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PPM DOTS Subgroup of DEWGLinking all health care providers to
National TB Programmes
PPM DOTS Subgroup Secretariat
DEWG, 27 October 2004, Paris
2003-2004 progress
• 2nd PPM DOTS Subgroup Meeting, SEARO, New Delhi, Feb. 2004
• Report on cost-effectiveness of PPM published
• "What makes PPM work?" Cross-site analysis published
• Intensified support to Countries
• Country missions to, Bangladesh, China, India, Kenya, Myanmar,
• PPM surveillance system being piloted in 12 of 14 cities scalingup PPM DOTS in India
• Facilitation of PPM project documentation
• Draft PPM DOTS guidelines under preparation
2003-2004 progress
NTPs alone may not make it: The example of Mumbai
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701Q
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Quarter
Ann
ualis
ed ra
te N
SP /
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000
Mumbai RNTCP
A True Public-Private Mix can help make it: The example of Mumbai
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Quarter
Ann
ualis
ed ra
te N
SP /
100,
000
TB hosp DOTNGOsMed colleges DOTMumbai PPMumbai RNTCP
40% increase by PPM providers
Source: RNTCP, Mumbai, India
PPM now implies: linking all public and all private health care providers to National TB Programmes in order to foster universal standards of care and
secure equity in access across the whole health care system
PPM DOTS progress in countries
22 High TB burden countries
High burden countriesHigh burden countries
HBCs perceiving need for involving private sector, September 2004
High burden countriesHigh burden countries
HBCsHBCs perceiving need to work with private sectorperceiving need to work with private sector
HBCs with PPM DOTS initiatives, September 2004
High burden countries with PPM initiativesHigh burden countries with PPM initiativesHigh burden countries without PPM pilotsHigh burden countries without PPM pilots
Prisons
Hospitals
High burden countries scaling up PPM High burden countries scaling up PPM
Growing evidence base
>40 PPM projects started >20,000 patients evaluated
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5
10
15
20
25
30
35
40
45
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Cum
ulat
ive
num
ber New PPM projects
started
Evaluated PPMprojects
Journal articles onevaluated PPMprojects
Treatment success New sputum smear positive cases
0
10
20
30
40
50
60
70
80
90
100
Hyd
erab
ad, I
ndia
Del
hi, I
ndia
Kann
ur, I
ndia
Mum
bai,
Indi
a
Lalitp
ur, N
epal
Man
ila, P
hilip
pine
s
Cav
ite, P
hillip
pine
s
Mak
ati,
Philip
pine
s
Yogy
a, In
done
sia
DFB
Ban
gla
Youn
gone
, Ban
gla
Yang
on, M
yanm
ar
Seou
l, Ko
rea
Nai
robi
, Ken
ya
HC
MC
, Vie
tnam
Trea
tmen
t suc
cess
(%)
Free drugs No free drugs
Baseline private sector treatment success
Upfront paym
ent
Impact on case notification (new sputum smear positive cases)
PPM Site
Baseline Rate
Increase
Evaluation Approach
Hyderabad 50/100,000 23% Compared to neighbouring TU Delhi 60/100,000 36% Change controlled Kannur 25/100,000 15% Change in same TU Lalitpur 54/100,000 61% Change in same area HCMC 100/100,000 18% Change controlled Punalur 25/100,000 50% Change in same TU Thane 50/100,000 14% Change in same TU
Cost-effectiveness of PPM DOTS
218
144118
338
143
0
50
100
150
200
250
300
350
400
450
Delhi PPM-DOTS
Delhi privatesector non-
DOTS
HyderabadPPM-DOTS
Hyderabadpublic sector
DOTS
Hyderabadprivate sector
non-DOTSAver
age
cost
per
pat
ient
suc
cess
fully
trea
ted
(yea
r 200
2 US
$ pr
ices
)
Figure: Cost-effectiveness of alternative strategies in Delhi and Hyderabad, societal perspective, i.e. costs include costs to public sector, private providers and patients/attendants †Error bars show 5th and 95th centiles in uncertainty analysis
Source: Katherine Floyd, STB
Equity and financial protection
• Economic analysis shows that patient costs reduced by >60% in Delhi and Hyderabad PPM compared to private non-PPM DOTS
• Preliminary data show high proportion of patients in PPM projects being poor (Symposium on PPM and MDGs 1st Nov)
Sustainability
• Hyderabad: since 1995
• Damian Foundation Bangladesh: since 1997
• Nepal: since 1998
• Several projects in India and Philippines running for 3-5 years
Way forward for the PPM DOTS Subgroup
• Complete PPM DOTS Guidelines
• Decentralise and strengthen technical capacity for PPM DOTS
• Continue mainstreaming PPM DOTS into DOTS expansion
• Disseminate and emphasize the international standard of tuberculosis care
Way forward, cont.• Facilitate resource mobilisation, e.g. strengthen PPM
component in GFATM proposals
• Explore PPM DOTS+ and PPM for TB/HIV
• Documentation and guidelines for different PPM strategies: Medical colleges, NGOs, individual PPs, Social Franchising
• Operational research on PPM and poverty related MDGs (equity in access, diagnostic delay, financial burden for patients)
It doesn't matter if a cat is black or white, so long as it
catches mice.
Deng Xiao Ping
On liberalisation of Communist Party rules, Time, January 6, 1986. Source: ”Political Quotations”, ed. Daniel B. Baker (1990)
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