17. Public Private Mix (PPM) For TB Control

In Bangladesh private practitioners constitute a large proportion of the service delivery infrastructure. Almost half of the patients with chest related problems are estimated to seek care from the private sector. Thus, it is important that the private sector is incorporated as an integral component in the delivery of TB services under the umbrella of the NTP. It is widely recognized and experienced that the quality of and access to health care provision can be greatly enhanced by involvement of all health care providers through PPM. The combined efforts of the public and private sector are critical for

Bangladesh in order to help halt and reverse the TB burden. Although many private providers in Bangladesh are already providing services to TB patients, TB management practices in the private sector are not standardized and the exact number of TB cases detected and treated in the private sector is not known. This is due to the lack of sufficient interaction and formal linkages between NTP, private, NGO and public sector providers. Their greater involvement in the delivery of services for TB will enable provision of high quality and effective TB services by all care providers.

NTP and its partners implement several PPM approaches:

1. Public with Private (example: NTP collaborating with NGOs and private sector)
2. Public with Public, (example: NTP collaborating with Medical College Hospitals, Defence, Police Health Services etc.)
3. Private with Private health care providers (example: NGOs working with Private Practitioners, Hospitals and Clinics etc.)

The current and potential providers of PPM are:

Institutional Providers:

• National TB Control Programme
• City Corporation Health Services
• NGO partners
• Academic Medical Institutions e.g.: Medical Colleges, Specialized Institutions and Universities
• Government Hospitals e.g.: District Hospitals, Upazilla Health Complexes, Chest Disease Clinics and Hospitals
• Corporate and social sectors e.g.: Export Processing Zone (EPZ), Port, Railway, Tea gardens, RMGs (Readymade Garment Industries) and other companies etc.
• Prison Health Services
• Defence/ Police Medical Services
• Private Hospitals, Clinics and Laboratories
• Professional associations and bodies, e.g., Medical professional associations, National anti TB association (NATAB) etc.

Individual Providers:

• Specialist Physicians
• Graduate Private Medical Practitioners (GPP's)
• Non-graduate PPs (NGPPs) e.g.: Sub-assistant Community Medical Officer (SACMO), Medical Assistant, Practitioners with LMF (Licentiate Medical Faculty) and MFPC (Member of the Faculty of Polio and Chickenpox etc.
• Non-qualified Informal Health Care Providers e.g., village doctors, pharmacists, drug sellers, pharmacy staff and owners etc. Refugee camp authorities Community Health Volunteers e.g.: Shastho Shebika, Cured TB Patient, etc.

The leadership and coordination of all partners and PPM activities is the responsibility of the NTP. For this purpose, NTP has established the PPM committee and working group whose responsibilities are to lead, advocate for resource mobilization, coordinate and provide guidance to all PPM activities.

The responsibilities of NTP include the following:

• Advocacy and policies to prioritise and place TB Control high on the agenda of the Government of Bangladesh (GOB) and MOHFW.
• Create, enhance and expand partnerships at all levels, including capacity building as per felt need.
• Ensure engagement of NTP staff at divisional, district and upazila levels in PPM planning, supervision, monitoring and reporting.
• Policy development and adaptation of related policies, tools, guidelines and strategies.
• Appropriate and timely dissemination of related TB documents and annual reports.
• Appropriate management of GOB resources and grants for ensuring uninterrupted supplies of anti-TB drugs, supplies, commodities and necessary financial support for activities.
• Training and supervision of providers.
• Program supervision, monitoring and evaluation.

The responsibilities of PPM Implementing Partners include the following:

• Local level planning for implementation of PPM related activities
• Appropriate and timely implementation of PPM activities outlined in annual operational plan which include providing free sputum smear microscopy, anti-TB drugs and organizing delivery of DOT. Appropriate recording and timely sharing of reports, tools, best practices and lessons learned with NTP and among other PPM partners.
• Utilization of national NTP guidelines and training materials while engaging the individual providers and ensure proper referral from the private sector partners and individual providers
• Training the individual providers
• Establishing successful linkages among NTP, providers and partners
• Proper supervision and monitoring using the standard tools approved by the NTP.

The responsibilities of individual providers include the following:

• Management of TB patients following the approved national guidelines.
• Ensuring proper referral of presumptive TB cases for testing as well as notification and referral of diagnosed TB cases to the NTP and the local implementing partners

To formalize partnership between Institutional providers and NTP, contractual tools such as Memorandum of Understanding (MoU) is to be used, whereas, to establish effective linkages with individual providers, NTP recommends the use of Letter of Agreement (LoA) as a tool for contract. These tools need to be drafted after discussion and with mutual consensus and it should clearly describe the exact roles, responsibilities and deliverable of the collaborating partners. While this approach is recommended, it should also be noted it may not always be feasible to enter into formal contracts with all the individual providers. In such cases, engagements through regular orientations and workshops should be prioritized to encourage their engagement with the national program.