Synergistic impact: Two approaches to end TB in Myanmar

March 21, 2024 by Phyo Wai Lynn, Eaint Myet Chai, Jessica Farley, and Kyaw Zin Thann

How one project's dual strategies of private sector engagement and integrated service delivery are improving access to care for people affected by TB.

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A medical officer working with PATH's PPIA–ISD project in Myanmar checks an X-ray sent via the Viber messaging app from a PPIA-affiliated X-ray center. Photo credit: PATH/Phyo Wai Lynn.

Myanmar is among the 30 highest tuberculosis (TB) and TB/HIV burden countries in the world. TB prevalence is highest in urban areas, and particularly in Yangon region, which accounts for 30% of the country’s TB notifications and 47% of all drug-resistant (DR)-TB notifications. The majority of people in the region seek health care in the private sector as their first point of contact. Therefore, engagement with private-sector providers is crucial to fill in the gaps in TB detection and treatment and ensure that TB and other integrated health care services are accessible to all.

Since October 2022, PATH has been implementing a TB REACH Wave 10 project, funded by the Stop TB Partnership, to do just this. The project, "Private Provider Interface Agency (PPIA) for Integrated Service Delivery (ISD)—Myanmar," or PPIA-ISD, aims to engage with the private sector to integrate TB services, increase TB notifications, improve treatment outcomes, and ensure high-quality care aligned with international standards. Additionally, the PPIA-ISD project is developing a comprehensive patient support system that goes beyond TB to provide ISD across disease areas. The project focuses on townships in the Yangon region with the highest need—Hlaing Thar Yar and Insein—two densely populated peri-urban areas with migrants, factory workers, and low socio-economic status where an estimated 3,600 people with TB have been missed and undiagnosed over the past three years.

Focusing on integration and person-centered service delivery, the PPIA-ISD project makes it easier for people seeking care to access affordable and diverse health care services, which aligns with Myanmar’s National Strategic Plan. Engaging private providers, pharmacies, general practitioners, private hospitals, and the National TB Program (NTP), the project facilitates linkages between diagnosis and treatment of TB and care for other related diseases. Drawing on the successful experiences of PATH India's PPIA project, the PPIA-ISD project is partnering with the Myanmar Health Assistant Association (MHAA) to integrate TB services sustainably in the private sector with an ISD emphasis, align with wider health system strengthening efforts, and ultimately enhance TB case detection and treatment to reduce TB transmission in Myanmar.

The private sector’s crucial role in TB care

The role of the private sector in TB is instrumental in bolstering primary health care efforts. In Myanmar, public health care resources can be limited, and private health care providers serve as an entry point for people with TB symptoms, offering accessible and timely care that is often the first step toward successful treatment outcomes. The active involvement of the private sector fills crucial gaps in TB care, extending the reach of services and improving health outcomes for vulnerable populations.

Pharmacies, which are numerous in every nook and cranny of Myanmar’s crowded peri-urban areas, serve as initial points of contact for TB screening and referral. Nearly all patients who start feeling unwell with TB symptoms or other health problems first seek help at local pharmacy shops. Similarly, charity clinics and local general practitioners (GPs) play a pivotal role in early TB detection within the private sector. Therefore, a few extra efforts by these care providers to inquire about TB symptoms can go a long way.

Recognizing this, PATH facilitated new processes to help these private providers connect people with TB symptoms to care. After mapping out all potential private providers in Insein and Hlaing Thar Yar townships, PATH trained and assigned PPIA promoters to connect and engage with area pharmacies, private clinics, and charity clinics and then link them with MHAA’s field agents for the next step of diagnosis and treatment services, while maintaining close communication with private providers.

As a results, pharmacists now have a clear pathway to refer their patients to nearby PPIA-affiliated GPs and charity clinics with the assistance of PPIA agents, who in turn connect refer patients for free chest X-rays and ultimately start the patient on a successful treatment journey. PATH’s relentless advocacy efforts with private providers brought about significantly higher engagement in the PPIA model: after service provider mapping, nearly 80% of providers agreed to take part in the project.

“This engagement showcased the impressive level of private providers’ interest and willingness to participate in TB prevention and care activities,” says Dr. Eaint Myat Chai, PATH’s PPIA-ISD Project Coordinator. “The [engagement of private providers] beyond the project targets can impact more TB case finding, wider service provider coverage, improved assessments for TB diagnosis and treatment services for patients, comprehensive patient supports, and improved community awareness for TB.”

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PATH’s PPIA promoter and field agent from MHAA working together to engage with a pharmacy shop in Insein township. Photo: PATH.

The collective efforts of the unsung heroes: PPIA promoters, field agents, hub agents, and medical officers

At the core of the PPIA-ISD project are the real heroes—the PPIA promoters, field agents, hub agents, and medical officers—whose relentless efforts drive its success. PATH recruited agents from local communities and provided comprehensive, hands-on TB training to address patient concerns—thus alleviating the workload of medical officers and other health care personnel—as well as training on private provider engagement which included role-plays to teach them how to effectively communicate with busy pharmacists and GPs.

Additionally, PATH provided basic in-person- and tele-counseling training to all project staff before integrating mental health services. This comprehensive support, which allows for tailors, person-centered care for each individual patient, plays a crucial role in improving treatment adherence and building the resilience of people affected by TB.

“The [PPIA staff] are like strikers scoring to win in a football match.”
— Mr. Nay Lin Aung, PPIA project manager with MHAA

These frontline health care promoters and PPIA agents tirelessly engage pharmacies, charity clinics, and GPs to establish a collaborative health care network. The field agents operate in hotspots, gathering vital information and building trust within providers and communities to ensure seamless access to health care resources. Simultaneously, hub agents stationed at X-ray centers ensure efficient coordination by facilitating chest X-ray recordkeeping and using virtual tools like Viber [a calling and messaging app] to maintain communication. Complementing these efforts, medical officers, often behind the scenes, play a pivotal role in the virtual assessment of X-ray results, confirming TB diagnoses and guiding subsequent steps for care.

Throughout the project, addressing the challenge of limited human resources for field and hub agents has been crucial. To enhance the efficiency of fieldwork and support services and reduce the paperwork burden on pharmacies and clinics participating in the project, PATH guided MHAA to establish a volunteer channel to access and maximize the untapped potential within the community to support project initiatives. Through these collective efforts, these unsung heroes collectively advance the PPIA initiative, making significant strides toward ending TB in Myanmar and contributing to broader health care progress.

Amplifying impact through an integrated approach

Within the framework of the PPIA-ISD project, integrated service delivery (ISD) stands out as a cornerstone of comprehensive care. Through the ISD approach a wide range of services are offered, including TB screening for patients with diabetes, HIV testing for all people with TB, HCV testing for patients with TB/HIV coinfection, and mental health assessments and ongoing support starting from the TB pre-treatment phase. This integrated approach amplifies the impact of TB interventions, ensures services for key populations, and lays the foundation for sustainable progress to improve overall health outcomes.

Screening for TB among people with diabetes

People with diabetes mellitus (DM) represent a vulnerable population at heightened risk of TB infection and complications. Recognizing this intersectionality, the PPIA-ISD project has integrated TB screening into routine DM care at participating health care facilities. PATH established a bi-directional approach which included (i) TB case finding among all patients with DM in the private sector through the PPIA-engaged providers; and (ii) screening for DM followed by referral linkage for all registered patients with TB who are over 40 years of age according to NTP’s guidelines.

This proactive approach not only facilitates early detection and treatment of TB among patients with DM, but also strengthens the continuum of care for both diseases. By addressing the dual burden of TB and DM through ISD, the project maximizes resources and improves health outcomes for this high-risk population.

To enhance TB screening among patients with DM, the project team established a weekly collaboration with the urban health center, where patients with DM undergo regular follow-up visits. In cases where symptoms indicative of TB are identified, the team utilizes the Screen for All checklist, accompanies the patient to the PPIA-engaged chest X-ray facilities, and provides regular follow-up support.

Integrating mental health support

Recognizing that mental well-being is a crucial aspect of holistic patient care and treatment adherence for people with TB, PATH provided TB counseling training to all field staff and integrated mental health assessments into routine TB care protocols. For all patients with TB notifications under the PPIA project, mental status is assessed using the PHQ-9 questionnaire and recorded two times: once at baseline (within one month of TB treatment initiation) and once at the end of the intensive treatment phase.

This approach aims to identify and address any underlying mental health concerns, to ensure that patients receive the support they need for optimal recovery and well-being. The consistent encouragement and guidance of project field staff helps people affected by TB to foster resilience and navigate the physical and emotional challenges associated with TB treatment.

Strengthening the system, empowering communities

At its core, PATH’s efforts under the PPIA-ISD project to link the collective capacity of the public and private sector represents a commitment to strengthening health care systems and, by extension, empowering communities. By integrating TB services into existing health care infrastructure, the project fortifies the foundation of the health care system, ensuring that it is capable of meeting the evolving needs of the population. This systemic strengthening extends beyond TB to encompass broader health goals, including universal health coverage and health equity. With improved access to high-quality health care, individuals can pursue healthier lives and brighter futures, free from the burden of TB and other preventable diseases.

The future of integrated, people-centered care through the PPIA-ISD approach

Through the strong collaboration with our local partner MHAA, bolstered by enthusiastic engagement from private providers and ongoing partnership with the public sector to foster relationships with NTP and township health departments, PATH’s PPIA-ISD project is spearheading innovative approaches to enhance efficient, person-centered health care delivery. By consolidating TB services with existing health care infrastructure, the ISD model streamlines patient pathways, minimizes fragmentation, and optimizes resource utilization.

Patients benefit from holistic care that addresses their diverse health needs in a seamless manner, reducing the burden of navigating disjointed health care systems. Health care providers, in turn, enjoy enhanced collaboration and coordination, enabling them to deliver high-quality, patient-centered care. Moreover, the PPIA with ISD approach fosters sustainability by leveraging existing resources and strengthening health systems from within.

“If we want patients to complete their treatment successfully, we must consider how comfortable they are throughout their treatment journey and fill all the gaps required to make their TB experience as easy and comfortable as possible.”
— Dr. Thurya, PPIA–ISD project medical officer

PATH’s work has shown the power of public-private interfacing and service integration. Going forward, the project is analyzing both programmatic and costing data, as well as documenting challenges, best practices, and lessons learned, that will inform potential scale-up of these novel PPIA-ISD approaches in other areas, with the ultimate aim to provide technical support and integrate the PPIA-ISD model into the NTP and expand to other regions. Through this, the PPIA-ISD project is paving the way for a more resilient and responsive health care system that is better equipped to tackle not only TB but also other public health challenges in Myanmar.