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Building Public/Private Partnership for Health System Strengthening

“GO NGO Partnership :BRAC experience ”Dr Farah Mahjabeen Ahmed

Bali Hyatt Hotel, Sanur, Bali21-26 June 2010

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Population: 156 Million

Area(sq km) :147,570

80% live in rural areas, 64% involved with agriculture.

Gross income per capita of US$540

Overall literacy rate is 47%

Enormous health and development challenges

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Progress in Health and development IMR -120/1,000 live births(1970) to 58 by 2006

U5M- 140/1,000 live births(1970)to 65 by 2006

Life expectancy at birth increased from 45 years in 1970s to 65 by 2006

TFR declined from 6.4 in 1971 to 2.7 by 2006

Yet challenges remainSource : BDHS 2007

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Challenges include: Unacceptably high MMR (320/ 100,000)

20% deliveries in health facilities or with skilled birth attendants

40% of the population has access to basic health care

Continuing high mortality/morbidity from Communicable/Chronic Diseases /NCD

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TB as a global crisis: more than 1 billion people suffer from TB

Bangladesh is the 6th among the world’s 22 high burden countries (WHO)

TB incidence in Bangladesh: 391/100,000 (2006)

Poor suffer most from TB

Rural Bangladesh and urban slums are especially vulnerable

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In 1993 GOB introduced the DOTS strategy

In 1996 GOB established the “Government-NGO Consultative Council” (GNCC) as a forum for open dialogue with the NGOs

BRAC Health Program formally became a partner in combating TB (1994)

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Types of Collaboration

Networking/Consultation

Contractual Agreements

Patronage

Partnering

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mutual respect, trust, strengths and values,

favourable policies, laws & regulatory frameworks;

effective mechanisms to monitor and measure

transparency and accountability

involvement of all stakeholders at every step;

continued commitment

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With measurable criteria for M & E, treatment protocols, policy guidelines and logistics by NTP

BRAC is providing services in 48 Districts covering a population of 89.9 Million ( BRAC TB annual report 2009)

In 2008, a total of 748,480 suspected TB cases were examines; 90,259 (12%) were diagnosed

Treatment success rate was 94% (2007)

Case detection rate was 73% Ref: WHO

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72.4 75.3 78.5 80.1 80.1 80.5 84 84 8589 91.5 91.7 92

0

10

20

30

40

50

60

70

80

90

100

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Rat

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Year

National Treatment Success Rate

---Treatment Success (%)

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Zafar Ullah, A N et al. Health Policy Plan. 2006 21:143-155; doi:10.1093/heapol/czj014

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The NTP adopted the WHO recommended strategy of DOTS in 1993. consisting of five components:

Political commitment Diagnosis by direct microscopy Directly Observed Treatment (DOT) Uninterrupted supply of drugs Standard recording and monitoring of

detection and treatment results

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Before 1993 TB control was limited to TB clinics and TB hospitals.

Field implementation integrated into the general health services, delivered by Upazilla Health Complexes in 80s.

NTP Bangladesh revised its strategies and adopted DOTS in 1993.

BRAC have been involved since 1994.

The objectives were to detect 70% ,cure at least 85 % by 2005 and reach the MDG by 2015.

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BRAC's TB program began in 1984 as a pilot where Shastho Sebikas (SS), or health volunteers, played a critical role.

SS’s disseminate information ,educate the community, detect/identify possible TB cases and oversee the DOTS treatment either at their own home or during house hold visits

Sputum were examined for confirmation ,also confirmed through other tests by the chest specialists

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Fixed Dose Combination drugs were given by SS under guidance of BRAC field staff/government or BRAC MO.

SS’s oversee DOTS has proven to be cost-effective (US$64 vs. US$92 in non Shastho Shebika areas) and has reduced the time taken to diagnose TB positive individuals. .

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Brought DOTS service closer to homes (distance ,time)

Created demand for services through community awareness & mobilization

Reduced the social and cultural barriers stigma

Established linkages between the community and services ,organized sputum collection thus helped to reduce delay in diagnosis ( remote areas)

Provide DOT’s and continuous follow up

Helped to refer complicated cases

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Client deposit BDT 200 ; upon completion, the 200 Taka is returned and 150 Taka is given by

BRAC to the SS as incentive.

The specialty of BRAC's DOTS strategy is that patients deposit Taka 200 (US$ 3.50) prior to

treatment and sign a bond with two witnesses for guarantee of treatment completion. If unable to pay, then the patient seeks support from the community to pay on his behalf.

If the community fails, the individual is given an exemption from the bond money.

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Treatment success in 2003 in BRAC areas was higher (almost 90%) compared to the national average (almost 85%).

High cure rates , despite rapid expansion of coverage, with proper implementation of the strategy and regular monitoring of reports on case finding, sputum smear conversion and treatment outcome.

Routine supervision by BRAC field staff

Internal monitoring and periodic research by monitoring and research division

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Shasthya Shebika Providing DOT’S

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Government–NGO Partnership in the health sector is not new in Bangladesh.

Partnership between the government and NGOs in TB, maternal and child health and family planning, Extended Programme of Immunization, leprosy elimination and nutritional programmes has been efficient and effective.

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Partnership ensures greater coverage and access through NGO service facilities and community-based infrastructures.

BRAC was able to increase awareness among the general population , leading to increased numbers of TB suspects at different health facilities.

Unified reporting systems enabled a full account of the NTP's programmatic performance.

Although NGOs are following NTP guidelines, they decide the operational strategy appropriate to their philosophy and thinking. This allows organizations to retain their independence while being accountable to the NTP.

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BRAC ‘s outreach covers estimated 89.9million people of all 48 districts of Bangladesh

Effective Involvement with Private practitioners

Sensitizing pharmacy holders and factory owners showed increasing referral of suspect

BRAC has been called upon to assist a number of countries including Afghanistan,Srilanka , Pakistan ,Sudan and Tanzania

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BRAC received two awards in 2007

'NATAB Award 2007' from the National Anti-Tuberculosis Association of Bangladesh

'STOP TB Partnership-Kochon Prize 2007' from the Kochon Foundation.

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Government and NGOs can be complementary in achieving

National Health Goals.

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