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

13

29

3942

50

58

59% 58%

57% 56% 55%

62%

0%

20%

40%

60%

80%

100%

2003 2004 2005 2006 2007 2008

% o

f co

un

trie

s w

ith

act

ive

TB

gra

nts

0

10

20

30

40

50

60

70

Nu

mb

er o

f co

un

trie

s

Number of countries with PPM activities within active grants

% of countries with PPM activities within active grants

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

67%

82%

52%

62%

50%56%

63%

0%0%

30%

60%

90%

2003 2004 2005 2006 2007 2008

% o

f co

un

trie

s w

ith

act

ive

TB

gra

nts

Latin America & the CaribbeanSouth and East AsiaSub-Saharan AfricaNorth Africa & the Middle EastEastern Europe & Central Asia

Trend of the proportion of countries with Global Fund support for PPM activities, by regionN=Number of countries with active TB grants per region

Number and proportion of countries with GF funding for PPM that involve different health providers

Trend of the number of countries with Global Fund support for PPM activities (proportion of countries with GF funding for PPM), by implementer

28 (48%)

24

1917

3

15 (26%)

141311

85

20 (34%)19

17

11

4

18 (31%)

0

5

10

15

20

25

30

2003 2004 2005 2006 2007 2008Num

ber

of c

ount

ries

wit

h G

F f

undi

ng f

or P

PM Prison Private NGO Others

Common types of collaboration within countries with GF funding for PPM across regions

Region (N)NGOs Prisons

Private Sector Other

Not specified

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%

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

THANKS

Acknowledgments Daniel Low BeerDonna leeAboua Ange-Joel DjomanCountry programs, Global FundNational TB Control Programs