Universal Access to TB Care Through Private Sector

Universal Access to TB Care Through Private Sector

Universal Access to TB Care Through Private Sector Involvement under RNTCP, Maharashtra. 5thNational Summit on Good & Replicable Practices and Innovations in Public Healthcare Systems, KAZIRANGA, ASSAM INTERVENTION 1 Empanelment of private X-ray a tool for augmenting TB diagnosis in Mumbai, Maharashtra INTERVENTION 2 Private Sector Engagement Towards End TB through Innovative Private Provider Support Agency (PPSA) in Mumbai, Maharashtra INTERVENTION 3 Access to free Fixed Drug Combination to TB patients seeking care in private sector through Nagpur Municipal Corporations (MH) efforts

Characteristic of these innovations a. b. c. they are supported through NHM resources Recognising the prominent role played by Private Practitioners in TB care and need of involvement of Private sector in TB Programme, Government of Maharashtra undertook innovative interventions for private sector engagement. undertaken by existing health system significant, quantifiable and replicable results are achieved through these interventions Outline of the INTERVENTION 1

Empanelment of private X-ray - a tool for augmenting TB diagnosis in Mumbai, Maharashtra Intervention 1: Empanelment of private X-ray - A tool for augmenting TB diagnosis in Mumbai, Maharashtra Objectives National Strategic Plan of Government of India for Tuberculosis depicts Detect as one of the Strategic Pillar to ensure early diagnosis and treatment towards goal of End TB 2025. Presumptive TB Cases Revised Pulmonary TB Diagnostic Algorithm (TOG-2016) policy of Upfront

Chest X-ray Sputum Microscopy Intervention This activity has been initiated since February 2018 in private sector and May 2018 onwards in public sector. NGOs have been selected through a tender process as per NHM/RNTCP guidelines to operationalise the Empanelment of X-ray facilities for presumptive TB cases amongst both public and private sector patients. Target is outsourcing 60000 presumptive TB patients to private X-ray facilities out of 1.5 lakh persons examined for TB every year in Mumbai. Proce ss All doctors (public and private sector) are sensitised and vouchers are kept at their clinic which are given

to patients by doctors after consultation. Patients redeem the voucher at the nearest X-ray clinic which are reimbursed by the NGO after validation. Patients receive free quality diagnostics nearest to their residence Results & From February Conclusion to August 2018 - Total 30,174 February to August 2018 presumptive TB Cases outsourced private facility presumptive TB Cases from both public and private sector 30,174 received free

chest X-ray through outsourced private facility. (27%) have been diagnosed TB and put on treatment amongst 7,347/30,174 (24%) of patients chest X-rays have those with Abnormal X-ray 7,347 found to be abnormal. 2,015 (27%) have been diagnosed with TB and put on treatment amongst those with abnormal X-ray. Outsourcing of X-rays has been found to be (24%) of patients chest X-rays have found to be abnormal

2,015 improving the accessibility of patients for X-rays thus reducing dropouts and out-of-pocket expenditure and augmenting early diagnosis of TB. INTERVENTION 2 Private Sector Engagement - Towards End TB through Innovative Private Provider Support Agency (PPSA) in Mumbai,

Maharashtra Intervention 2 Private Sector Engagement -Towards End TB through Innovative Private Provider Support Agency (PPSA) in Mumbai, Maharashtra The National Strategic Plan (NSP) for TB has put forward a goal to end TB in India by 2025 -- five year ahead of the targets set by Sustainable Development Goals (SDGs). It is estimated that about 50% of TB patients seek care from private sector in Maharashtra. Hence, this intervention was undertaken to provide comprehensive diagnostic and treatment services of TB to patients through private sector. Objectives 1 2

3 4 5 Intervention Following institutes are involved for Private sector engagement Nursing Homes/Hospitals- 385 Formal Private Doctors-273 Informal Private Providers-1584 X ray Labs -177, Retail Chemist198 Innovative scheme- PPSA (Private Provider Support Agency) was approved under National Urban Health Mission. Private Provider Support Agency is identified as interface agency to engage the private sector. PPSA Model for Integration Under NUHM & RNTCP

Chest X-ray voucher Gene Expert/ CBNAAT Treatment/FDC Linkage to RNTCP Nikshay Notification Treatment adherence Counselling PPSA performance from February to July 2018 Direct CBNAAT through Public Sector A B

C D Out of A), No. of pts. Out of A), No. of pts. who are No. of pts. whose who are 'Rifampicin CBNAAT is done Sensitive' and 'Rifampicin notified Resistant' * No of pts. Notified (clinically Diagnosed) 3143 955 1056

(25%) (7.6 %) (12.5%) 12515 X-ray done -5014/20006 (25%) were found to be Abnormal X- ray Notification Notification Total (Drug (Drug Sensitive Notification Sensitive Patients) Patients) E

G (B+D) 4199 (46.2%) H (E+G) 4889 9088 (Govt. FDC-4925) Conclusion RNTCP Maharashtra continues to provide quality free diagnostic and treatment services to even private sector TB patients through PPSA. PPSA would be further enhancing the capacity to extend 2018 (till July 2018)

418/ Lakh Total TB Notification for Mumbai services to all Private Providers to reach out to all TB Patients in Mumbai as a step towards TB Free Mumbai. 180/ Lakh TB Notification from private sector One-to-one sensitization of private doctors INTERVENTION 3 Access to free Fixed Drug Combination to TB patients seeking care in private sector through Nagpur Municipal Corporations (MH) efforts

UATBC activities by the NGO To ensure access to quality assured free TB a. b. Services to all the TB patients irrespective of source of care and thus reduce out-of-pocket expenditure to TB patients in private sector. Facilitate notification of TB cases diagnosed and treated in private sector. Intervention 3: Access to free Fixed Drug Combination to TB patients seeking care in private sector through Nagpur Municipal Corporations (MH) efforts INTERVENTION c.

Allow public sector to provide free diagnostic, treatment and extend public health services such as counseling, drug-susceptibility testing, contact investigation, ADR Support d. Ensure treatment completion and improved treatment adherence of TB patients in private sector To further enhance the coverage and quality of care, Nagpur Municipal Corporation involved NGO (Disha Foundation) under RNTCP NGO PP Partnership scheme as interface agency between Public and Private Sector in April 2017. Mechanism for augmenting uptake of Free FDCsThesein private sector Free FDCs are pre-fitted with ICT Conducting strategic IEC for

generating demand among public for free FDCs. supported (99 DOTS) adherence tracking mechanism which acts as value proposition to PPs for prescribing Free FDCs as it provides daily adherence log for their patients. Outcome I Sr. No. Particulars 1 Agency Registered 2 3

Active Agency Total Beneficiary Total no. PPs 472 Pharmacy 140 PPs 247 Pharmacy 56 5303 Private sector involvement status

Impact on TB case notification in Nagpur Municipal Corporation Outcome II Period Total 2016 1Q 17 2Q 17 3Q 17 4Q 17 Type of Medicine Private Drugs RNTCP FDC 1342 368 395

572 608 1342 368 395 541 520 0 0 0 31 (5%) 88 (14%) 1Q 18 775 611 164 (21%)

2Q 18 986 615 371 (37%) July 18 257 106 151 (59%) Beneficiary Trend for free Anti-TB Medicines through PPs/private chemist No of Rif From AprilTB detected Resistant Specimen

17 to July among Rif Resistant Cases Transported 18 tested referred to RNTCP Total 2489 465 74 Specimen transportation 11 3.2 40%

Results and conclusion 80% 8.2 UDST offered to ~40% notified private sector patients Public health action (telephonic + home visit) provided to 95% of notified private sector patients residing in Nagpur corporation area Strategic investment for involvement of some public-private interface agency for augmenting service delivery in private sector may be a cost-effective intervention considering a challenge of TB elimination Plan Maharashtra intends to expand these Private sector engagement initiatives in rest of the state.

State intends to end TB by 2025 as per National Strategic Plan under the guidance of Government of India Drug resistant TB services will also be provided to patients in private sector. ! !! THANK YOU!

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