Public Private Partnership on the Fight Against Malaria

1. Public Private Partnership on the Fight Against Malaria Dr. KhengSim, Deputy Director, CNM Intercontinental Hotel, Phnom Penh November 7, 2012 1

2. Outline • Background • PPP on the Fight Against Malaria: Design and Implementation • Lessons Learned • Recommendations 2

3. Challenges in the private health sector • Presence of Counterfeit/Sub-Standard drugs and Oral ArtemisininMonotherapies • Incorrect diagnosis of malaria, low compliance to National Treatment Guidelines and MOH policies; • No system for the collection of epidemiological data or routine monitoring of case management and anti-malarial drugs; • Limited interaction between public and private providers for diagnosis, treatment, referral, data sharing, etc. 3

4. PPM Background: From Pilot to National Strategy Policy Assessment & Mapping BMGF AMFm Development & Implementation of National PPM Strategy SSF Funding Sources Lessons learned will contribute to next phase Nationwide Implementation (CNM, PSI &URC) Expansion (CNM & URC) Piloting & Implementation PATH Pilot 2010 2011 2012 2013 - 2015 Policy Development

5. The Goal & Objectives of the PPM initiative… Goal: • To support activities to contain the spread of drug-resistant malaria parasites via improved diagnosis, referral, and prescribing behaviors and increased malaria case surveillance in the private sector • Objectives: • Counterfeit and Monotherapiesare not available • All patients receive parasitological diagnosis • Patients receive appropriate drug regimens • Patients are referredaccording to the National Policy (signs of severe malaria or recurrent malaria and all pregnant women and children under five years of age) • Routine surveillance data are collectedfrom private sector providers 5

6. Public-Private Partnership (PPP) activities Engaging Private Sector Providers for Improved Surveillance and Case Management: Private Health Care Providers (pharmacies, drug outlets ), Engaging industry for improved access to ACTs (manufacturers, importers ) Engaging businesses to expand LLIN coverage(farms, plantations, transportation companies, telecommunications companies etc). CNM has also recently entered into an agreement with MobiTel, a telecommunications company in Cambodia, to supply hardware and free SMS BCC

7. Engaging Private Sector Providers for Improved Surveillance and Case Management PSI distributes and sells subsidized, nationally recommended ACTs and RDTs to private health care providers throughout the country and has collaborated with private providers to bundle nets with insecticide sachets. A pilot “PPP Project” to engage private sector providers in malaria control efforts, improve diagnosis and prescribing behaviors, and increase malaria case surveillance. In addition, CNM has also partnered with the Ministry of Interior Anti-Economic Crime Police (MoIE) and the Department of Drugs and Food (DDF) to intensify enforcement and regulatory activities in the private health sector

8. Engaging industry for improved access to ACTs The CNM decided to participate in the AMFm, an innovative financial mechanism to improve access to affordable ACTs throughout the supply chain. Unfortunately, at the time of writing, Cambodia has been unable to access an ACT that is eligible for the co-payment mechanism

9. Engaging businesses to expand LLIN coverage CNM has piloted a program to expand coverage of LLINs amongst migrant and mobile populations. Workers can borrow a LLIN from their farm owner through the LLIN Lending Scheme. CNM is therefore able to reach and protect a vulnerable group, through partnering with private business.

10. PPM implementation and scale-up is now under way… CNM aims to work with Provincial and OD teams to implement PPM nationwide under the framework of the PPP Strategy and the National Elimination Strategy. As PPM enters into the implementation stage, each OD is enacting the following steps: Completed; 10 OD’s Completed; 6 OD’s Ongoing; 6 OD’s Mapping, Analysis & Selection of PPs Data Collection & Supportive Supervision Orientation Training IMPLEMENTATION

11. Who makes PPM work? Building a strong team OD by OD • Potential Staff to fill positions: • OD Chief • Chief of Drug Bureau • Deputy Director • Malaria Supervisor • OD Staff working with private sector • Chiefs of Administrative Districts. • PPM team: • i) Focal Point • ii) Deputy Director • iii) Chief, Drug Bureau • iv) One staff to assist the FP • Selecting a competent and motivated focal point at the peripheral sites is of primary importance • PPM focal point (FP) and team responsibilities include: • Helping to recruit PPM staff for PHD/OD team • Selection of registered, willing private providers to participate in the program • Training of public and private sector providers • Design and implementation of follow up plan for supportive supervision Positions within the PPM teams and potential staff for filling these positions:

12. Implementing PPM has advantages for multiple stakeholders Private sector perspective • Providers have improved confidence and knowledge to test, treat and refer according to National Treatment Guidelines and MoH policies. • Providers benefit from increased support from public sector • Providers know when and where to refer clients • Have knowledge to test, treat and refer according to national guidelines • Private providers are eager to participate and welcome the opportunity to be integrated into the system and improve their skills Public sector perspective • Many more clients will be referred • Less severe cases will occur due to earlier referral • National Program will have access to case management and surveillance datafrom the private sector Client perspective • Improved access to appropriate diagnosis and treatment services .

13. Drug Inspection & Destruction

14. Diagnosis &TreatmentPrivate Sector • Official letter on Ban of Arthemisininmonotherapieswas issued by MOH on 23 March, 2009 • Disseminated the MoH Announcement on ban ArtemisininMonotherapies to 54 private sectors at national level by conducting National stakeholder meeting on 29 /04/2009 • Conducted Provincial stakeholder meeting on 19 /07/09 in Battembang province to inform 64 private sectors in zone 1 about National Malaria containment policy and to disseminate the MoH Announcement on ban ArtemisininMonotherapies to private sectors • Conducted Drug Inspectors Training on 28-29/12/2009 in Siem Reap with a total of 70 participants from 24 provinces • Mapping target private sectors in 9 provinces in zone 1 & 2 ( Except Siem Reap)

15. Public Private MixFollowing CNM’s Model Mapping private sector outlets MoU Training Routine Support & Supervision Data Collection >1,000 providers routinely supported / yr >150,000 RDTs to be returned / yr >1,600 providers trained / yr >1,600 outlets mapped 2012 Targets Program running since 2003

16. Public & Private Approaches working together 39%people said they bought their net from the market 38%said they received their net from the Government/NGO [n= 22,528 Households: 2009 Household Survey] Free Net Campaigns Net Markets &

17. National Coverage 1 million nets are imported into Cambodia annually • PSI has supplied: • 793,509 Kits (2010) • 700,000 Kits (2011) • 700,000 Kits (2012) • 80.2% • Of net outlets nationwide had bundled nets in stock (2012 Coverage Survey)

18. Lessons learned through implementation • One size does not fit all. Success of the PPM depends to a great degree on the level of decentralization that has been built into the program • Consistent supervision is important and can serve as an avenue for dissemination of important information to the private sector • Having a committed PPM team at the PHD/OD level is critical to the success of the program • Discussion with providers has revealed that the poorest patients often don’t want to be referred due to the expenses associated with transportation to and treatment in the public sector • It is important to install a tracking mechanism to see where the patients go/what they do after they are referred. This step in the process is still being refined.

19. Recommendations for PPM going forward… • While CNM will offer technical support and resources for PPM, national scale-up will require the commitment of local authorities and elimination task forces for rapid and effective implementation. • Make access to malaria diagnosis and treatment and prevention a priority in OD and further operationalize PPM; • Ensure high quality diagnosis and treatment services in the public sector for clients referred from Private Providers; • Ensure strong support and commitment from the Provincial Governor to facilitate implementation of PPM at Provincial and District Levels.

20. PPM going forward… expectations for Phase 2 implementation • Under Phase 1, the PPM program has been instigated in 10 OD’s (2 in Battambang) • With the help of partner organizations, PPM plans to scale up further in SSF Phase 2. By 2015 CNM will have oversight of 18 ODs in 10 provinces. PPM projects will also be launched by PSI and URC to cover additional ODs and Provinces

21. THANK YOU VERY MUCH