Monitoring PPM contributions – from operational research to regular reporting Knut Lönnroth Stop TB Department 5 th PPM Subgroup Meeting Cairo, 4 June.

Monitoring PPM contributions

– from operational research to regular reporting

Knut Lönnroth

Stop TB Department

5th PPM Subgroup MeetingCairo, 4 June 2008

Evidence on contribution

• Case detection increase: 10-50% locally

• Treatment quality: 85% treatment success rate

• Cost-effective (cost per additional cure is low)

• Cost reduction for poor patients (~100 $ less)

• But, on from small to medium scale projects

HBCs with PPM DOTS initiatives, 2004

High burden countries with PPM initiativesHigh burden countries with PPM initiatives

High burden countries without PPM pilotsHigh burden countries without PPM pilots

High burden countries scaling up PPM High burden countries scaling up PPM

HBCs with PPM DOTS initiatives, 2006

High burden countries with PPM initiativesHigh burden countries with PPM initiatives

High burden countries without PPM pilotsHigh burden countries without PPM pilots

High burden countries scaling up PPM High burden countries scaling up PPM

HBCs with PPM DOTS initiatives, 2007

High burden countries with PPM initiativesHigh burden countries with PPM initiatives

High burden countries without PPM pilotsHigh burden countries without PPM pilots

High burden countries scaling up PPM High burden countries scaling up PPM

Open circles mark the number of new smear-positive cases notified under DOTS 1995–2006, expressed as a percentage of estimated new cases in each year. The solid line through these points indicates the average annual increment from 1995 to 2000 of about 134 000 new cases, compared to the average increment from 2000 to 2006 of about 242 000 cases. Closed circles show the total number of smear-positive cases notified (DOTS and non-DOTS) as a percentage of estimated cases.

Progress towards the case detection target

0

10

20

30

40

50

60

70

80

1990 1995 2000 2005 2010 2015

Year

Ca

se d

ete

ctio

n r

ate

, sm

ea

r-p

osi

tive

ca

ses

(%

)

average rate of progress 1995–2000

WHO target 70%

DOTS begins

(a) 40% (4 million cases) missing!

PPM Subgroup created

Smear-positive TB cases undetected by DOTS programmes in eight high-burden countries, 2006

0

50

100

150

200

250

300

350

Ind

ia

Nig

eria

Ch

ina

Eth

iop

ia

Pak

ista

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Ind

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esia

Ban

gla

des

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So

uth

Afr

ica

20

10

7.7

6.3

4.2 4.13.6 3.4

What we want to know on national level

1. How many (%) providers are involved through PPM, by type of provider, and type of activity

2. Number (%) of cases detected through referral and/or diagnosis, by provider type

3. Number (%) of patients treated under PPM, by provider type

4. (Cohort analysis, by provider type – though not equally important)

Intensified urban PPM districts; India (14): Summary of contribution by different health sectors – 3rd qtr 2006 to 2nd qtr 2007)

Towards Universal Standard of Care by all Providers, The example of Mumbai

0

10

20

30

40

50

60

701

Q1

99

9

2Q

19

99

3Q

19

99

4Q

19

99

1Q

20

00

2Q

20

00

3Q

20

00

4Q

20

00

1Q

20

01

2Q

20

01

3Q

20

01

4Q

20

01

1Q

20

02

2Q

20

02

3Q

20

02

4Q

20

02

1Q

20

03

2Q

20

03

3Q

20

03

4Q

20

03

Quarter

An

nu

alis

ed r

ate

NS

P /

100,

000

TB hosp DOT

NGOs

Med colleges DOT

Mumbai PP

Mumbai RNTCP

40% increase by PPM providers

Source: Ambe et al 2005

How? – Tools are ready!

• New recording and reporting system – revised forms and guidelines

• Conventional laboratory and district TB registers can be used to get most of the information

• Complement with PPM situational analysis data to enumerate providers and their involvement

Appendix 10

TUBERCULOSIS LABORATORY REGISTER

Year

Reason for examination Results of specimen Signature Remarks Lab serial

No.

Date Name Sex M/F

Age Name Treatment Unit / Address - new patients

diagnosis* follow up* 1 2 3

*These are diagnosed New or Relapsed cases ** These are patients on chemotherapy

LT enter name of referring provider based on:

A. Lab request/referral form

B.Oral info about who sent patient

Provider (code)

DISTRICT TUBERCULOSIS REGISTER

Type of patient**Date ofRegistration

District TBNo.

Name (in full)

Sex M/F

Age Address (in full)

Name Treatment Unit / Date Start treatment andregimen*

Diseaseclassification

P/PE New

(N) Relapse

(R)Treatmentafter failure

(F)

Treatmentafter default

(D)

Transfer in(T)

Other (O)

Name (code) of DOT provider

Reporting?

• Not part of quarterly reports!! – too cumbersome, and not required

1. Record for sake of district level management

2. Extract information as and when required for monitoring and evaluation

3. Report yearly, based on sample of district or sentinel sites

4. Report to Global TB Report and to PPM Subgroup meeting:

Pakistan

Provider group Involvement (Please mention yes or no or level of involvement)

Contribution(Please provide available data on contribution of different PPM providers )

Professional associations

Yes: What percentage? What percentage?

Corporate Sector Not yet

Hospitals Yes: What percentage? What percentage?

Informal providers Yes: What percentage? What percentage?

Private laboratories Not yet

Private clinics Yes: What percentage? What percentage?

PPM notification, EMRO 2008

Distribution of smear positive TB cases by source of referral

0

73

90 0

100

0 3

50

100

0

0

0

0 0

0

00

25

0

100

20

68

100

26

0

100

48

0

007

18

0

74

0 0

47

25

00 0 5 0 0 0 0 2 0 0

0%

20%

40%

60%

80%

100%

Djibouti Egypt Jordan Kuwait Lebanon Oman Somalia Syrian ArabRepublic

West Bankand Gaza

Strip

Yemen

Self, New ss + Community,New ss + Public, New ss + Private, New ss + Others, ss+

Questions

• What are the practical steps that countries need to take to start pilot and fully implement a system to record and report on PPM?

• What advocacy is needed to promote PPM monitoring on national level?

• Policy for data management on country and global level?