable local use of data for analysis and

corrective action


Recommendation 3Ensure maximal chance of treatment success

MoPH should mount a campaign among both patients and health staff to improve treatment outcomes based on direct observation of treatment (DOT) which should include: Patient-centered care with careful explanation by health staff of what is

required of patients Focusing of DOT resources towards high risk patients (HIV, elderly,

uninsured, marginalized etc) with monitoring quality of care Proper management of co-morbidities, Enablers to poor patients Better data flow (with unified electronic data management system) Adequate financial resources

In Bangkok, the BMA should take responsibility for a monitoring unit and mobile outreach service that follows up cases using DOT providers/peer educators and support service to private practitioners eg as in San Francisco, US

Leading NTP staff should be supported to help achieve pro-DOTS behaviour change in staff as well as patients


Recommendation 4Provision of suitable care for all migrants in need

MoPH to promote active TB case finding and migrant sensitive TB health

service delivery among non-Thais

MOPH should further explore innovative financing approaches to ensure

migrants' universal health coverage and in bordering countries

MoPH to develop innovative measures to identify unregistered non-Thais in

unified electronic data management system, perhaps through a unique ID

number

MoPH to extend access to care among non-Thai through coordinated

approaches with INGO, and local NGOs and CBOs

Expand political commitment and local initiatives to establish cross border

referral mechanismse.g. between Mae Sot and Myawaddy

MoPH to prepare a cross-border application for the Global Fund to support

a comprehensive multi-national effort to provide access to universal health

care in all countries bordering Thailand


Strategic and cross-cutting issues

The team advises: Encouragement of a greater role in TB care and

support of civil society organizations (CSOs) / NGOs

Development of a technical assistance plan Preparation of a detailed National Strategic Plan


Follow Up

A mission within 2-3 months of electronic database experts to advise on how to set up the web-based unified recording and reporting system

Review progress with a small team of international experts in 2015

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