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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
n
Ind
on
esia
Ban
gla
des
h
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?