Social Determinants of TB in Myanmar
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This document summarizes social determinants of tuberculosis (TB) in Myanmar. It finds that Myanmar has a high TB burden, with over 200,000 new cases and a prevalence of 525 per 100,000 people in 2010. Poverty is widespread, with 7 out of 10 households falling in the lower or lower-middle socioeconomic classes. Seeking care from private providers and drug shops is common. A social franchising model was implemented to expand access to quality TB diagnosis and treatment through private clinics. This led to increased case detection and treatment success, with franchised clinics contributing to over 13-16% of national TB treatment by 2012 in a cost-effective manner.
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Social Determinants of TB in Myanmar
- 1. Social Determinants of TB in Myanmar
- 2. Myanmar Profile at a glance • Population: 55 millions • Rural 65% > Urban 35% • Graduate 8% ↔ illiterate 7% • Occupation (>18+): 30% unemployment • Human Development Index: 132nd/169 • Health expenditure 1.3% of GDP (17$/capita) Source: Consumex 2010/UN strategic framework 2012-2015 (Myanmar)
- 3. Monthly Income & Expenditure (2010) Income > Expenditure Lower SE Lower middle 80 USD 120 USD 93 USD 140 USD 7 out of 10 Households fall in Lower and Lower middle SE. 1USD = 1000kyats Source: Consumex 2010 / www.asiahealthcareblog.com Sources of spending/Myanmar
- 4. Magnitude of TB burden in Myanmar (2010) New cases Prevalence MDR TB HIV in TB 384/100,000 525/100,000 4.2% 10.4*% >200,000 280,000 ~5500 >13,000 Source: NTP review, 2011 total population * 2nd highest after Thailand in the region
- 5. Regions States Urban Rural 522/100,000 838/100,000 903/100,000 526/100,000 TB Prevalence Source: NTP review, 2011/TB in Southeast Asia region report, WHO (2012) 278/100,000 Myanmar SEA average One of the world’s 22 high TB burden countries
- 6. MDGs for TB in Myanmar 404 404 404 384 0 922 628 596 525 461 133 67 58 49 66 0 100 200 300 400 500 600 700 800 900 1000 1990 2005 2007 2010 2015 incidence prevalence death rate Source: NTP review, 2011
- 7. Brief description on current health services in a community ---------------- Voluntary HWs Quacks Grocery shops Health Assistant/MWs Quacks Grocery shops Health services given by Doctors/nurses Medical doctors Drug shops Public → Private → Township Village tract Village
- 8. National TB prevalence survey (2009) showed Where they go for their chronic cough + 26% 19% 10% Drug shops Private GPs Public hospital/clinic
- 9. Source: PSI/Myanmar Marketing Plan for TB, 2011 Health seeking Going to DOTS Complete diagnosis Starting treatment Complete treatment Patient behavioral determinants for TB management Cost Cost Cost Knowledge Knowledge KnowledgeDistance Received risk Stigma Attitude Expectation Stigma
- 10. Source: PSI/Myanmar Marketing Plan for TB, 2011 Health seeking Going to DOTS Complete diagnosis Starting treatment Complete treatment Behavioral interventions for TB management Mass media Health talks Peer to peer Time, cost, distance to DOTS facilities Quality of care Counseling Time, cost, distance to diagnosis/Treatment Time, cost, distance to diagnosis/Treatment Continued supply Quality of care Counseling Continued supply
- 11. ↓ TB incidence and prevalence Improved health seeking and treatment compliance Activities Output Purpose Goal Strategic framework for Social marketing - franchising Opportunity MotivationAbility Availability Quality of care Brand appeal Social norm Knowledge Self efficacy Social support Intention WTP ThreatBelief Outcome expectation Population Characteristics Social Marketing Intervention Product Place Price Promotion Behavioral Determinant
- 12. Product Go and check for TB if coughing >2 weeksSocial practice: Taking complete course of treatment Social idea: TB curable and life threatening if not treated Tangible product:
- 13. Pricing Laboratory diagnosis TB drugs cost Wages/travel cost Cost for management of side effects Free of charge Free of charge Reimburse for the poor Refer to NTP facilities Services fee to clinic Free of charge
- 14. Clinical Social franchise services FranchiseeFranchiser Branding Training Standards Commodities Following the standards INGO Private Health care providers Place Sun Quality Health in urban Sun Primary Health in rural
- 15. Integrated health services through SQH & SPH Sun Primary Health Integrated services: RH, Malaria, TB, HIV/STIs Pneumonia, Diarrhea Integrated services: Malaria, Pneumonia, Diarrhea RH referral, TB referral Sun Quality Health
- 16. SQH and SPH coverage in a township + v v + hospital RHC SPH >1500 SQH in 200 townships >1800 SPH in 80 townships Rural Health Center
- 17. Social Franchising (PPM DOTS) Model Technicalsupport Drugs&Labmaterialsupply Training Drugs supply HIV tests TB Pt supports Diagnosis TB/HIV DOTS, CPT TB pt supports Rural Case detection DOTS observer Monetary P4P Sputum microscopy Family DOTS Refer TB suspect Referral fee TB contact referral incentives Urban Peri-urban TB patients
- 18. Promotion: incentives and support Negative pricing to Transport/wages cost disbursed Service fee Referral to SQH Non- monetary SQH - 3.5$ (HIV test/TB) - outstanding SPH - 0.5$ (observer) 4$ outstanding Drug shop - - 1$ outstanding Laboratory - 0.3$ - - TB patients 40$ (poor only) - 2$ (contact) Nutrition
- 19. Promotion: media and Interpersonal communication Airing through 3 TV stations 7 FM stations
- 20. Counseling Defaulter tracking Health talkUrban Rural DOTS/Defaulter-track Health talkReferral Drug shops (Urban) Referral Promotion: media and Interpersonal communication
- 21. Increased TB case treatment as scaling up 0 5000 10000 15000 20000 25000 30000 2004 2005 2006 2007 2008 2009 2010 2011 2012 Sputum positive : ~30% ↑13 to 16% contributed to National TB treatment Source: PSI/Myanmar MIS Drug shops-citiesSPH-rural SQH only SQH + SPH SQH-urban TSR 85% Defaulter 5%Cure rate 73%
- 22. Quality of care: results from research data 0% 20% 40% 60% 80% 100% 120% TB follow-up Client satisfaction (TB) Source: PSI/Myanmar Research Department report, 2010 and 2011
- 23. Rural Urban Equity: Distribution of TB active participants- national sample vs. SQH Source: Montagu et al. (2011). Can subsidized private TB care serve the poor ? Evidence from Myanmar NTP SQH
- 24. Cost-Effectiveness: Cost per DALY in TB program 3.449 TB treated successfully and completely 1 DALY= 145.08 $1 TB DALY to be averted = Source: PSI Annual Cost Effectiveness Report, 2009 DALY: Disability Adjusted Life Year
- 25. Thanks