Health system barriers and opportunities to scale up DR-TB management
Dr. Thandar Lwin Deputy Director, National TB Programme, Department of Health
Presentation outlines PMDT Scale up plan Situation analysis for PMDT scale up WHO Health System Framework Service Delivery Health Workforce Health Information System Medical Products/Technologies Health Financing System Leadership & Governance
Conclusion
WHO-recommended Stop TB Strategy
National MDR-TB Strategic Plan (2011-2015)
* More rapid expansion ongoing ** Expansion 38 townships
Budget requirement - USD ~ 53 million
Expansion plan (with committed resources) Number of regions or states with Number of TB/MDR-TB centers treatment with Xpert center
Number of townships with MDRTB treatment center
Secondline antiTB drugs committed from donors
Year
Reference diagnostic labs with culture/ DST
2012
2
6
2
38
442
2013
3
24
7
53
1092*
2014
4
38
13
68
500
2015
5
38
13
100
800
2016
5
38
13
100
1000
* GF + UNITAID
Number of MDR enrolled on treatment 2009-2013 (2nd quarter) 1200
MDR TB Patients Pilot YGN: 266 MDY: 43
Cumulative number
1000
1084
GF YGN: 631 MDY: 107 Other State and Region: 37
800
861 796
Total = 1,084 523
600 426 400
287 247 125
200
43
64
158
192
304
354
376
End DOTS-Plus pilot project
92
0 2009 2009 2010 2010 2010 2010 2011 2011 2011 2011 2012 2012 2012 2012 2013 2013 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2
Pilot Cohort - Treatment Outcome (July 2009 - June 2011) Cured
Died
Failure
Refuse Default
YGN
172
45+6
3
1
MDY
29
7
0
0
Total
201 (68.6%)
52+6 (19.8%,)
3 (1.%)
Total
201 70%
52 17.7%
Total
249+6= 28 255 2
38
1 30 287+6= (0.3%) (10.2%) 293
3 1 (1%) (0.3%)
30 10.5%
Total cohort cases (July 2009 – June 2011) ---- 309 cases Died before treatment ---- 6 cases Still on treatment ---- 16 (MDY- 5 cases & YGN- 11 cases)
287
Pilot cohort - Treatment Outcome (July 2009 - June 2011) n = 287 0.3% 1%
10.5%
Cured:
18%
Died: 70%
Failure: Refuse: Default:
Case notifications MDR-TB (2008-2013) Year
Cases (Solid/Liquid Culture/LPA)
Cases put on SLD
2010
312
192
2011
690
162
2012
778
442
2013 (Q1)
426
65
2013 (Q2)
376
218
Year 2010 2011
Notified
Treated 312 690
Waiting (Lab confirmed) 312 192 120 810 162
2012
778 442
2013 (1st Q)
426 65
2013 (2nd Q)
376 218
648 1426 984 1410 1345 1721 1503
Fund UNITAID 112 (UNITAID) 50 (GF) GF GF GF
Issues Coverage
HRD
Stigma
Diagnosis – delay, HR, sputum transportation, lab. maintenance Treatment – delay, HR, Drug availability, DOT, referral linkage
M&E, R&R system
Infection control PMDT scale up Inter-sectorial – NAP, hospitals, labs Partners involvement
Patient support Funding
Interdepartmental electricity
The WHO Health System Framework System building blocks
Overall goals/outcomes
SERVICE DELIVERY
HEALTH WORKSFORCE
ACCESS COVERAGE
IMPROVED HEALTH RESPONSIVENESS
HEALTH INFORMATION
MEDICAL PRODUCTS, VACCINES, TECHNOLOGIES
HEALTH FINANCING
LEADERSHIP & GOVERNANCE
QUALITY SAFETY
SOCIAL AND FINANCIAL RISK PROTECTION IMPROVED EFFICIENCY
Service Delivery Opportunities
Barriers
• DOTS countrywide through Primary Health Care network • Unique involvement of GPs though PSI and MMA • Collaboration with NGOs • Collaboration with community health workers • Advocacy, social mobilization, raising awareness of TB/MDRTB • Active TB case-finding strategy • PMDT in 7 Regions/States
• Cultural, social and financial barriers • Vulnerable populations • Migrants • Hard-to-reach areas • Limited geographical expansion of MDR-TB and TB/HIV services • Terrain/infrastructure/ communication/logistics • Involvement of drug sellers, traditional healers
Health Workforce Opportunities • Staff – 1028 TB staff – Central level – State/Regional level – Total (101) TB teams
• Capacity building: – Hospital staff, NTP staff
• Integrated with PHC : TMOs & BHS were trained in basic TB control & MDR-TB Management at PMDT sites • Involvement of GPs
Barriers • Limitation in HRD & capacity building • Multipurpose BHS with increasing demand • Hard-to-reach areas • Over work load of staff in PMDT sites • Under staff in reference laboratories • Limited infection control measures for health staff
330 townships, 69 districts, 14 Regions/States Kachin State
Sr. No.
Sagaing Div. Shan(N) State Chin State Shan(S) State
Mandalay Div. Rakhine State
Magwe Division Bago (W) Ayarwaddy Div.
Shan(E) State
Kayah State Bago (E)
Yangon
Kayin State
Mon State
Tanintharyi Div.
TB Center Upper/Lower Myanmar TB Center
States/Regions
TB Centers
1
Kachin State
Myitkyina
2
Shan (South)
Taunggyi
3
Sagaing Region
Monywa
4
Magway Region
Magway
5
Mandalay Region
Mandalay
6
Shan (North)
Lashio
7
Shan (East)
Kyaington
8
Tanintharyi Region
Myeik
9
Bago Region
Bago
10
Mon State Kayin State
Mawlamyine
11
Rakhine State
Sittwe
12
Yangon Region
Yangon
13
Kayah State
Loikaw
14
Ayeyarwaddy Region
Pathein
No. of districts with TB team = 47 / 69 No. of townships with TB team = 54/(261=330-69)
Health Information System Opportunities • Basic DOTS recording and reporting system was already used countrywide • Global online data reporting system of WHO • Improved communication in Myanmar • New WHO recording and reporting system
Barriers • Electronic recording & reporting system not in place yet for TB or PMDT • Needs more Infrastructure & communication facilities like ADSL for email & internet access • Computer skills
Medical Products/Technologies Opportunities • Quality assured first, secondline anti-TB drugs & ancillary drugs FOC for TB/MDR-TB patients • Two state-of-the-art TB reference laboratories & two BSL 3 labs in 2013/2014 • QC for microscopy, culture & DST • New TB/MDRTB diagnostics (GeneXpert) being rolled-out
Barriers • Over the counter availability of anti-TB drugs of unknown quality, weak in regulation • All NTP products are procured by international agencies (no experience in-country) • In-country production not reaching WHO standards • Needs training & maintenance for new TB/MDRTB diagnostic tools
New tools
Health Financing System Opportunities • Government commitment to universal health coverage and increased contribution to health expenditure • GF (NFM) & 3MDG Fund more investing in PMDT • Other positive donor communities (USAID, UNITAID, JICA etc.)
Barriers • Out-of-pocket by patients leading to catastrophic health expenditures • Sustainability of funding for SLDs, Ancillary Drugs, MDR-TB lab investigation & infection control • Incentives support for MDR-TB patients & DOT providers
Government Budget for NTP (1996-1997 to 2012-2013) Years 1,200,000
Kyats in thousands
1,000,000
800,000
600,000
400,000
200,000
0
Budget for Programme Management
Budget for Drug Procurement
Data source: NTP Annual Reports
Leadership/Governance Opportunities • Myanmar Health Sector hCoordination Committee (M-HSCC) • TSG for TB • National Expert DR-TB Committee • National Strategic Plan • National (updated) policy, SOPs & guidelines
Barriers • Regulatory framework • System design (decentralization) • Accountability
National Strategic Plan (2011-2015) & New PMDT Guideline
A Guide for MDR-TB Treatment Supporter
National Strategic Plan (2011-2015)
PMDT SOP revised in 2013
Training module for Basic Health Staff
Conclusion • Universal access to TB, TB/HIV and MDR-TB management needs strengthening in all 6 health system building blocks • Both vertical and horizontal (PHC) approaches are needed to overcome barriers • It is beyond the reach of NTP • High political will, commitment is essential – intra, inter departmental involvement • Development partners should put more support on system strengthening.
Thank you