Health system barriers and opportunities to scale up DR-TB management

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